ONL178
Surviving Sepsis Campaign

Sepsis Statistics

Populations at risk:

Approximately 750,000 new cases of sepsis occur each year. While sepsis can affect anyone, all hospitalized patients are at increased risk. Those at highest risk include:

• The very young and the very old
• Those with severe injuries or medical conditions
• Pre-existing infections, and those immunocompromised
• Those with a genetic predisposition to sepsis

Sepsis Mortality Statistics:

A sepsis diagnosis carries with it a very real risk of mortality. Risk of demise is 10-20% with simple sepsis, but increases up to 50% with severe sepsis and to 60% with septic shock. These frightening statistics, along with recognition that evidenced based practice changes could impact them, was the impetus for the Surviving Sepsis Campaign .

• Overall inpatient mortality= 34% mortality

• Sepsis= 10-20% mortality

• Severe Sepsis= 30-50% mortality

• Septic Shock= 50-60% mortality

Sepsis Descriptions and Definitions

Surviving Sepsis Campaign Background

The work to improving sepsis patients' outcomes began in 2003 with the convening of infectious diseases and critical care experts from across the world, representing 11 international organizations. Culling through and rating the evidence available, this group developed guidelines (published in 2004) for bedside care of severe sepsis and septic shock and updated these guidelines in 2008 and 2012. The stated objectives were to increase awareness and diagnosis of septic patients followed by implementing EBP changes and reduce sepsis related mortality. Measuring the impact of changed practice was requisite and an international data base was developed and implemented.

The Surviving Sepsis Campaign is in partnership with the Society of Critical Care Medicine, European Society of Intensive Care Medicine, and International Sepsis Forum. These groups teamed up with the Institute of Health Care Improvement to promote the campaign. It has been endorsed by numerous nursing organizations including the American Association of Critical Care. Additional supporting organizations include the following: American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; American Thoracic Society; Australian and New Zealand Intensive Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Society of Critical Care Medicine; and the Surgical Infection Society among others.

The Purpose of the Surviving Sepsis Campaign

To "Reduce the mortality associated with sepsis by 25% over the next five years."

Steps to Take

1. The first step is early and rapid identification of severe sepsis and septic shock. 
2. Once identified, rapid implementation of EBP resuscitation elements within 1-6 hours.
3. Lastly, implement evidenced based practices that continue to support the patient after the initial EBP resuscitation phase.

Reviewing the Evidence

The experts reviewed existing evidence to determine the specific items to be included. Their intent was to include as recommendations only those interventions that demonstrated improved outcomes in severe sepsis and septic shock, specifically identified as reduction in mortality. 

The expert panel grouped the recommendations into early goal directed therapy or resuscitation interventions. Available evidence supporting the recommendation was graded as 1, strong and 2, weak; quality of supporting data was designated as A, very high to D very low. In order to be included as a recommendation, at least 80% of the expert panel participants had to agree that the item should be included as a recommendation. The strength was identified as 1 or strongly supported if at least 70% of the group indicated a strong support for the item. The element was assigned a 2 or weak support if less than 70% of the experts strongly supported the item. Factors that resulted in upgrading or downgrading of specific evidence are included for your review.

Underlying Methodology

• Random controlled trial (RCT)
• Downgraded RCT or upgraded observational studies
• Well-done observational studies
• Case series or expert opinion

Factors that May Decrease the Strength of Evidence

• Poor quality of planning and implementation of available RCT suggesting high likelihood of bias
• Inconsistency of results (including problems with subgroup analysis)
• Indirectness of evidence (differing population, intervention, control, outcomes, comparison)
• Imprecision of results
• High likelihood of reporting bias

Main factors that May Increase the Strength of Evidence

• Large magnitude of effect (direct evidence, relative risk (RR) >2 with no plausible confounders)
• Very large magnitude of effect with RR>5 and no threats to validity (by two levels)
• Dose response gradient

Method Used by the Expert Team to Grade

The method used by the expert team to grade the level of the evidence is outlined above. While it is ideal to have an abundance of well-designed, randomized controlled trials (RCT), this clearly is not always available. At times, the best evidence available may be expert opinion or review of clinical cases. Additionally, some RCT, while they have merit, are not optimally designed or conducted. Thus, while the findings are important, they do not lend the same power of assurance as do other more well-designed studies. Taking this into account, the group rated the quality of supporting data for recommendations from A to C, with A representative of the most well studied based on available data and D with the least available research support.

Resuscitation and Management Bundle Elements

The expert panel identified six interventions for implementation in severe sepsis and septic shock patients. Together, this is referred to as the resuscitation bundle or early goal directed intervention. Every bundle component was graded a 1 or "strongly" supported. Level of evidence ranged from A to C. This indicates that a need for continued research on each bundle element remains. The group postulated that implementation of each of these bundle elements was beneficial in mortality reduction in patients with severe sepsis or septic shock and thus, should occur in every case.

Initial Resuscitation

The Resuscitation Components are to be completed ASAP and all within the first 6 hours of identification :

1. Blood cultures are to be drawn prior to antibiotic administration.

2. A serum lactate should be drawn.

3. Broad spectrum antibiotics are to be administered within the first hour of recognizing severe sepsis/septic shock in hospitalized patients.

4a. An initial fluid bolus of 30 ml/kg IV of normal saline for:

• Hypotension (systolic <90 mmHg or MAP < 65 mmHg) or
• Lactate> 4mmol/L
• Goal of treatment = MAP > 65 mmHg

4b. Vasopressors for hypotension not responding to initial fluid.

• Levophed (norepinephrine) preferred
• Goal of treatment = MAP > 65 mmHg

5. Central Line- measure Central Venous Pressure (CVP) (monitor for goal of 8-12 mmHg) if fluid resuscitation does not result in goal blood pressures.

• Insert Central line if BP parameters not met after initial fluid bolus of 30 ml/kg and no evidence of further responsiveness and further fluids..
• Insert Central Line if Lactate > 4 mmol/L
• Measure CVP as soon as possible after Central Line insertion.
• Acceptable central lines to measure CVP: subclavian, jugular or PICC. Central lines not supported by research to measure CVP include: groshong, hickman, implanted ports and femoral

6. ScvO2 (suplin vena cava oxygen saturation goal >70%) or Svo2 (mixed venous oxygen saturation > 65%

• Measure as soon as possible.
• Periodic or continuous measurement recommended.
• Obtain blood sample from distal port of central line if periodic measurements are used.

*It is of note that serial lactates with a goal of >10% decrease was not inferin to.

Nursing Impact in Surviving Sepsis Campaign

Early Identification

1. Early identification is a necessary first step that must precede timely implementation of the early resuscitation bundle elements, and thus to decreasing sepsis related mortality.

Early identification is enhanced through the use of a screening tool that provides cues to sepsis related signs and symptoms. An example of a severe septic shock screening tool and checklist used at an Omaha, NE hospital is linked below. It can be used any time severe sepsis/septic shock is suspected. It is important to point out that signs or symptoms explained by other disease processes, medications, etc., are NOT to be selected.

This tool is very sensitive, but NOT SPECIFIC. When a tool is very sensitive, it will identify most patients who have severe sepsis or septic shock. When a tool is noted to be NOT SPECIFIC, it means that there will be many false positives. This tool is used to screen patients for severe sepsis / septic shock. It does NOT diagnose the patient. There are several other disease processes that can cause similar symptoms. With this in mind, it is necessary for the physician to evaluate the patient and make the diagnosis of severe sepsis or septic shock

Elevated Lactate - What Does It Mean?

Physiology of Lactate

1. Anaerobic metabolism occurs when tissue does not have adequate oxygen to produce cellular energy from glycolosis via the more efficient Krebs cycle.

2. An end product of anaerobic metabolism is lactate

3. Lactate can be taken up by the liver, heart and kidneys and further metabolized to CO2 and ATP (energy)

Everyone with an elevated lactate does not have sepsis. Elevated lactate may occur from conditions causing:

1. Inadequate tissue perfusion

2. Increased production of lactate

3. Decreased metabolism of lactic acid

4. Inadequate tissue oxygenation

Examples of conditions that can cause elevated lactate:

1. Vigorous exercise or grand mal seizures (increased production)

2. Shock from causes other than sepsis, such as life threatening anemia, cardiogenic or neurogenic shock (reduced tissue perfusion)

3. Severe hypoxemia (increased production)

4. Cirrhosis or hepatic failure (decreased metabolism)

5. Drugs such s Nipride, Tylenol overdose, cyanide (increased production)

6. And many more!

Screen patient #1 using the Sepsis Screening Tool

1. 75 year old with recent abdominal surgery, now with generalized, constant, severe abdominal pain, rebound tenderness, no

history of chronic illness or medications

• Temperature = 95.8° F

• WBC = 21,000; Hgb 14.0

• HR = 89 bpm, RR = 18 bpm, BP = 88/40 (MAP= 56mm Hg)

• Lactate 1.8, glucose 118

Screen patient #2 using the Sepsis Screening Tool

2. 65 year old diabetic, recent treatment with chemotherapy for lung CA, with acute lower limb cellulitis

• Temperature = 100.6°F

• HR = 84 bpm, RR = 18 bpm, BP = 98/64 (MAP = 74mm Hg)

• WBC = 11,000; Hgb 14.0; platelet count 145,000

• Blood sugar 136 mg/dL; crt 1.8 mg/dL,

• Lactate 1.4

Screen patient #3 using the Sepsis Screening Tool

3. 55 year old with severe COPD not on home O2; no other chronic diseases

• Chief complaint of increased SOB and productive cough

• Rales and rhonchi throughout all lung fields

• Temperature = 102.6°F

• HR = 124 bpm; RR = 18 bpm; BP = 84/40 (MAP = 55 mm Hg)

• WBC =25,000; Hgb 13.0; platelet count 94,000; INR 2.4 (no anticoagulants)

• Blood sugar 156 mg/dL; crt 3.8 mg/dL (baseline 1.1), lactate 4.5 mmol/L,

• CXR = Bilateral pulmonary infiltrates

• O2 on at 4 L/min to maintain SpO2 >90%

• Confused and slow to respond (No sedatives)

Nursing Impact in Surviving Sepsis Campaign-Continued

Immediate Interventions

2. Initiate immediate interventions (Resuscitation Elements). Mobilize resources to the patient by calling the Rapid Response Team (RRT).

Resuscitation/Treatment

3. Anticipate MD orders for immediate resuscitation/treatment: an MD order set for severe sepsis/septic shock should be available at your hospital inclusive of the resuscitation and management bundle items. Please note, this is an order set for severe sepsis and septic shock, not for simple sepsis or bacteriemia patients. To provide ease of use, the order set can be started outside of critical care but call the Rapid Response Team (RRT) to get the experts to assist.

Resuscitation Elements

• Broad spectrum antibiotic administered within the first hour of recognizing severe sepsis/septic shock. In the presence of septic shock, each hour delay increases the risk of mortality. The preponerance of evidence suggests that this is also influential in those with severe sepsis.

• Blood cultures prior to antibiotic administration

• Serum lactate measured

• Initial fluid bolus 30 ml/kg IV fluid for hypotension (SBP < 90 mm Hg or MAP < 65 mmHg) or lactate > 4 mmol/L

• Vasopressors for hypotension not responding to initial fluid Levophed (norepinephrine) preferred

• Fluids to achieve a CVP 8 - 12mmHg - Insert central line if not responsive to initial fluid bolus and give adequate fluid

• Intervention to achieve a ScvO2 > 70% - after CVP pressure > 8 mmHg. This may include blood, oxygen, etc.

• Implementation of the fluids, antibiotics and lab specimens should begin ASAP and not wait for admission to a higher level of care.

Priority Interventions

1.Fluid resuscitation at 30ml/kg given as a bolus

2.Target time for fluid is 30ml/kg cm 3 hours of recognition

3.Antibiotic administration within the first hour of recognizing severe sepsis/septic shock

4.Blood cultures prior to antibiotic administration;

5.Lactate level obtained ASAP

6. These priority first interventions are believed to be more beneficial the earlier they are implemented. Delay in any could result in failure to rescue

Transfer

4. Prepare patient for transfer to higher level of care (Critical Care). Patients diagnosed by a physician with severe sepsis and septic shock generally benefit from being transferred to Critical Care for aggressive resuscitation therapy.

* Please note: A positive screen on the screening tool does NOT diagnose the patient for severe sepsis. A physician must make the diagnosis.

Communication

5. Handoff / Communication Tool

To facilitate timely intervention and to promote complete information at handoff, a communication tool was developed at a local Omaha medical center entitled: "Severe Sepsis/Septic Shock Checklist". It should be initiated for all patients with identified severe sepsis or septic shock. It assists the nurse with communication of the essential resuscitation bundle elements already instituted and reveals what still needs to be completed.

Measuring Outcomes and Process Measures

Measuring compliance with each aspect of the resuscitation and management bundles is important. Meeting the specified process measures should impact the patient's outcome and reduce mortality.

Click Diagram A for a visual connection of the process measures to the clinical outcome.

Nursing's Impact

Nursing is in a key position to help prevent and recognize severe sepsis and septic shock. The nurse is to:

• Maintain compliance with hand washing and sterile technique.

• Be alert for severe sepsis and septic shock. Use the screening tool to help identify patients with possible severe sepsis or septic shock.

• Call an RRT and notify the physician if severe sepsis or septic shock is suspected.

• Begin the severe sepsis order set if ordered by the physician. On the general nursing unit that may include obtaining labs, starting the fluid bolus and antibiotic while preparing for transfer to critical care.

Nursing has a huge impact on the outcome of these patients experiencing severe sepsis or septic shock.

• Assure correct fluid bolus (30 ml/kg).

• Document accurate intake and output and communicate if 30ml/kg of IV fluid has been reached.

• Assure antibiotic given ASAP and within the first hour of recognizing severe sepsis/septic shock.

• Facilitate communication of interventions with use of the "Severe Sepsis/Septic Shock Checklist" or similar hand off tool.

• Connect Central line to CVP monitor to ensure adequate fluid resuscitation.

Remember: Delay in recognition or treatment of severe sepsis and septic shock increases the patient's risk of death.

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