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Vol. 23, No. 4, APRIL 2006


Practice Alert: Severe Sepsis

The goal of the AACN Practice Alerts is to help nurses and other healthcare practitioners carry their bold voices to the bedside to directly impact patient care. Practice Alerts are directives from AACN that are supported by authoritative evidence to ensure excellence in practice and a safe and humane work environment.

Expected Practice:

• Assess all patients and immediately notify physician when a patient presents with risk factors for sepsis, which includes documented or suspected infection and 2 or more of the following SIRS criteria.

o Heart rate > 90 beats per minute
o Temperature < 36 C (96.8 F) or > 38 C (100.4 F)
o Respiratory rate > 20 breaths per minute or PaCO2 <32mm Hg or mechanical ventilation
o White blood cell count > 12,000/mm3 or < 4000mm3 or <10% mature neutrophils
• Obtain serum lactate measurements.
• Obtain blood cultures as well as cultures from all potential sites of infection prior to initiating broad-spectrum antibiotics.
o Evaluate for and remove other potential sources of infection (ie, obviously infected invasive devices).
• Administer fluids to maintain mean arterial pressure at > 65 mm Hg, central venous pressure (CVP) 8-12 mm Hg and central venous or mixed venous oxygen saturation >70%.
• Administer vasopressors if necessary to achieve a mean arterial blood pressure of 65 mm/Hg if fluid replacement is not successful.
• Obtain cortisol stimulation test and start continuous low-dose steroid infusion.
• Maintain cardiac output at normal physiologic levels.
• Maintain blood glucose levels at < 150mg/dL.
• Consider administration of human recombinant activated protein C (drotrecogin alfa activated) for patients at risk for dying and presenting with septic shock, sepsis with multiple organ failure and sepsis induced acute respiratory distress syndrome.

Supporting Evidence:
• More than 750,000 cases of severe sepsis occurred annually (year 2000) and mortality ranges from 28%-50% with an overall hospital mortality of about 30%.1 Sepsis (infection and 2 of the 4 SIRS criteria) can rapidly progress to severe sepsis (infection + organ dysfunction + SIRS criteria) to septic shock (persistent tissue hypoxia with vasopressors on board) within 24 hours.1-4 Treatment should be initiated regardless of where the patient is located within the hospital. A prospective randomized study of 263 emergency department patients diagnosed with severe sepsis or septic shock showed that patients treated aggressively with a goal direction towards tissue oxygenation within the first 6 hours of presentation had a 16% improvement in mortality. Another small retrospective study showed a decrease in mortality in patients identified with signs of severe sepsis and treated within the first 6 hours.3,5.6 (Level V )
• Serum lactate levels can be elevated in the setting of a normal or increased cardiac output. The measurement of serum lactate can reflect occult decreases in global tissue perfusion and as such may be an indicator of organ dysfunction. The presence and the clearance rate of lactate are associated with increases in patient morbidity and mortality.3,7 (Level IV)
• Early administration of appropriate antibiotics decreases mortality in patients with Gram positive and negative bacteremias. Empiric broad spectrum antibiotics should be initiated prior to identification of the infecting organism and reassessed after 48-72 hours based on culture results and clinical data.8
• According to the Surviving Sepsis Campaign guidelines, during the first 6 hours of treatment the goal is to achieve and maintain a CVP of 8-12 mm Hg or 12-15 mm Hg for patients receiving mechanical ventilation and a MAP of at least 65 mm Hg. with fluid resuscitation.7 Dobutamine is identified as the medication of choice to increase cardiac output to normal levels or to improve lactate clearance when cardiac output is not being measured. Two large clinical trials did not show a benefit from increasing CO above physiologic normal levels in order to increase oxygen delivery to the tissues.9-11 Available data do not support the use of low dose dopamine for renal protection.12 (Level V evidence)
• Colloids have not been shown to be of more benefit than crystalloid for fluid resuscitation. One large randomized controlled trial compared 4% albumin with normal saline in the treatment of patients requiring volume resuscitation found no significant difference in mortality between the groups. Several literature reviews have concluded that choice of fluids does not appear to change outcomes. 13,14 (Level V)
• In the setting of hypotension fluid replacement should be optimized before vasopressors are started. No high-level evidence exists to identify the most appropriate vasopressor to use for the treatment of septic shock and selection is based on multiple clinical parameters. However, in the Surviving Sepsis Campaign Guidelines for the Management of Severe Sepsis and Septic Shock norepinephrine or dopamine are identified as the initial vasopressors of choice to increase vascular tone and blood pressure.7
• Two meta analyses concluded that administration of high dose corticosteroids are of no benefit or may be detrimental to patients with septic shock.15,16 (Level VI) In vasopressor dependent shock, the addition of low-dose exogenous cortisol has been shown to improve the uptake of the patients own and the exogenously administered sympathetic stimulants when serum cortisol levels are low.17 (Level IV)
• Maintaining glucose levels within normal range (80-110 mg/dL) but at least < 150mg/dL has been shown to decrease morbidity and morality in a surgical population but did not focus on septic patients. Maintaining glucose levels < 150mg/dL showed reduced morbidity but not mortality in critically ill medical patients with sepsis.18-19 (Level V)
• In a large double blind study, human recombinant activated protein C (drotrecogin alfa activated) decreased mortality by 6% in patients with severe sepsis and decreased mortality by 13% for patients at high risk for death (ie, patients having an APACHE II score of 25 or greater).20, 21 (Level V)

What You Should Do:
• Educate all nursing staff on the risk factors and clinical signs of sepsis.
• Create an interdisciplinary team including but not limited to physicians, pharmacist, respiratory care practitioner, nursing and dietitian to develop protocols or guidelines for the initial identification and management of the patient presenting with signs of sepsis. Consider development of a rapid response team to facilitate prompt identification and treatment of patients with sepsis.

AACN Grading of Evidence System
Level I: Manufacturer’s recommendations only
Level II: Theory based, no research data to support recommendations: recommendations from expert consensus group may exist
Level III: Laboratory data, no clinical data to support recommendations
Level IV: Limited clinical studies to support recommendations
Level V: Clinical studies in more than one or two patient populations and situations to support recommendations
Level VI: Clinical studies in a variety of patient populations and situations to support recommendations.

Need More Information or Help?
Call the AACN Practice Resource Network at (800) 394-5995, ext. 217. Practice Alerts are available online at www.aacn.org > Clinical Practice.

References
1. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303-1310.
2. Ahrens T, Tuggle D. Surviving severe sepsis: early recognition and treatment. Crit Care Nurse. October 2004;24(suppl):2-13.
3. Rivers E, Bryant N, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-37.
4. Rivers E, McIntyre L, Morro DC, Kandis KR. Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity. Can Med Assoc J. 2005;173:1054-1065.
5. McIntyre LA, Fergusson DA, Cebert PC, et al. Are delays in the recognition and initial management of patients with severe sepsis associated with hospital mortality? Crit Care Med. 2003;31(suppl):A75.
6. Engoren, M. The effect of prompt physician visits on intensive care unit mortality and cost. Crit Care Med. 2005;33:727-733.
7. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32:858-870.
8. Bochud P-Y, Bonten M, Marchetti O, Calandra, T. Antimicrobial therapy for patients with severe sepsis and septic shock: an evidence-based review. Crit Care Med. 2004;32(11 suppl):S495-S512.
9. Hayes MA, Timmins AC, Yau EH, et al. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med. 1994;330:1717-1722.
10. Gattinoni L, Brazzi L, Pelosi P, et al. A trial of goal-oriented hemodynamic therapy in critically ill patients. N Engl J Med. 1995;333:1025-1032.
11. Beale RJ, Hollenberg SM, Vincent JL, Parrillo JE. Vasopressor and inotropic support in septic shock: an evidence-based review. Crit Care Med. 2004;32(11 suppl):S455-S465.
12. Bellomo R, Chapman M, Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomized trial. Lancet. 2000;356:2139-2143.
13. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350:2247-2256.
14. Vincent JL, Herwig G. Fluid resuscitation in severe sepsis and septic shock: An evidence-based review. Crit Care Med. 2004;32(11 suppl):S451-S454.
15. Lefering R, Neugebaruer EA. Steroid controversy in sepsis and septic shock: a meta analysis. Crit Care Med. 1995;23:1294-1303.
16. Cronin L, Cook DJ, Carlet J, et al. Corticosteroid treatment for sepsis: a critical appraisal and meta-analysis of the literature. Crit Care Med. 1995:1430-1439.
17. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288:862-871.
18. Van den Berghe G, Wouters, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359-1367.
19. Van den Berghe G, Wilmer A, Hermans G, e al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354:449-461.
20. Bernard GR, Vincent JL, Laterre PF, et al. Recombinant human protein C worldwide evaluation in severe sepsis (PROWESS) study group: efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001;344:699-709.
21. Bernard GR, Margolis BD, Shanies HM, et al. Extended evaluation of recombinant human activated protein C United States trial (ENHANCE USA): a single-arm phase 3B multicenter study of drotrecogin alfa (activated) in severe sepsis. Chest. 2004:125:2206-2216.


What Picture Are We Painting?
The Advanced Practice Nurse Is a Role Model


By Pamela Popplewell, MSN, APRN-BC, CCRN

Somebody is watching you. Each day as you work and interact, the decisions you make, your judgments, your skills and reactions are being evaluated by the people with whom you work. Some will be watching you with a critical eye, some with admiration or curiosity, some with indifference. Regardless, people are watching—and that makes you a role model for nurses and nursing.

Remember when you first became a nurse? When I was new to the nursing profession, I worked on a surgical floor and struggled with the steep learning curve during the first year. I frequently had clinical questions but only occasional ethical or moral concerns. I remember carefully watching a nurse practitioner who worked for the cardiothoracic service. She was skilled in both clinical practice and in her interactions with staff. The nurses on the floor respected her and we all relied on her for decisions about the patients on her service and for advice on other clinical situations that arose. I remember thinking I wanted to be just like her. Many years have passed, and now that I am a nurse practitioner for the General Surgery service, it occurs to me that my situation has become a lot like hers.

I do not believe that we choose to be role models but rather that circumstances place us in that position. Although some of us may wish to avoid being a role model, as advanced practice nurses we are leaders and we must lead thoughtfully and with intention.

Leadership as Art
Max DuPree discusses the responsibilities of role models in his book, Leadership Is an Art. He proposes that leadership involves stewardship of an organization and its staff members. This stewardship includes the responsibility to create within the institution a legacy of clinical competence; the basis for a “good” reputation, and an institutional value system for the people within the organization who will drive individual behavior. This value system provides meaning, caring and purposeful commitment to the work that occurs daily and shapes the development of future leaders within the organization (p12-15). DuPree further describes leadership as owing the corporation the visible order and commitment that comes with a “rational environment (that) values trust and human dignity and provides the opportunity for personal development and self fulfillment in the attainment of the organization’s goals” (p16). Who is in a better position than an advanced practice nurse to fulfill this role?

Nurses are the heart of a medical institution. The nursing profession is where the “rubber meets the road.” Caring, competence, and support of human dignity are all paramount to nursing, and advanced practice nurses are in a prime leadership position to ensure that these happen. We are the “good stewards” of role modeling in nursing and for our healthcare organization. We embody the credibility of our profession. We must not only communicate the important values, but we must live by them, practice them daily, and be true to them.

Seeing the Big Picture
Donald Laurie defines and discusses what he identifies as the seven essential acts of leadership in his book, The Real Work of Leaders. His number one essential act for leaders is to instruct them to “get on the balcony.” This is meant to represent the ability to see the big picture, and to get a better perspective of the entire situation. The ability to see the problem within the larger context of the organization allows for more informed decisions. The true challenges can be identified, and the chance of solving the real problem is enhanced. The relevance of daily work to desired outcomes is more easily visible and applicable. Advanced practice nurses provide much of this perspective. Examples of this occur in my practice quite frequently. Staff nurses will approach me to inquire about individual patient management. Many times their questions lack the perspective that I have of why a drain was placed in a certain location, what the specific concerns are about a patient’s condition or a detailed plan of care. I can give them critical information essential to providing better nursing care for this patient. Likewise, I am able to discuss problems they encounter with the physician staff on my team. I am truly “on the balcony” viewing patient care, between the nurses’ and the physicians’ or other providers’ perspectives.

Advanced practice nurses also play a valuable organizational role. As providers we can tailor our care to best utilize the resources of the organization while keeping the goals of the institution in mind. We can monitor and participate in quality improvement activities to better serve our patient population and to create an institutional legacy. We are in a position to participate in development of hospital policy and procedure to ensure that safe, effective, and clinically appropriate guidelines are developed with the true role of nursing represented.
So, each day as we practice and interact with the various disciplines at our workplace, we are being quietly watched. Our leadership skills are being evaluated and someone is determining if they are going to be “just like you”—or if they believe they could find a better mentor or role model elsewhere. This is why it is important that we be constantly vigilant; our actions could determine what lasting impression someone may develop about nurses and nursing. Whether we like it or not, we are painting the picture of nursing each day. What picture are you painting?


Practice Alerts to Include Rating for Levels of Evidence


By Marilyn Hravnak, RN, PhD, ACNP-BC, FCCM,
and Cheri S. Blevins, RN, BSN

AACN’s research vision is that critically ill patients and their families will be cared for by nurses who actively question their practice and base their practice on research. Therefore, AACN’s research agenda promotes the creation of cultures of inquiry, broad sharing and data-driven practice. To foster a culture of data-driven practice, AACN promotes critical care nursing practices that reflect the current state of the science.

To support development and dissemination of evidence-based practice recommendations to members, AACN implemented Practice Alerts in February 2004 These articles provide succinct, dynamic directives supported by current literature to promote evidence-based practice at the bedside, to enhance practice excellence, and to encourage safe, humane working environments.

The Research Work Group develops the Practice Alerts, choosing topics and exploring literature for related research. Then, recommendations for expected practice are made based on the supporting evidence.

In past Practice Alerts, although the supporting evidence was summarized, the strength of the evidence used to support each of the recommendations was not provided. However, grading systems that rank the strength of evidence are increasingly being used by professional organizations including the American College of Cardiology, American Heart Association, American College of Chest Physicians, American Academy of Pediatrics, American Board of Family Practice, Society of Critical Care Medicine, Centers for Disease Control and the U.S. Preventive Services Task Force, among others.

These grading systems, usually denoted by numbers or letters, allow clinicians to determine if a recommendation is supported by strong or weak scientific evidence. The clinician can then confidently apply recommendations with a strong evidence grade when treating most patients; more careful thought and discussion may be warranted before using recommendations with weak supporting evidence.

The grading scales used by the organizations noted above are diverse. The rating scale that AACN has chosen ranges from I to VI, with the levels indicated as follows:

I. Manufacturers recommendation only.
II. Theory based-no research data to support recommendations; recommendations from expert consensus group may exist.
III. Laboratory or bench data only-no clinical data to support recommendations
IV. Limited clinical studies to support recommendations.
V. Clinical studies in more that one or two different populations or situations to support recommendations.
VI. Clinical studies in a variety of patient populations and situations to support recommendations.

As indicated in the above grading system, the higher the Roman numeral, the stronger the scientific evidence supporting the recommendation. This grading system is currently used for rating recommendations in AACN’s Protocols for Practice and AACN Procedural Manual for Critical Care.1

The Research Work Group reviewed many grading taxonomies, but determined that it would be desirable to maintain consistency with the taxonomy used in the other AACN documents. This grading system will be used first with the 2006 Practice Alerts. Topics to be covered during the year include alcohol withdrawal, sepsis, sedation management, blood transfusion and conservation measures, open visiting, and blood pressure monitoring.

To access the Practice Alerts archive, click on http://www.aacn.org/AACN/practiceAlert.nsf/vwdoc/PracticeAlertMain.

Members of the Research Work Group are (from left, front row)
Marilyn Hravnak, Kathleen Miller, Christine Schulman, Cheri Blevins
and Debbie Barnes, and (from left, back row) Maureen Seckel, Beth
Hammer, Janice Powers and Sherill Cronin.

Q:

What is the best evidence for using the Trendelenburg position to maintain blood pressure in a patient in hypovolemia? I have read the article of Bridges, N. & Jarquin-Valdivia, A. A. (2005) in the American Journal of Critical Care1 and am unclear about the conclusions.

A:

In an early study, Sibbald et al2 compared the hemodynamic effects of the Trendelenburg position (15 to 20 degree head down position) in 15 hypotensive and 61 normotensive patients. They measured baseline heart rate, systolic, diastolic and mean arterial pressure (MAP), pulmonary artery systolic (PAs), diastolic (PAd) and mean pressure (MPAP), pulmonary wedge pressure (PWP) and cardiac outputs. The bed was then tilted 15 to 20 degrees head down for three to five minutes and measurements were repeated. In the nonhypotensive patients there was an increase in preload, decrease in afterload and a small increase in flow. In the hypotensive group, there was no measurable effect on the MAP and the cardiac index decreased. The authors’ conclusions were that “the Trendelenburg position cannot be advocated to result in any consistent beneficial hemodynamic response when used in the management of the critically ill normo or hypotensive patient.” (p 223). Although this early study was not included in Bridges and Jarquin-Valdivia’s review, it does support their conclusions that “Trendelenburg is probably not a useful position for resuscitation.” (p 367). It is a technique many of us learned in school and have passed along to succeeding generations of nurses. However, in light of current evidence this is not a practice that should be used as a first-line response to management of resuscitation in the hypotensive patient.

References
1. Bridges N, Jarquin-Valdivia AA. Use of the Trendelenburg position as the resuscitation position: To T or not to T? Am J Crit Care. 2005;14:364-368.
2. Sibbald WJ, Paterson NAM, Holliday RL, Baskerville J. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Crit Care Med. May 1979;7:218-224.

Do you have a practice-related question? Call AACN’s Practice Resource Network at (800) 394-5995, ext. 217, or e-mail practice@aacn.org.


Public Policy Update

CDC Recommendations Seek to Increase Influenza Vaccinations
The Centers for Disease Control and Prevention has announced enhanced recommendations designed to increase influenza vaccination coverage among healthcare personnel as a way to protect patients and staff from influenza. The new recommendations provide strategies to make vaccine more accessible to healthcare workers and to help facilities better determine coverage rates and the reasons their staff have for not getting vaccinated.

The recommendations are designed to highlight the importance of healthcare personnel getting vaccinated each year. Currently, fewer than half of healthcare workers get vaccinated for flu each year, posing a serious health risk to their patients.

The recommendations ask facilities to monitor influenza vaccination coverage at regular intervals during influenza season and provide feedback of ward-, unit-, and specialty-specific coverage to staff and administration. For more information, go to http://www.cdc.gov/od/oc/media/pressrel/r060209.htm.

Nursing Coalition Urges Increased Nursing Education Support
Americans for Nursing Shortage Relief, a coalition of nursing organizations that includes AACN, recently issued a letter to President George W. Bush encouraging the allocation of increased federal funding for Nursing Workforce Development programs authorized by Title VIII of the Public Health Service Act. The letter advances that federal prioritization of nursing education programs will help alleviate the national nursing shortage that poses a threat to patient safety and the quality of treatment administered in emergency departments.
For more information about the group’s legislative efforts, go to http://www.awhonn.org/awhonn/?pg=875-12550-3260-7650-17420.

For more information about these and other issues, visit the AACN Web site.

Grants


July 1 is the deadline to apply for the following AACN nursing research grants:

Clinical Inquiry Grant
This grant provides awards up to $500 to qualified individuals carrying out clinical research projects that directly benefit patients and/or families. Interdisciplinary projects are especially invited. Ten awards are available each year.

End-of-Life/Palliative Care Small Projects Grant
This grant provides awards of $500 each to qualified individuals carrying out a project focusing on end-of-life and/or palliative care outcomes in critical care. Examples of topics are bereavement, communication issues, caregiver needs, symptom management, advance directives and life support withdrawal. Two awards are available each year.

Medtronic Physio-Control AACN Small Projects Grant
Cosponsored by Medtronic Physio-Control, this grant funds an award up to $1,500 to a qualified individual carrying out a project focusing on aspects of acute myocardial infarction, resuscitation or sudden cardiac death, such as the use of defibrillation, synchronized cardioversion, noninvasive pacing, or interpretive 12-lead electrocardiogram. Examples of eligible projects are patient education programs, staff development programs, competency-based educational programs, CQI projects, outcomes evaluation projects, or small clinical research studies.

To find out about AACN’s research priorities and grant opportunities, visit the Research area of the AACN Web site or e-mail research@aacn.org.