sepsis care bundles.pptx

sepsis care bundles.pptx

1. SEPSIS CARE BUNDLES

2. Sepsis Life threatening organ dysfunction caused by a dysregulated host response to infection 2 features of SIRS plus a suspected or proven infection Modest degree of organ dysfunction when infection is first suspected is a/w in hospital mortality >10%

3. Altered host response to infection leading to organ dysfunction

4. Systemic Inflammatory Response Syndrome (SIRS) 2/4 criteria(1 of which must be abnormal temp/abnormal leukocyte count) 1. Core temperature >38.5°C or <36°C (rectal, bladder, oral or central catheter ) 2. Respiratory rate >2 SD above normal for age or acute need for mechanical ventilation not related to neuromuscular disease or GA

5. 3. Tachycardia: Mean heart rate >2 SD above normal for age in absence of external stimuli,chronic drugs or painful stimuli Unexplained persistent elevation over 0.5-4hr In children <1yr old,persistent bradycardia over 0.5hr(mean heart rate <10 th percentile for age in absence of vagal stimuli, β-blocker drugs or congenital heart disease)

6. 4. Leukocyte count elevated or depressed for age(not secondary to chemotherapy) or >10% immature neutrophil

7. Severe Sepsis Sepsis plus 1 of the following: 1. Cardiovascular organ dysfunction defined as: Despite >40 mL/kg of isotonic IVF in 1 hr: • Hypotension <5 th percentile for age or systolic BP <2 SD below normal for age or • Need for vasoactive drug to maintain BP

8. or Two of the following: • Unexplained metabolic acidosis: base deficit >5mEq/L • Increased arterial lactate: >2 times upper limit of normal • Oliguria:urine output <0.5 mL/kg/hr • Prolonged capillary refill:>5sec • Core-to-peripheral temperature gap: >3°C

9. 2. Acute respiratory distress syndrome as defined by PaO2/FIO2 ratio ≤300 mmHg,bilateral infiltrates on chest radiograph and no evidence of left-sided heart failure or Sepsis plus ≥2 organ dysfunctions (respiratory, renal,neurologic,hematologic or hepatic)

10. Septic Shock 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

11. Sepsis plus cardiovascular organ dysfunction Septic shock can be identified by the presence of: Persisting hypotension requiring vasopressors to maintain MAP >/= 65mmHg Serum lactate levels >2 mmol/L despite adequate volume resuscitation Presence of septic shock increases mortality to 40%

12. IDENTIFICATION OF SEPSIS Sequential organ failure assessment score (SOFA SCORE)

13. Organ failure is assessed by SOFA An increase in total Score >/= 2 above the baseline is indicative Baseline score is assumed to 0 unless the child is known to have pre existing organ dysfunction before the onset of infection Can be used in children with appropriate MAP and creatinine levels

14. Screening for patients with likely hood of sepsis qSOFA score Includes three variables: H:Hypotension A:Altered mentation T:Tachypnea

15. Quick SOFA score >/= 2 should alert the physician that the child is likely to progress to sepsis

16. Bundles are group of “therapies” built around best evidence-based guidelines which when implemented together produce greater benefit in terms of outcome than individual therapeutic interventions Proposed based on holistic principle that whole is greater than sum of its parts

17. HOUR 1 BUNDLE Measure lactate level & re measure lactate if initial value is more than 2 mmol/L Take sample for blood culture before starting antibiotics(if it does not delay initiation of antibiotics unduly) Start broad spectrum antibiotics

18. Start rapid administration of at least 30ml/kg of crystalloids for patients with hypotension or lactate >4mmol/L Start vasopressors if hypotensive,during or after fluid administration to maintain a MAP >65 mmHg

19. Measure lactate levels Indirect measure of tissue perfusion Increased S.lactate levels - tissue hypoxia Also increased in excessive beta adrenergic stimulation-accelerated aerobic glycolysis

20. If initial lactate is elevated >2mmol/L-re measure in 2 to 4 hrs Lactate level decrease once perfusion improves-at a rate of 1mmol/hr-good tissue perfusion

21. Obtain blood cultures prior to starting antibiotics Administer broad spectrum antibiotics Empiric broad spectrum antibiotics with one or more IV antimicrobials to cover all likely pathogens should be started immediately Step down antibiotics once organism is identified Antibiotics should be discontinued once a decision is made that the patient has no infection

22. Administer IV fluid For stabilisation of sepsis induced tissue hypoperfusion Begin immediately and completed in 3 hrs Minimum of 30ml/kg of IV crystalloids

23. Apply vasopressors If BP is not restored after initial fluid resuscitation,vasopressors should be started within 1 hour to maintain MAP >/= 65

24. ACCM Bundles in management of septic shock Recognition bundle Resuscitation bundle Stabilisation bundle Performance bundle

25. RECOGNITION BUNDLE 1.Trigger tool-Tool for rapid identification of patients likely to have sepsis Vital signs,physical examination,at risk population 2.Rapid clinician assessment within 15 mts for any patient that is identified by trigger tool 3.Activation of sepsis resuscitation bundle within 15mts in pts with suspicion of septic shock

26. RESUSCITATION BUNDLE IV access(3 try) or intraosseous line within 5 mts Appropriate fluid resuscitation initiated within 30 mts Initiation of broad spectrum antibiotics within 60 mts Blood culture if no delay in antibiotic administration Appropriate use of peripheral or central ionotrope within 60 mts

27. STABILIZATION BUNDLE 1.Multimodal monitoring to guide fluid,hormonal and cardiovascular therapies to attain normal MAP-CVP for age & ScvO2 >70% 2.Administration of appropriate antibiotic therapy and source control

28. PERFORMANCE BUNDLE Identification of barriers to attaining above mentioned bundles 1.Measurement and adherance as well as achievement of goals & individual components 2.Assessment of barriers as well as unintended consequences such as inappropriate antibiotic duration or use of excessive fluids for resuscitation

29. Capillary refill of ≤2 sec Normal blood pressure for age Normal pulse Warm extremities Urine output >1mL/kg/hr Normal mental status ScvO2 saturation ≥70% Cardiac index between 3.3 and 6.0 L/min/m2

30. THANK YOU

31. BUNDLE CARE FOR INFECTION PREVENTION IN NICU

32. PERIPHERAL LINE BUNDLE (insertion bundle) A.Before procedure Verify order for peripheral IV access Check for allergies (latex, plaster…) Ensure the skill of the inserter Correctly identify the patient Verbal consent from caretaker

33. B.Setup for procedure Gather all the appropriate equipment Wash hands for 2 minutes with soap & water, dry and wear gloves

34. Use appropriate instruments to identify vein in difficult situation Select the site. Avoid areas near local infections, previous venipuncture site

35. C.Procedure Apply tourniquet proximal (at least 2 inches)to site of insertion A pply warm pack/ warm the area so that vessels are visualized easily Use aseptic non-touch technique (hand hygiene, correct glove use, key site protection, non-touch technique, key part disinfection and aseptic field management) Clean the area( 2” around the site of insertion) for at least 30 seconds and allow it to dry After cleaning area the site should not be touched with hands Drape if needed (put the limb on a sterile paper/ towel) Successfully perform venipuncture using properly sized devise Verify placement by aspirating blood and flushing

36. Secure the catheter using adhesive tapes, making sure that the catheter tip is not covered It is preferable to avoid the movement of the joint by applying splint If 2 attempts fail, get help from experts

37. D.Documentation Label with date, time and size of catheter used Enter the date, time, size of catheter and name of inserter in case sheet

38. Maintenance of peripheral intravenous cannula (PIVC) device (Maintenance bundle) Daily evaluation for catheter position patency/ occlusion limb symmetry signs of phlebitis (erythema, tenderness, pain or swelling) pressure sores due to cannula hub infiltration/ extravasation

39. PIVC devi c es should be changed before 96 hrs of insertion/ earlier if there is complication or it is needed no more. Flushing of PIVC Use aseptic non-touch technique clean access port with chlorhexidine and alcohol for 15-30 s allow it to dry prior to accessing the system Assessment of PIVC dressings and splints look whether it is clean, wet/ dry, splint tapes are loose/ too tight

40. If PIVC is used intermittently only for administration of medicines Flush the cannula prior to infusion/ every 8hrs with 0.5-2ml normal saline with a 5-10 ml syringe Flushing is done in pulsatile manner (push-pause motion) D one immediately after placement of cannula, prior to and after infusion of drugs/ fluids and prior to and after drawing blood

41. Change of PIVC dressings and securement of cannula Transparent film dressing (tegaderm)/sterile film dressing for cover ing the insertion site Dressings kept dry, clean and intact Use IV board/ splint to secure PIVC, ensuring the limbs and digits are in neutral position Can keep a sterile cotton ball beneath the hub of cannula to avoid pressure sores

42. If wet/ soiled, carefully remove the old dressing holding the cannula in place all the time Inspect the insertion site and hub of cannula for signs of inflammation If ok , prepare the skin with 2% alcohol +chlorhexidine solution and allow it to dry

43. Documentation All observations and actions taken documented with date and time. Name of the staff also documented

44. Removal bundle: No PIVC should be kept > 72 hrs. Do not keep PIVC unnecessarily or in anticipation. If any complications like phlebitis, extravasation , promptly remove cannula and manage the site as per the protocol. If no local problem at insertion site press the site for 3-5 minutes to prevent bleeding Never apply plaster at the site. Donot put n ew cannula at the same site/ nearby site for the next few days

45. C hang ing of extension sets: Extension sets has to be changed when the access devise has changed/ or if found contaminated/ broken Extension sets are to be primed using aseptic non-touch technique before attaching to cannula. After flushing/ administration of drugs, use positive pressure clamping technique.

46. CLABSI BUNDLE Use appropriate hand hygiene Use chlorhexidine for skin preparation Use full barrier precautions during catheter insertion Avoid femoral catheter Remove unnecessary catheters. Avoid TPN/ LIPID infusion via central catheter Avoid multi- lumen catheter Scrubbing the hub of catheter before infusion/ Q8H

47. VAP BUNDLE Hand hygiene Maintain asepsis by wearing mask, gown, gloves while intubation ET should stay in sterile pack till using, tip should not be touched Fix ET well to prevent accidental extubation and reduce number of reintubation ET kept horizontal to prevent the condensed water entering in to the lung

48. Use auto fill technique to fill humidification chamber with distilled water Change the humidifier every day Head end should be elevated 30 deg wear sterile gloves for suction, first tracheal suction and then mouth discard suction catheter after single use

49. ET suction is done only when it is necessary. Always use inline suction. Avoid saline instillation for removal of secretion in ET. 2 personal should be available for suction Oral suction as and when necessary Clean the mouth regularly Use colostrum rub to cheek to prevent colonization Remove ET at the earliest

50. References: Nelson textbook of paediatrics edition 21 Surviving sepsis campaign international guidelines for management of septic shock and sepsis associated organ dysfunction in children-published in 2020 Infection control in NICU suitable for a peripheral newborn care-new indian journal of paediatrics,volume 5