Dấu hiệu cảnh báo: Các bảng điểm nhận biết sớm sepsis - Barbara McLean

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<b>Heed the Warning:</b>

<b>Early Warning Scores for </b>

<b>Sepsis Identification</b>

Vietnam 2019: Sepsis

Barbara McLean,

MN, CCNS-BC, NP-BC, FCCM
Grady Health Systems

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OBJECTIVES

• To understand and be able to identify the

differences between Sepsis and Shock

• To appreciate the role of SIRS in identifying

patients at risk

• To understand the morbidity and mortality of Sepsis

in relation to length of stay, current guidelines, cost
to health care systems.

• To understand modalities of treatment which

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. accessed August 7, 2015

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<i><b>Sepsis 2016</b></i>

• <b>Infected: Use SIRS + suspicion</b>

• <b>Sepsis (with organ dysfunction)</b> – now defined as
life-threatening organ dysfunction caused by a

dysregulated host response to infection. <i><b>This is a </b></i>
<i><b>clinical diagnosis.</b></i>

o Identify with modified SIRS and Change in LOC

• <b>Septic Shock</b> – a subset of Sepsis with circulatory and
cellular/metabolic dysfunction associated with a higher
risk of mortality. <i><b>This is a clinical diagnosis.</b></i>

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<i>JAMA</i>. 2016;315(8):762-774. doi:10.1001/jama.2016.0288

<b>Suggested Clinical Criteria for </b>

<b>Sepsis (if in ICU?) </b>

Infection + 2 or more SOFA points (above
baseline)

<b>Consider Sepsis outside ICU if</b>

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QUICK SOFA / QSOFA

<b>> 22/ min</b> <b>SBP </b>

<b>≤100mmHg</b>

In patients with infection a qSOFA

score > 2 is associated with higher

mortality and prolonged ICU stay.

<i><b>SEPSIS Scoring Tool: Adding Organ Dysfunction</b></i>

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MEWS Scoring Algorithm: Making it Simple

•

Uses vital signs to generate an acuity score

•

No process change or manual entry

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5-6

7+

MEWS SCORING ALGORITHM: MAKING IT SIMPLE

1-4

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<b>3 </b>

<b>hr</b> <b>6 h</b>

<b>r.</b>

S

t

EP-1: EARLY MANAGEMENT BUNDLE

<b>Measures & Intervention Required:</b>

 Blood culture before

antibiotics

 Antibiotics

 Fluid resuscitation

 Lactate level

Set Measure ID # SEP-1-8; Early Management Bundle, Severe Sepsis/Septic Shock

<b>Interventions Required:</b>

 Lactate level repeated (If

elevated)

 Vasopressors if necessary

 Optimize fluid

Severe Sepsis

Time Zero

StEP-1 By <i><b>3</b></i> Hours

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<i>BEFORE 3 HOURS ARE UP!</i>

<b>To Be Completed by 3 Hours</b> <b>Of Time Of Presentation:</b>

1. Obtain blood cultures prior to administration of
antibiotics.

2. Measure lactate level.

3. Administer broad spectrum antibiotics.

4. Administer 30ml/kg crystalloid for hypotension,

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StEP-1 By <i><b>3</b></i> Hours

“Delays in administering all four

guidelines recommendations,

<i>even </i>

<i>when they did not exceed 3 hours</i>

,

were associated with a significant

increase in in-hospital mortality.”

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<b>3 </b>

<b>hr</b>

SEP-1: EARLY MANAGEMENT BUNDLE

<b>Measures & Intervention Required:</b>

 Blood culture before

antibiotics

 Antibiotics

 Fluid resuscitation

 Lactate level

Grady RRT protocol

Severe Sepsis

Time Zero

<i><b>Our Clock Is One Hour!</b></i>

<b>1 h</b>

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<b>Guidelines For Initial Resuscitation In Patients </b>
<b>With Sepsis Or Septic Shock</b>

. Rhodes A et al. Intensive Care Med. 2017;43:304-377.

<b>Initial resuscitation </b>
<b>guidelines</b>

• <b>At least 30 mL/kg of IV crystalloid fluid </b>
<b>recommended within the first 3 hours</b>

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<b>Study</b> <b>Year</b> <b>Mortality Before (%)</b> <b>Mortality After (%)</b>

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3 Recent Large Randomized Control Trials:

Although advanced severe sepsis therapies (such as central
line placement, SVO2 goals, etc) did not show improved

outcomes, <b>all were randomized after early recognition and </b>

<b>standard therapies including antibiotics and fluid </b>

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Combo Therapy

•

Choose

o

Aminoglycosides or Aztreonam or

Ciprofloxacin

o

Cephalosporins,

(1st and 2nd Generation) <i>- or –</i>

o

Clindamycin

<i>- or -</i>

Daptomycin

- <i>or </i>

-Glycopeptides

<i>- or -</i>

Linezolid

<i>- or -</i>

Macrolides

<i>- or –</i>

Penicillins

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<b>3 </b>

<b>hr</b> <b>6 h</b>

<b>r.</b>

SEP-1: EARLY MANAGEMENT BUNDLE

<b>Measures & Intervention Required:</b>

 Blood culture before

antibiotics

 Antibiotics

 Fluid resuscitation

 Lactate level

Set Measure ID # SEP-1-8; Early Management Bundle, Severe Sepsis/Septic Shock

<b>Interventions Required:</b>

 Lactate level repeated (If

elevated)

 Vasopressors if necessary

 Optimize fluid

Severe Sepsis

Time Zero

StEP-2 By <i><b>6</b></i> Hours

<b>1 h</b>

<b>r</b>

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<b>3 </b>

<b>hr</b> <b>6 h</b>

<b>r.</b>

Severe
Sepsis

Time Zero

<b>Interventions Required:</b>
<b>ALL of Severe Sepsis +</b>

 <b>Fluid 30 ml/kg</b>
<b>(NO exclusionary </b>
<b>criteria)</b>

<b>Physical Exam (ALL)</b>

• Vital Signs (T, HR, RR, BP)
• Cardiopulmonary exam

• Capillary refill evaluation
• Peripheral Pulse evaluation
• Skin evaluation

<b>Hemodynamics (2 of 4)</b>

• CVP
• SVO₂

• Bedside cardiovascular ultrasound
• Passive leg raise / fluid challenge

Shock Assessment

<b>Interventions Required:</b>
<b>Persistent Hypotension</b>

 Within 1 hour of fluid add
VASOPRESSOR

<b>Persistent Hypoperfusion</b>
<b>OR Lactate > 4</b>

 Shock Assessment (1 of 2)

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COMMON ISSUES IN SHOCK

• Inadequate oxygen delivery to meet metabolic

demands

• Results in global tissue hypoperfusion and

metabolic acidosis

• Most important, evidence of hypoperfusion: All

shocks

o hypotension

o Lactic acid

o Base deficit

o SvO2 or ScV02

o pH

Focus on tissue acidosis
and

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COMPENSATORY RESPONSE IN SHOCK

• Inadequate systemic oxygen delivery

activates autonomic responses to maintain

systemic oxygen delivery

• Sympathetic nervous system

• NE, epinephrine, dopamine, and cortisol release

• Causes vasoconstriction, increase in HR, and increase of
cardiac contractility (cardiac output)

• Renin-angiotensin axis

• Water and sodium conservation and vasoconstriction
• Increase in blood volume and blood pressure

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Acute kidney injury _{Myocardial injury}

<b>LOW MAP IS ASSOCIATED WITH SERIOUS </b>
<b>ADVERSE EVENTS</b>

Risk of both kidney and cardiac injury increases with decreasing MAP

<i>Adapted from Walsh M et al. Anesthesiology. 2013;119:507-515.</i>

0.12

30 40 50 60 70 80
Lowest MAP (mm Hg)

P
rob
ab
ili
ty

o
f
ac
ut
e
k
idn
ey
inj
ury
0.04
0.06
0.08
0.10
0.08

30 40 50 60 70 80
Lowest MAP (mm Hg)

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<b>DURATION OF LOW MAP AND ADVERSE EVENTS </b>

<i>Adapted from Walsh M et al. Anesthesiology. 2013;119:507-515.</i>

0 minutes 1 to 5 minutes 6 to 10 minutes 11 to 20 minutes >20 minutes

A

dj

usted

od

ds

ratio

1
1.5
2
2.5

Acute kidney injury Cardiac complication Myocardial injury

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TAKE HOME POINTS

•

Suspect Sepsis Early

•

Quantify patients at risk with MEWS

•

Make it automatic

•

Re-Evaluate Patients Promptly

•

Treat as a team event and if determine

patient is septic treat as a “code sepsis”

•

Apply antibiotics as STAT drugs

•

Use your clinical judgment as you fluid

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To Save Lives

...

<b>Early</b> fluid resuscitation

<b>Early</b> identification

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And STOP SEPSIS!

Barbara McLean,

MN, CCNS-BC, NP-BC, FCCM
Grady Health Systems

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<a href=' accessed August 7'>. accessed August 7</a>