Sepsis 3 – Definitions,

Identification and Management

Barbara Fagan, BScN, MEd, RN, CCNE, CNCC(c)

Faculty, Critical Care Nursing Program

Registered Nurses Professional Development Centre,

Halifax, NS
Declarations
About RNPDC

We are moving to one regulator for all nurses in the province – LPN, RN,
NP (One regulator, one nursing body)
RNPDC receive our funding from NS department of health and wellness
to meet the needs for specialty training in the province
IEN entry – Maritime assessment center
Interprofessional faculty and offer interprofessional programming
We now fall under IPPL umbrella in NSHA

REBRANDING is coming
Little bit about NS/NSHA
Adult ICUs in NSHA
Sepsis Defined/The Global Impact - WHO, 2018

Sepsis arises when the body’s response to any infection injures its own
tissues and organs. If not recognized early and managed promptly, it
can lead to septic shock, multiple organ failure and death.
Sepsis is a global complication of infections in all countries (estimated to
affect 30 million people worldwide yearly/6 million deaths)
Sepsis particularly affects low- and middle-income countries
Sepsis remains a major cause of maternal and neonatal morbidity and
mortality.
The Global Impact of Sepsis - WHO, 2018

Sepsis is frequently underdiagnosed at an early stage when it is still

potentially reversible.
In the community setting, sepsis often presents as the clinical
deterioration of common and preventable infections.
Sepsis also frequently results from infections acquired in health care
settings, which are one of, if not the most frequent adverse events
during care delivery. As these infections are often resistant to
antibiotics, they can rapidly lead to deteriorating clinical conditions.
Canadian Data – CIHI (2016) “Care in Canadian ICUs”
Canadian Sepsis Foundation (2018)
Problem is not new…so who are the key EBP players?
IHI in early 2000s – VAP and CLABSI bundles
ESICM in 2002 Barcelona Declaration (2002):
We have the technology and resources today to treat most conditions
and injuries yet infection, which has been killing people since history
began, still defeats us.”
“Physicians have tried their best to tackle the scourge of sepsis but
without greater resources, education, and awareness, their efforts
can only have limited success.”
-Prof. Graham Ramsay, ESICM President
Barcelona Declaration (2002)

Tackle Sepsis using 5 points:

1. Diagnosis - Facilitate early and accurate diagnosis through the
adoption of one, single, clear definition of sepsis.
2. Treatment - Ensure appropriate and timely use of treatments and
interventions via consistent clinical protocols.
3. Referral - Recognize universally acceptable referral guidelines in all
countries of the world.
4. Education - Provide leadership, support, and information to clinicians
about sepsis management.
5. Counseling - Post-ICU care and counseling for sepsis patients to
ensure continuous quality care by providing a framework for
improving and accelerating access to post-ICU care and counseling
for patients
Who are the other key EBP players?

SCCM in US; American College of Chest Physicians; Canadian Critical

Care Society
Surviving Sepsis Campaign – formed following the Barcelona Declaration;
Published guidelines 2004, 2008, 2012, 2016, 2018 Bundle update…
International Consensus Definitions – 1991, 2001 and latest 2016 (task
force made up of members of SCCM & ESICM)
Sepsis 3 - Objectives

1. Define sepsis and septic shock using the Third

International Consensus Definitions for Sepsis and
Septic Shock (Sepsis-3).
2. Apply qSOFA and SOFA criteria to identify those at
risk outside the ICU and identify those with end-
organ dysfunction.
3. Select and apply best practice management
strategies for patients with sepsis.
Sepsis -3 Definitions (2016)

Sepsis should be defined as life-threatening organ

dysfunction caused by a dysregulated host response
to infection.

For clinical operationalization, organ dysfunction can be represented

by an increase in the Sequential [Sepsis-related] Organ Failure
Assessment (SOFA) score of 2 points or more, which is associated
with an in-hospital mortality greater than 10%.
Sepsis -3 Definitions (2016)

Septic shock should be defined as a subset of sepsis

in which particularly profound circulatory, cellular,
and metabolic abnormalities are associated with a
greater risk of mortality than with sepsis alone.

-patients with septic shock require vasopressors to maintain a mean

arterial pressure of 65mmHg or greater and serum lactate level
greater than 2 mmol/L (>18mg/dL) in the absence of hypovolemia.
This combination (vasopressor support and increased lactate) is
associated with hospital mortality rates greater than 40%.
SOFA criteria

Organ dysfunction can be identified as an acute change in total SOFA

score greater than or equal to 2 points consequent to the infection.
• The baseline SOFA score can be assumed to be zero in patients not
known to have preexisting organ dysfunction.
• A SOFA score of greater than or equal to 2 reflects an overall mortality
risk of approximately10% in a general hospital population with
suspected infection. Even patients presenting with modest
dysfunction can deteriorate further, emphasizing the seriousness of
this condition and the need for prompt and appropriate intervention,
if not already being instituted.
qSOFA
Problems with applying qSOFA (ER perspective)
Case Study

Mr. John Smith, a 72 year old, 80kg male is admitted direct from OR
following abdominal surgery
• Earlier in the day he presented to ER with abdominal pain
• PMedHx - ↑BP, Dyslipidemia, ETOH abuse and a cognitive impairment
• In ER his assessment reveals: drowsy and confused when roused, peripherally cold
and cyanosis; Vitals: T 38.0, HR 129, RR 24 B/P 75/50; abd tense and distended
• I L of crystalloid given for hypotension
• CT abd shows extraluminal gas & feces, perforated sigmoid colon; cultured (blood x
2, urine when foley inserted; unable to obtain sputum) and given broad spectrum
IV antibiotics and then taken immediately to the OR for repair

What is Mr.Smith’s qSOFA score?

Arrival in ICU

• Post Hartmann’s – re-anastamosis and abd washout

• Anesthetized and fully ventilated on FiO2 of .4
• Arterial line and central line in place
• Levophed infusion to support BP
• EBL -500mls – 4L of crystalloid and minimal BP, U/O during case
• Vitals: T- 35.6, HR 120, RR 12 (vent), BP 88/52
• Initial ABGs show pH 7.32, paCO2 28mm Hg, pa02 85mm Hg, HCO3
20 mmol/L, Lactate 3 mmol/L

Think/Pair/Share: What considerations do you need to think

about/data do you need to calculate out SOFA score? What are your
thoughts regarding Mr.Smith’s care? What are the priorities?
Kleinpell, 2017
2016 Surviving Sepsis Guidelines

Sepsis and septic shock are

medical emergencies and we
recommend that treatment and
resuscitation begin immediately.
Best Practice Statement
Source Control

• We recommend that a specific anatomic

diagnosis of infection requiring emergent
source control be identified or excluded as
rapidly as possible in patients with sepsis or
septic shock, and that any required source
control intervention be implemented as soon
as medically and logistically practical after the
diagnosis is made.
(Best Practice Statement).
Antibiotics

• We recommend that administration of IV

antimicrobials be initiated as soon as possible after
recognition and within 1 h for both sepsis and septic
shock.
(strong recommendation, moderate quality of
evidence).
• We recommend empiric broad-spectrum therapy
with one or more antimicrobials to cover all likely
pathogens.
(strong recommendation, moderate quality of
evidence).
Fluid Resuscitation

• We recommend that in the resuscitation from

sepsis-induced hypoperfusion, at least 30ml/kg of
intravenous crystalloid fluid be given within the first
3 hours.
(Strong recommendation; low quality of evidence)

• We recommend that following initial fluid

resuscitation, additional fluids be guided by
frequent reassessment of hemodynamic status.
(Best Practice Statement)
Fluid Therapy

• We recommend crystalloids as the fluid of choice

for initial resuscitation and subsequent intravascular
volume replacement in patients with sepsis and
septic shock
(Strong recommendation, moderate quality of
evidence).

• We suggest using albumin in addition to crystalloids

when patients require substantial amounts of
crystalloids
(weak recommendation, low quality of evidence).
Blood Pressure

We recommend an initial target mean arterial pressure

of 65 mmHg in patients with septic shock requiring
vasopressors.
(Strong recommendation; moderate quality of
evidence)
Vasopressor Therapy

• We recommend norepinephrine as the first choice

vasopressor
(strong recommendation, moderate quality of
evidence).

• We suggest adding either vasopressin (up to 0.03

U/min) or epinephrine to norepinephrine with the
intent of raising MAP to target, or adding
vasopressin (up to 0.03 U/min) to decrease
norepinephrine dosage.
(weak recommendation, low quality of evidence)
If shock is not resolving quickly…

• We recommend further hemodynamic assessment

(such as assessing cardiac function) to determine the
type of shock if the clinical examination does not
lead to a clear diagnosis.
(Best Practice Statement)

• We suggest that dynamic over static variables be

used to predict fluid responsiveness, where
available.
(Weak recommendation; low quality of evidence)
Lactate can help guide resuscitation

• We suggest guiding resuscitation to normalize

lactate in patients with elevated lactate levels as a
marker of tissue hypoperfusion.
(Weak recommendation; low quality of evidence)
Summary of 2016 Guidelines

• Start resuscitation early with source control,

intravenous fluids and antibiotics.
• Frequent assessment of the patients’ volume
status is crucial throughout the resuscitation
period.
• We suggest guiding resuscitation to normalize
lactate in patients with elevated lactate levels
as a marker of tissue hypoperfusion.
User’s Guide to the 2016 Surviving Sepsis Guidelines
User’s Guide to the 2016 Surviving Sepsis Guidelines
Remember our Case Study - Mr. Smith

Data for SOFA?

Considerations for treatment?
Priorities?
Feb 2018 - AJN
March 2018 NEJM - Steroids – ADRENAL study results
July 2014 CCM - Fluids- Balanced vs. Crystalloids

-fluid choice and amount has been very controversial in the literature
-Much in the past was on crystalloids vs. colloids

Debate on how to choose between crystalloids for resuscitation

-RL/Plasmalyte have electrolyte compositions which are more similar to

plasma

Fluid resuscitation with NS → NS +++chloride content and strong ion

difference and has been known to contribute to hyperchloremia and
metabolic acidosis which is associated with undesirable
consequences.

RCTs underway…
June 2018 – CCM Surviving Sepsis Campaign Bundle
update HOUR-1 Bundle (Levy & Rhodes)
The patient’s voice…
Questions?

Feel free to contact me:

[email protected]
References
Canadian Sepsis Foundation (2018). Sepsis. Retrieved from:
https://canadiansepsisfoundation.ca/
Canadian Institute for Healthcare Information (2016). Care in Canadian
ICUs. Ottawa, ON: Author.
Dellinger, R.P, Schorr, C.A. & Levy, M.M. (2017). A users’ guide to the
2016 surviving sepsis guidelines. Critical Care Medicine, 45(3), 381-
385.
Dumont, T., Francis-Frank, L, Chong, J., & Balaan, M.R. (2016). Sepsis
and septic shock: Lingering questions. Critical Care Nursing
Quarterly, 39(1), 3-13.
Fairmann, M. (2016). My story with sepsis. Retrieved from:
https://www.youtube.com/watch?v=mZqG8X6dUoI
Flynn Makic, M. B. & Bridges, E. (2018). Managing sepsis and septic
shock: Current guidelines and definitions. American Journal of
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Howell, M.D., & Davis, A.M. (2017). Management of sepsis and septic
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Kleinpell, R.M., Schorr, C.A, & Balk, R.A. (2016). The new sepsis
definitions: Implications for critical care practitioners. American
Journal of Critical Care, 25(5), 457-464.
References
Levy, M.M. & Rhodes, A. (2018). The surviving sepsis campaign bundle:
2018 Update. Critical Care Medicine, 46(6), 997-100,
Montanaro, N. (2016). Sepsis resuscitation: Consensus and
controversies. Critical Care Nursing Quarterly, 39(1), 58-63.
Raghunathan, K., Shaw, A. Nathanson, B, Sturmer, T., Brookhart, A. …&
Lindenauer, P.K. (2014). Association between choice of IV crystalloid
and in-hospital mortality among critically ill adults with sepsis.
Critical Care Medicine, 42(7), 1585-159.
Rhodes, A., Evans, L.E., Alhazzani, W., Levy, M.M., Antonelli, M. &
Dellinger, R.P. (2017). Surviving Sepsis Campaign: International
Guidelines for Management of Sepsis and Septic Shock: 2016.
Critical Care Medicine, 45(3), 487-552.
Seckel, M.A. (2017). Sepsis-3: The new definitions. Nursing2017
Critical Care, 12(2), 37-43.
Society of Critical Care Medicine (2018). Surviving Sepsis Campaign.
Retrieved from: http://www.survivingsepsis.org/Pages/default.aspx
Venkatesh, B., Finfer, S. Cohen, J. Rajahandari, D. …& Myburg, J. (2018).
Adjunctive glucocorticoid therapy in patients with septic shock.
NEJM, 378(9), 797-808.
World Health Organization (2018). Sepsis. Retrieved from:
http://www.who.int/sepsis/en/