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NATIONAL SEPSIS AWARENESS MONTH PRESENTED BY TEXAS PILLAR HEALTHCARE SPEAKER: TREN ST. JULIEN RN, BSN AMERICAN NEPHROLOGY NURSES ASSOCIATION MEMBER PERITONEAL DIALYSIS INTERNATIONAL MEMBER SEPSIS ALLIANCE LINK


NATIONAL SEPSIS AWARENESS MONTH UTILIZING HOME INFUSION THERAPY TO PREVENT SEPSIS SPEAKER TREN ST. JULIEN RN, BSN


NATIONAL SEPSIS AND SHOCK AWARENESS MONTH

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HRES 342 IH 113th CONGRESS 1st Session H. RES. 342 Expressing support for the designation of September 2013 as ‘National Sepsis and Septic Shock Awareness Month’. IN THE HOUSE OF REPRESENTATIVES September 12, 2013 Mr. FITZPATRICK submitted the following resolution; which was referred to the Committee on Oversight and Government Reform RESOLUTION Expressing support for the designation of September 2013 as ‘National Sepsis and Septic Shock Awareness Month’. Whereas sepsis is a medical condition that occurs due to an immune response to infection; Whereas the released immune chemicals into the blood to fight infection can cause impaired blood flow, which injures the body’s organs; Whereas in severe cases blood pressure drops, the heart weakens, and septic shock can occur, exposing the patient to multiple organ failure which can lead to death; Whereas sepsis is a serious medical condition and a leading cause of death; Whereas about 750,000 people in the United States are infected by sepsis annually; Whereas the National Institute of General Medical Sciences at the National Institutes of Health has estimated that between 28 and 50 percent of people infected die, attributing to more United States deaths than prostate cancer, breast cancer, and AIDS combined; Whereas it is estimated that approximately $17,000,000,000 annually is spent combating sepsis in the United States; Whereas the number of sepsis related deaths is currently on the rise in the United States; Whereas many symptoms of sepsis mimic other conditions, making sepsis difficult to diagnose; and Whereas September 2013 would be an appropriate month to designate as ‘National Sepsis and Septic Shock Awareness Month’ to raise awareness and encourage the education of patients, families, and health care professionals on the seriousness of early detection as the key to survival: Now, therefore, be it Resolved, That the House of Representative supports the designation of ‘National Sepsis and Septic Shock Awareness Month’.


SPESIS AWARENESS MONTH SEPTEMBER 2013


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Definition The term systemic inflammatory response syndrome (SIRS) was coined in 1992 by a panel composed of members of the American College of Chest Physicians and Society of Critical Care Medicine. They convened to develop consensus definitions of critical illness for the purposes of clinical trial design. SIRS describes the host response to a critical illness of infectious or noninfectious cause, such as burns, trauma, and pancreatitis. More specific definitions are as follows: Sepsis is SIRS resulting from a presumed or known site of infection. Severe sepsis is sepsis with an acute associated organ failure. Septic shock, a subset of severe sepsis, is defined as a persistently low mean arterial blood pressure despite adequate fluid resuscitation. Refractory septic shock is a persistently low mean arterial blood pressure despite vasopressor therapy and adequate fluid resuscitation.1 SIRS can be readily diagnosed at the bedside by the presence of at least two of the following four signs: body temperature alterations (hyperthermia or hypothermia), tachycardia, tachypnea, and changes in white blood cell count (leukocytosis or leukopenia).


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Prevalence and incidence Sepsis is the leading cause of death in noncoronary intensive care units (ICUs) and the 10th leading cause of death in the United States overall. The incidence of severe sepsis in the United States is between 650,000 and 750,000 cases.2,3 More than 70% of these patients have underlying comorbidities and more than 60% of these cases occur in those aged 65 years and older. When patients with human immunodeficiency virus are excluded, the incidence of sepsis in men and women is similar. A greater number of sepsis cases are caused by infection with gram-positive organisms than gramnegative organisms, and fungal infections now account for 6% of cases. After adjusting for population size, the annualized incidence of sepsis is increasing by 8%. The incidence of severe sepsis is increasing greatest in older adults and diverse populations. The rise in the number of cases is believed to be caused by the increased use of invasive procedures and immunosuppressive drugs, chemotherapy, transplantation, and prosthetic implants and devices, as well as the increasing problem of antimicrobial resistance.


Pathophysiology Inflammatory Cascade Severe sepsis can occur as a result of infection at any body site, including the lungs, abdomen, skin or soft tissue, or urinary tract and as a result of a primary blood stream infection, such as in meningococcemia. Bacteria are the pathogens most commonly associated with the development of sepsis, although fungi, viruses, and parasites can cause sepsis. The pathophysiology of sepsis can be initiated by the outer membrane component of gram-negative organisms (e.g., lipopolysaccharide [LPS], lipid A, endotoxin) or gram-positive organisms (e.g., lipoteichoic acid, peptidoglycan), as well as fungal, viral, and parasitic components (Fig. 1). Signaling by these mediators occurs via a family of transmembrane receptors known as Toll-like receptors. Within the monocyte, nuclear factor-κB (NF-κB), is activated, which leads to the production of proinflammatory cytokines, tumor necrosis factor α (TNF-α), and interleukin 1 (IL-1). TNF-α and IL-1 lead to the production of toxic downstream mediators, including prostaglandins, leukotrienes, platelet-activating factor, and phospholipase A2. These mediators damage the endothelial lining, leading to increased capillary leakage.4 Furthermore, these cytokines lead to the production of adhesion molecules on endothelial cells and neutrophils. Neutrophilic endothelial interaction leads to further endothelial injury through the release of the neutrophil components. Finally, activated neutrophils release nitric oxide, a potent vasodilator that leads to septic shock.


• Signs and symptoms • Clinical signs that may lead the physician to consider sepsis in the differential diagnosis include fever or hypothermia, unexplained tachycardia, unexplained tachypnea, signs of peripheral vasodilation, unexplained shock, and unexplained mental status changes. Hemodynamic measurements that suggest septic shock are an increased cardiac output, with a low systemic vascular resistance. Abnormalities of the complete blood count (CBC), laboratory test results, clotting factors, and acute-phase reactants might indicate sepsis ( Table 1). • • •


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Appropriate Antimicrobial Treatment Many clinical studies have demonstrated a twofold increase in mortality caused by sepsis when inappropriate antimicrobial therapy is given. More recent animal and human studies have demonstrated an incremental but statistically significant increase in mortality with each hour delay in the administration of appropriate antibiotic therapy from the onset of septic shock.19 When the clinician encounters a patient with severe sepsis, the site of infection and causative organism(s) often are unknown. Empirical antibiotics must be given in these cases. Appropriate empirical antimicrobial therapy must be guided by the knowledge of the most common sites of infection and the most common infecting organisms. A clinical trial of patients with severe sepsis has revealed that the lungs are the most common sites of infection, followed by the abdomen and urinary tract.20 In terms of pathogen type, gram-positive organisms cause sepsis slightly more often than gram-negative organisms; fungal organisms account for approximately 6% of cases.3 The most common gram-positive organisms are Staphylococcus aureus and Streptococcus pneumoniae, and the most common gram-negative organisms are Escherichia coli, Klebsiella spp., Pseudomonas spp., and Enterobacter spp.20 Samples for blood cultures should be taken from a percutaneous site and from any intravascular catheters. Samples for Gram staining and culture should be taken from suspected sites of infection. Table 2 indicates appropriate empirical antibiotic choices by site of infection.


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Glycemic Control Tight control of the blood glucose level during sepsis might be expected to decrease the rate of infectious complications and improve outcomes in patients with sepsis. In a clinical trial conducted in a surgical ICU predominantly in patients following cardiac surgery, maintaining the blood glucose level below 110 mg/dL was associated with improved survival, fewer blood stream infections, shorter ICU stays, and fewer episodes of acute renal failure compared with a group in whom the glucose level was maintained between 180 and 200 mg/dL.37 A second study completed in the medical ICU showed a mortality benefit with tighter glycemic control only in patients with stays in the ICU of 3 days or longer.38 A threshold glucose level of 145 mg/dL was associated with improved mortality in a prospective observational study.39 A German trial (VISEP) was stopped when mortality was not improved in the tight glycemic control arm and more hypoglycemic events were observed.35 Current data suggest targeting a blood glucose level of no lower than 150 mg/dL in a critically ill patient.


NATIONAL SEPSIS AWARENESS Antibiotics In severe sepsis, broad spectrum antibiotics are recommended within 1 hour of making the diagnosis. For every hour delay in the administration there is an associated 6% rise in mortality. Antibiotic regimens should be reassessed daily and narrowed if appropriate. Duration of treatment is typically 7–10 days with the type of antibiotic used directed by the results of cultures.

Blood culture bottles: orange label for anaerobes, blue label for aerobes, and yellow label for pediatrics


NATIONAL SEPSIS AWARENESS MONTH

http://www.sccm.org/Documents/SSC-Guidelines.pdf


NATIONAL SEPSIS AWARENESS MONTH 2013 GUIDELINES CRITICAL CARE MEDICINE JOURNAL


NATIONAL SEPSIS AWARENESS MONTH


NATIONAL SEPSIS AWARENESS MONTH EARLY DETECTION IS THE KEY


NATIONAL SEPSIS AWARENESS MONTH THE BENEFITS OF HOME EMPIRICAL THERAPY AND SEPSIS PREVENTION: • BLOOD CULTURES, • PEAK AND TROUGH LEVELS, • 24 HR LAB RESULTS, • MONITORING CHRONIC INFECTIONS, • SEPSIS DETECTION, PREVENTION, MONITORING TO ALERT PHYSICIAN AND MEDICAL TEAM


NATIONAL SEPSIS AWARENESS MONTH

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