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

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• 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]

(1)

Heed the Warning:

Early Warning Scores for Sepsis Identification

Vietnam 2019: Sepsis

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

(2)

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

(3)(4)

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

(5)(6)

Sepsis 2016Infected: Use SIRS + suspicion

Sepsis (with organ dysfunction) – now defined as 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

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

(7)(8)

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

Suggested Clinical Criteria for Sepsis (if in ICU?)

Infection + or more SOFA points (above baseline)

Consider Sepsis outside ICU if

(9)

QUICK SOFA / QSOFA

> 22/ min SBP

≤100mmHg

In patients with infection a qSOFA score > is associated with higher

mortality and prolonged ICU stay

SEPSIS Scoring Tool: Adding Organ Dysfunction

(10)

MEWS Scoring Algorithm: Making it Simple

• Uses vital signs to generate an acuity score

• No process change or manual entry

(11)(12)

5-6 7+

MEWS SCORING ALGORITHM: MAKING IT SIMPLE

1-4

(13)(14)

3

hr 6 h

r.

StEP-1: EARLY MANAGEMENT BUNDLE

Measures & Intervention Required:

 Blood culture before

antibiotics

 Antibiotics

 Fluid resuscitation

 Lactate level

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

Interventions Required:

 Lactate level repeated (If

elevated)

 Vasopressors if necessary

 Optimize fluid

Severe Sepsis

Time Zero

StEP-1 By 3 Hours

(15)

BEFORE HOURS ARE UP!

To Be Completed by Hours Of Time Of Presentation:

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,

(16)

StEP-1 By 3 Hours

“Delays in administering all four

guidelines recommendations, even when they did not exceed hours,

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

(17)

3

hr

SEP-1: EARLY MANAGEMENT BUNDLE

Measures & Intervention Required:

 Blood culture before

antibiotics

 Antibiotics

 Fluid resuscitation

 Lactate level

Grady RRT protocol

Severe Sepsis

Time Zero

Our Clock Is One Hour!

1 h

(18)

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 hours

(19)

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

(20)

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

(21)

Combo Therapy

• Choose

o Aminoglycosides or Aztreonam or

Ciprofloxacin

o Cephalosporins, (1st and 2nd Generation) - or –

o Clindamycin - or - Daptomycin - or

-Glycopeptides - or - Linezolid - or - Macrolides

- or – Penicillins

(22)

3

hr 6 h

r.

SEP-1: EARLY MANAGEMENT BUNDLE

Measures & Intervention Required:

 Blood culture before

antibiotics

 Antibiotics

 Fluid resuscitation

 Lactate level

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

Interventions Required:

 Lactate level repeated (If

elevated)

 Vasopressors if necessary

 Optimize fluid

Severe Sepsis

Time Zero

StEP-2 By 6 Hours

1 h

r

(23)

3

hr 6 h

r.

Severe Sepsis

Time Zero

Interventions Required: ALL of Severe Sepsis +

Fluid 30 ml/kg (NO exclusionary criteria)

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

Shock Assessment

Interventions Required: Persistent Hypotension

 Within hour of fluid add VASOPRESSOR

Persistent Hypoperfusion OR Lactate > 4

 Shock Assessment (1 of 2)

(24)

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

(25)

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

(26)

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.

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)

(27)

DURATION OF LOW MAP AND ADVERSE EVENTS

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

0 minutes to minutes to 10 minutes 11 to 20 minutes >20 minutes

A

dj

usted

od

ds

ratio

1 1.5 2.5

Acute kidney injury Cardiac complication Myocardial injury

(28)

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

(29)

To Save Lives

Early fluid resuscitation

Early identification

(30)

And STOP SEPSIS!

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

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

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