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

• Septic Shock – a subset of Sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality.. This is a clinical diagnosis.[r]

Heed the Warning:

Early Warning Scores for

differences between Sepsis and Shock

patients at risk

in relation to length of stay, current guidelines, cost

to health care systems.

include management, such as fluid resuscitation

and pharmacological interventions.

.http://www.cdc.gov/nchs/data/databriefs/db62.pdf accessed August 7 , 2015

In-hospital death 8X higher compared to other diagnoses

Sepsis 2016

life-threatening organ dysfunction caused by a

dysregulated host response to infection This is a

clinical diagnosis.

o Identify with modified SIRS and Change in LOC

cellular/metabolic dysfunction associated with a higher

risk of mortality This is a clinical diagnosis.

are medical emergencies and it is recommended that treatment and resuscitation begin immediately

2016 Sepsis-3

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

Suggested Clinical Criteria for

Sepsis (if in ICU?)

Infection + 2 or more SOFA points (above

baseline)

Consider Sepsis outside ICU if

Infection + 2 or more qSOFA points

easy to quantify with EWS

QUICK SOFA / QSOFA

≤100mmHg

In patients with infection a qSOFA

score > 2 is associated with higher

mortality and prolonged ICU stay

SEPSIS Scoring Tool: Adding Organ Dysfunction

AVPU

MEWS Scoring Algorithm: Making it Simple

• Uses vital signs to generate an acuity score

• No process change or manual entry

• An additional tool to help identify deterioration

SCORING SYSTEMS

3

S t EP-1: EARLY MANAGEMENT BUNDLE

Measures & Intervention Required:

 Blood culture before

BEFORE 3 HOURS ARE UP!

To Be Completed by 3 Hours Of Time Of Presentation:

1 Obtain blood cultures prior to administration of antibiotics.

defined as a “mean arterial pressure” MAP<65 or lactate ≥4mmol/L.

StEP-1 By 3 Hours

“Delays in administering all four

when they did not exceed 3 hours,

were associated with a significant increase in in-hospital mortality.”

SCCM journal April 2018 Volume 46 Number 4

3

SEP-1: EARLY MANAGEMENT BUNDLE

Measures & Intervention Required:

 Blood culture before

Guidelines For Initial Resuscitation In Patients

With Sepsis Or Septic Shock

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

Initial resuscitation

guidelines

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

• An initial target MAP of at least 65

mm Hg in patients with septic shock requiring vasopressors

Study Year Mortality Before (%) Mortality After (%)

3 Recent Large Randomized Control Trials:

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

outcomes, all were randomized after early recognition and standard therapies including antibiotics and fluid

resuscitation which are the goals of UNC Code Sepsis

3

SEP-1: EARLY MANAGEMENT BUNDLE

Measures & Intervention Required:

 Blood culture before

Physical Exam (ALL)

• Vital Signs (T, HR, RR, BP)

• Cardiopulmonary exam

• Capillary refill evaluation

• Peripheral Pulse evaluation

• Skin evaluation

Hemodynamics (2 of 4)

• CVP

• SVO2

• Bedside cardiovascular ultrasound

• Passive leg raise / fluid challenge

COMMON ISSUES IN SHOCK

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

Focus on MaP and perfusion

Acute kidney injury Myocardial injury

LOW MAP IS ASSOCIATED WITH SERIOUS ADVERSE EVENTS

Risk of both kidney and cardiac injury increases with decreasing MAP

Adapted from Walsh M et al Anesthesiology 2013;119:507-515.

DURATION OF LOW MAP AND ADVERSE EVENTS

Adapted from Walsh M et al Anesthesiology 2013;119:507-515.

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

Acute kidney injury Cardiac complication Myocardial injury

Serious adverse events can occur even when duration of low MAP is short

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

resuscitate

To Save Lives

Early fluid resuscitation

And STOP SEPSIS!

Barbara McLean, MN, CCNS-BC, NP-BC, FCCM

Grady Health Systems

Atlanta GA USAbmclean1@GMH.edu