My hospital is implementing the Sepsis Lighthouse Solution when we go live with Cerner in July. I learned that in the new system, a SIRS alert occurs when there are 3 (not 2) SIRS criteria present and a sepsis alert occurs when there are 2 SIRS criteria and evidence of organ failure. This is a change from our current protocol of 2 SIRS + suspected infection = sepsis alert and Sepsis Alert + SBP<90 or Lactate>4 = CODE SEPSIS. The architects say these changes were made to avoid alert fatigue, but I am concerned that we will be missing many cases of sepsis if holding alerts until 3 SIRS criteria are met. Do others have experience with these thresholds? I would be interested in hearing others' opinions. Thanks in advance, Rick Rutherford, M.D.Sepsis Task Force ChairVentura County Medical Center
From: [email protected] To: [email protected]; [email protected] Date: Wed, 2 Jan 2013 12:48:57 -0600 CC: [email protected] Subject: Re: [Sepsis Groups] Maternal sepsis with low scvo2 When I have a patient with a low SCVO2 – I Look at a variety of items. I like to start with first the oxygen consumption side – What are her demands that I can help with – basic things like – fever, anxiety, pain, shivering and muscle activity – I try to take care of this and treat this first. Secondly I look at oxygenation – is that adequate? Do we need to increase her Fi02 – is she ventilating appropriately? Then I look at her HGB Is she bleeding – is she anemic? Do we need to transfuse?? Third, I look at Cardiac output – whats the HR and do I need to treat ? Then what is my pre-load, afterload and contractility status to make sure I am giving the appropriate product to the patient whether that be a positive inotrope, vasopressor or fluids. Just my way of looking at all the items that affect SCVO2. Hope this is helpful!! Angela Craig APN,MS,CCNS Clinical Nurse Specialist Intensive Care Unit Cookeville Regional Medical Center 931-783-5035 From: [email protected] [mailto:[email protected]] On Behalf Of Sparling-Broccolo, Erin ARMC-SICU Sent: Wednesday, December 19, 2012 11:16 AM To: [email protected] Cc: Houston, Katrina ARMC-Performance Improvement Subject: Re: [Sepsis Groups] Maternal sepsis with low scvo2 While not an expert, and my realm of experience is generally not in the Maternal-Child realm, I can offer the following thoughts…The key thing is her lactate. If her lactate is normalizing that indicates that oxygenation demands are being met on a cellular level, and even though the extraction is elevated, supply is meeting current demand with anaerobic metabolism resolved (creating and delivering another human being, healing and dealing with sepsis is hard work!!). The arguably empiric administration of PRBCs with normalizing lactate and clinical improvement carries risk that may outweigh the benefits. The big picture should be examined for patient specific factors that would tilt one in favor of transfusion – is she currently on supplemental 02? What is her activity level? Is she on bed rest or ambulating? Is she able to tolerate the increased activity required for discharge and to prevent other complications such as VTE? Is she currently on Iron supplementation and stool softener? Why is her hgb 8.2? What was her CBC baseline – both count and morphology? I did not see mention of whether there was significant bleeding during the C section that accounts for this level, but can it be adequately explained? Any splenomegaly? I see that you mention that she did have thrombocytopenia but it is resolving. I am sure you have considered iatrogenic causes such as HIT or common pharmacologic culprits in the differential. You don’t mention morphology so I am guessing there is no issue there. Erin Sparling Broccolo MSN-Ed RN CCRN Critical Care Clinical Nurse Educator Arrowhead Regional Medical Center Colton, CA [email protected] 909-580-2556 . From: Houston, Katrina ARMC-Performance Improvement Sent: Wednesday, December 19, 2012 8:08 AM To: Fletcher, Annabelle ARMC-Performance Improvement; Sparling-Broccolo, Erin ARMC-SICU Subject: FW: [Sepsis Groups] Maternal sepsis with low scvo2 Hmmm! Wish we could help… From: [email protected] [mailto:[email protected]] On Behalf Of Dr.Sunil T Pandya Sent: Tuesday, December 18, 2012 6:55 PM To: [email protected] Subject: [Sepsis Groups] Maternal sepsis with low scvo2 Hi friends, We have a young lady who had premature rupture of membranes (PROM), had an emergency Cesarean section after 48Hrs, was already on prophylactic antibiotics (IV. Cephazolin) as per the protocol. Intraoperatively developed refractory hypotension / full blown SIRS (Unexplained by low dose spinal), and chorio amnionitis - severe sepsis was suspected / and confirmed (High vag swab at admission revealed Klebsiella growth) considering 48 hrs of PROM. Sepsis profile / CVP line inserted for fluid administration and vasopressors support. Lactate was 4 and SCVO2 was 48%. (Hb-10g). Change of antibiotics as per the cultures and fluids and nor adr / organ supports etc. have helped her and is stabilizing. Her lactate improved and is within normal limits. SCVO2 is still @ 55% and her Hb is 8.2g%. CLinically she is doing good and on soft diet. Blood culture also was positive for klebsiella My question to the the expert is: My fellows were debating whether to give her couple of units of Packed cell transfusion in view of low ScVO2.....I seek you opinion as well - Does she need blood transfusion? She has come out of all organ dysfunctions (Renal / ALI / Low plt) and is asymptomatic and white cell counts are 10800/cumm, Polymorphs - 72%, Bands - 4%! Thanking you in advance! Regards, Sunil ------------ Dr.Sunil T Pandya Hon. Secretary, Association of Obstetric Anaesthesiologists, India (www.aoaindia.com) Hon. Secretary, Society of Obstetric Medicine, India Head, Dept. of Anaesthesia, Pain and Critical Care, Fernandez Hospital (Health care for Women and the Newborn), www.fernandezhospital.com Director, Prerna Anaesthesia and Critical Care Services Pvt Ltd (www.prernaanaesthesia.com) Hyderabad, India. Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. 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