instructor-jaime.hannans – Page 7 – CI Keys

Sepsis Bundles applied in MICU

October 28, 2015/in /by Kelsey Lester

The Surviving Sepsis Campaign was designed to create a reliable system to take care of patients with severe sepsis. It is then broken down into “Bundles” to simplify the steps in care. Each hospital can individualize their protocol but it has to have the basics of the bundles.

Bundle one needs to be done within 3 hours. This is usually done in the emergency room.

1. Measure lactate level

2. Obtain blood cultures prior to administration of antibiotics

3. Administer broad spectrum antibiotics

4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L

Bundle 2 needs to be done within 6 hours.

5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg

6. In the event of persistent hypotension after initial fluid administration (MAP<65 mmHg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table1.

7. Re-measure lactate if initial lactate elevated.

To evaluate tissue profusion and volume assessment there are two recommended options.

EITHER:

Repeat focused exam (after initial fluid resuscitation) by licensed independent

practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.

OR TWO OF THE FOLLOWING:

• Measure CVP

• Measure ScvO2

• Bedside cardiovascular ultrasound

• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

I had a patient in the MICU with suspected sepsis and even 24 hours her lactate levels were being measured. She had cultured performed in ER and was being administer broad band abx. We were monitoring her MAP >65 and she had received vasopressors prior to ICU placement. We did give her 2 500ml bolus which increased her pressure and reduced her HR. We performed focus exams every 4 hours and continually monitored her CVP and ScvO2. I didn’t look at the Cottage Hospital sepsis protocol but compared to the Surviving sepsis Protocol we were following the recommendations.

Sepsis Protocol

October 27, 2015/in /by Carlangelo Llanos

In Cottage Hospital, when a pt presents with signs and symptoms of sepsis, a policy called SLAY SEPSIS Resucitation protocol is in placed for the healthcare team to follow, especially in the ED. The acronym stands for:

Sepsis

Lactate/Labs

Activate team/Antibiotics

Yell for fluids

Straight to Critical Care

Early goal directed tx

Pressors

ScVO2 Monitoring

Insulin

Source Control/Steroids

The main steps are to initiate severe sepsis or septic shock order set. Then supplemental O2 or intubation for mechanical ventilation must be done. Lastly central line or pulmonary artery catheter placement must be accomplished for ScvO2 and SvO2 monitoring.The rest of the tx will then be based on the pt’s CVP, MAP, ScVO2/SvO2 values.Lastly, per the recommended initial empiric abx therapy for pts with severe sepsis and shock protocol, the type of antibiotics used will depend where the suspected source of infection is located.

Reference:

Cottage Health (n.d.). SLAY SEPSIS Resuscitation Protocol. Unpublished Internal Document.

Cottage Health (n.d.). Recommended Initial Empiric Antibiotic Therapy for Patients with Severe Sepsis and Septic Shock. Unpublished Internal Document.

End of Life Care

October 27, 2015/in /by Breehan Yohe-mellor

End of life care is a subject that is difficult for me to ponder. Although I know that death will certainly be part of my career as a nurse, I have never been one of those people who speak glibly about death. I have always seen it as a very serious and rather frightening topic.

The few times I have pondered the possibility of my own death, I would want my husband to be the person to make decisions for me. I know that he and my parents and siblings are close and would work together to make the best decision for my well-being. Being a young adult, I would want everything possible done to keep me going as long as possible and I know that my husband and family members would certainly agree to that.

I haven’t had any discussions about this topic with my family members except to tell them that I would never want to be cremated, I find the thought of being burned after death rather grotesque. Other than that, my family and I don’t discuss my after-death wishes, mainly because they do not expect to be around for that time and because I have not made any advance directives. As stated before, it’s not a topic I relish talking or thinking about. Thinking more about it, I suppose I should make one despite being 29 years old. I do participate in sports and activities such as horseback riding that could potentially cause harm and/or fatalities. It’s just very hard to think about.

My peers are of a similar mindset due to our age and general good health. I do think culture plays a role here. In this affluent town here in the U.S., we expect to live long healthy lives. If we are seriously injured, we expect to survive thanks to the healthcare system here.

I found an article from the UK’s The Telegraph that reflects my attitude. It states that more than half of Brits in relationships don’t know their partner’s end of life wishes, which interestingly enough, was something that was openly talked about in the Victorian era. This makes sense to me because back then, people were only expected to live into their 40s.

As the author notes, more open discussions about death are needed. This could inspire more people to sign up for things such as organ donation and assist those whoare still in the living world .

Sepsis Protocols and Guidelines

October 27, 2015/in /by Maryna Tarasenko

According to the article “Early goal-directed resuscitation of patients with septic shock: urrent evidence and future directions,” central goal in the treatment of septic shock is the maintenance of adequate tissue perfusion with hemodynamic support, which includes intravenous fluid resuscitation, administration of vasopressors, inotropes, and packed red blood cells (Gupta et al., 2015). Early administration of antibiotics is also recommended. However, the authors state that obtaining at least two blood cultures prior to initiation of antibiotics is required. The authors pointed out to the evidence showing that each hour delay in the administration of antibiotic that is appropriate for the pathogen is associated with a 7.6 % increase in mortality (Gupta et al., 2015). Early goal directed therapy is still a widely accepted strategy, but the latest research showed that this policy does not significantly decrease mortality in patients with septic shock compared with usual care (Gupta et al., 2015). As a part of this approach, during the first 6 hours of septic shock, the patient needs to get a central venous catheter with an oximetric port for continuous monitoring of central venous pressure (CVP) and central venous oxygen saturation (ScvO2). Resuscitation with intravenous fluids, vasopressors, and packed red blood cells is required and titrated to specific parameters (Gupta et al., 2015).

Another article suggests that the most important intervention is the early bed site assessment of hemodynamic parameters and cardiac biomarkers (Sasko, 2015). Aggressive hemodynamic treatment has been shown to increase the survival of patients in septic shock (Sasko, 2015). The authors emphasized that early recognition, control of the source as well as effective therapy with antibiotics and hemodynamic stabilization are the most important cornerstones of the sepsis therapy (Sasko, 2015).

References

Gupta, R., Hartigan, S., Kashiouris, M., Sessler, C., & Bearman, G. (2015). Early goal-directed resuscitation of patients with septic shock: Current evidence and future directions. Critical Care, 19(286), 1-10. DOI 10.1186/s13054-015-1011-9

Sasko, B., Butz, T., Prull, M., Lieberton, J., Christ, M., & Trappe, H. (2015). Earliest bedside assessment of hemodynamic parameters and cardiac biomarkers: Their role as predictors of adverse outcome in patients with septic shock. International Journal of Medical Sciences, 12(9), 680-688. doi:10.7150/ijms.11720

Protected: Sepsis Protocols // Santa Barbara Cottage Hospital

October 27, 2015/in /by Jessica Braziel

Protected: End of Life Care

October 25, 2015/in /by Jaime Hannans

Protected: End-of-life Care

October 25, 2015/in /by Tracy Westcott

Surviving Sepsis Campaign Bundles

October 25, 2015/in /by Tracy Westcott

In order to contribute to our understanding of sepsis management, I searched sepsis protocols and found the “Surviving Sepsis Campaign Bundles” through the Centers for Disease Control and Prevention website.

The Surviving Sepsis Campaign Bundles include:

To be completed within 3 hours:

Measure lactate level
Obtain blood cultures prior to administration of antibiotics
Administer broad spectrum antibiotics
Administer 30 mL/kg crystalloid for hypotension or lactate greater or equal to 4 mmol/L

To be completed within 6 hours:

Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP greater or equal to 65 mm Hg
In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was greater or equal to 4 mmol/L, re-assess volume status and tissue perfusion and document findings
Re-measure lactate if initial lactate was elevated

Please review video at:

http://www.medscape.com/viewarticle/831158

References

Levy, M. (2014). Surviving sepsis campaign: The takeaways. Retrieved from www.medscape.com/viewarticle/831158

End Of Life Care

October 25, 2015/in /by Jaime Hannans

End of Life Care

Ever since the death of my sister I found it very hard to talk about death of even think about it. Because talking about something makes it real and gives it power. For the longest time I spoke only of life with death not a topic for conversations. Then the most amazing thing in my life happened. My beautiful amazing son was born. The epitome of life, love and compassion. Then when he turned 4 he asked. “Pappa does everything die”. This forced me to confront the issue, talk about it and think about it. So I decided I will face death but on my terms. So our family had a conversation about, end of life wishes, DNR, what procedures can be done. We even spoke about who may be in the room when procedures like CPR and intubation is done. Even when life support could be turned of. This again really hammered home for me how I wanted to spare my family the sadness of seeing all these procedures done to me, and that only the medical staff may be in the room. I have seen CPR done and have done it myself with family in the room and I could see how seeing this brought them anguish and pain. It was a relief to be able to voice my wishes and hear my loved ones wishes. And it turns out we feel the same way. It was a cathartic moment to realize a loved one will make sure my wishes are adhered to

End-of-Life

October 25, 2015/in /by Maryna Tarasenko

End of life care is a very complicated topic. When I get older or become very sick, I will make sure to get a DNR status. I would like to die peacefully and naturally without any attempts to prolong my life for a short time. It seems that multiple resuscitation attempts can make the end of life a much more traumatic experience for me as well as for my family members. I know it is important to take care of this issue ahead of time, but in case I am not capable of making my own decisions, I would like one of my children or my husband to do it for me. My family feels the same way. They expressed a desire not to continue life support, if there is no hope for recovery and/or they are in a vegetative state. I did not include my younger son into this conversation. I don’t think he is ready to discuss this topic and he gets very emotional.

I think it is very important to provide comprehensive information to the patients and talk about their end-of-life care. According to a study conducted in 2015, patients who have end-of-life conversations with their physicians are “less likely to experience physical distress at life’s end, less likely to undergo high-intensity interventions, less likely to die in the Intensive Care Unit, more likely to receive outpatient hospice care and be referred to hospice earlier” (Periyakoil, Neri, & Kraemer). The authors identified six barriers (reported by health care providers) to the effective end-of-life conversations with diverse patients.

Barrier 1: Language and medical interpretation issues

“Language barrier, inability to communicate with patient/family and ensure they understand the discussion.”
“Inherent language barrier – medical terms are difficult enough for fluent speakers.”
“It is hard to talk about sensitive topics through an interpreter.”

Barrier 2: Patient/ family religious and spiritual beliefs about death and dying

“Religious cultural values may lead people to prefer life-sustaining treatments that we may see as futile.”
“Reconciling religious ‘obstructions’ to a DNR status.”
“Discussions of God and afterlife beliefs.”

Barrier 3: Doctors’ ignorance of patients’ cultural beliefs, values and practices

“Doctors not understanding the cultural values surrounding end-of-life care for a patient with different ethnic/religious background.”
“Cultural norms that differ from my own causing me to inadvertently offend the patient or his/her family.”
“Not knowing how to discuss goals in a way that makes sense to someone with different views about death based on different beliefs about spirituality and afterlife.”

Barrier 4: Cultural differences in truth handling and decision making

“In some cultures, patients may not want their diagnoses/prognoses discussed with them directly and will instead appoint a family member as surrogate decision maker. It can become difficult however, to be sure that that family member is acting in the best interest of the patient and acting with the patient’s preferences in mind vs. their own.”
“Eliciting the personal wishes of a female from a culture in which men make all the decisions can be difficult.”
“I think it’s fair to say that some cultures conversations about death as something to be avoided at all costs, which is not necessarily how I, as a health care provider, feel about it.”

Barrier 5: Patient/family’s limited health literacy

“Certain medical terms may be difficult to explain in a way the patient can understand.”
“They may not be used to the health system they find themselves in and it may be overlooked that they lack what we would consider common knowledge.”
“Incomplete understanding of what resources/therapies that can be versus should be provided for a patient.”
“Misunderstanding what is described by resuscitation, thinking it means we are giving up completely on treatment.”

Barrier 6: Patient/family’s mistrust of doctors and the health care system

“Mistrust/misunderstanding of the motivations of the medical community”
“Patients may believe that care is being “withdrawn” from their loved one because of racism.”
“Certain cultures lack trust in the medical profession, do not believe physicians have their best interests at heart.”

It is important for the nurses to be aware of these barriers and facilitate the end-of-life conversations. Having comprehensive information can help the patients as well as their family members make reasonable decisions and avoid traumatic experiences.

References

Periyakoil, V., Neri, E., & Kraemer, H. (2015). No easy talk: A mixed methods study of doctor reported barriers to conducting effective end-of-life conversations with diverse patients. PLoS ONE, 10(4), 1-13. DOI:10.1371/journal.pone.012232

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