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Hello everyone. My name is Brenda Shelton, and I'm a Clinical Nurse Specialist at the Johns Hopkins Cancer Center in Baltimore Maryland. I'm here today to talk to you about, "What's up, what's down, and identifying signs of sepsis." As well, I'm going to address the challenges of implementing the sepsis core measure in oncology. Now, as you know, sepsis infection is one of the most common complications that occurs with patients, both during the treatment and even outside of a treatment related regimen. It is the most common cause of non-malignant death in all patients with cancer. So, what I'm going to talk to you a little bit about is, what the evidence suggests is important.
There was a group called the Surviving Sepsis Campaign that first convened in 1992 and set forth some recommendations for identifying sepsis. The definitions that we are operating by are, systemic inflammatory response syndrome, or SIRS, which is two or more of the following symptoms. A temperature greater than 38.3 or less than 36, heart rate greater than 90, a respiratory rate greater than 20, a white count greater than 12,000 or less than 4,000, or more than 10% bands. If you pair two of those criteria along with a probable suspicion or high risk for infection, this is really termed, "Sepsis". It doesn't have to be a confirmed infection at all.
Severe sepsis is that level where you are moving into organ dysfunction, and signs of then organ dysfunction are defined as, "Altered mental status, decreased urine output, thrombocytopenia without another cause, a lactate greater than two, again, hypotension prior to any fluid resuscitation." Septic shock is defined as, "a hypotension or an elevated lactate above four in the face of already having given fluids." These definitions were already set forth by the Surviving Sepsis Campaign, and when we really looked at all the literature, these are the guidelines followed by 38 countries and a hundred and some organizations.
These are the premise for which most of us operate on our best practices in our institutions. They also are the basis in which the sepsis core measure criteria were developed in 2015. So, you think about this and you're like, "Well, where does neutropenic fever fit in because, that's what I'm used to using?" And if you think about it, we don't even really use a 38.3 as a cutoff point. Many of us are thinking of a temperature greater than 38.0 for two times within an hour but, when you add those SIRS criteria along with the fact that the patient is in neutropenic, and then neutropenic fever actually falls in as sepsis.
When we think about sepsis, we think, "Oh, that's worse than SIRS, and that's worse than febrile neutropenia." So, we should be thinking, potentially, one step away from severe sepsis. The basic premise of Surviving Sepsis guidelines are to have a process in which you screen patients for possible sepsis, you evaluate the potential risk for infection and then you implement some early diagnostic test to identify whether the patient is infected, you seek to identify a source and decide if you are going to administer antimicrobials, all at the same time, ensuring organ profusion.
This little circle goes on and on, and around in circles so that you're continuously always screening for new signs and symptoms of worsening sepsis. Now, you might say, "Oh, that's an awful lot. That's an awful lot to remember." In fact, in the actual presentation, I talk about three hour recommendations, six hour recommendations, and 24 hour recommendations. The reality is, all you have to do, according to the landmark study by Rivers in 2001, is just do this as best you can 37% of the time. If you just accomplish 37% of all the expectations, you can reduce mortality.
This was mirrored in a study at MD Anderson. So, I guess I want to reinforce that, it is that defined process that helps you, make sure you don't miss patients, that you can really influence outcomes. The core measure was built on all of this, and this began in 2015. The intent was to mirror the recommendations, although they don't exactly match them. So, there are a few differences. They don't recommend central lines and they give you a three hour window to accomplish antimicrobials. Whereas, the initial guidelines suggested within the first hour.
This core measure, I'm sure many of you are experiencing in your own hospital, is going to eventually be linked to reimbursement but, it's not yet reported data because, as a country, we're doing so poorly at doing this all of the time. The largest threat to implementation of the core measure is recognizing the septic patient early. But the problem is, oncology patients are gonna trigger the sepsis core measure almost 50% of the time. We probably only need a revised screening process that's very specific to our patients, and the full presentation gives you a little bit of an idea of what I would suggest this might be.
The other thing is, as I mentioned, the core measure only expects us to give antimicrobials within three hours but in fact, we know the data says, that if you give an antibiotic in 60 minutes, you have a better outcome. In fact, for every hour after the first hour that you don't give that antibiotic, then you're going to have an increased mortality of 7.6% higher. So, this is a nice slide that gives you a synopsis of the expected core measure requirements, as well as Surviving Sepsis Campaign's suggestions. You see drawing blood cultures and lactate early on, deciding on antimicrobials, giving broad spectrum antimicrobials, giving a full 30 milliliters per kilogram of crystalloid fluids if the patient is hypotensive, repeating your lactate when elevated, and administering vasopressors if the patient is persistently hypoperfused.
The key takeaways from the entire presentation are that, time zero starts at the time you recognize this patient can be infected. That means, for all of you that work outpatient, that's you. That means, for all of us that work inpatient, that's the minute they hit the door, not when the doctor sees them. Screening for sepsis can aid early recognition and we know that timely interventions can reduce mortality. The key takeaways are that you recognize these key interventions, you act on them quickly, and you're getting blood lactate blood cultures, you're giving IV fluids as appropriate, and antimicrobials as quickly as you can after prescription.
In summary, what I think I'd like to have them take home is that there's some very key evidence based practice interventions to guide our sepsis management, and they expand beyond the febrile neutropenia literature. For more information on all of this, you're welcomed to look at the full presentation. In there, you have also an email. You can contact me with further questions.