sepsis bundle 2018,SSC

INTRODUCTION
The "sepsis bundle" has been central to the implementation of the Surviving Sepsis Campaign (SSC) from the first publication of its evidence-based guidelines in 2004 through subsequent editions (1-6). Developed separately from the guidelines pub- lication by the SSC, the bundles have been the cornerstone of sepsis quality improvement since 2005 (7-11). As noted when they were introduced, the bundle elements were designed to be updated as indicated by new evidence and have evolved accordingly. In response to the publication of "Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016" (12, 13), a revised "hour- 1 bundle" has been developed and is presented below (Fig. 1).    The compelling nature of the evidence in the literature, which has demonstrated an association between compliance with bundles and improved survival in patients with sepsis and septic shock, led to the adoption of the SSC measures by the National Quality Forum (NQF) and subsequently both by the New York State (NYS) Department of Health (14) and the Centers for Medicare and Medicaid Services (CMS) ( 15) in the USA for mandated public reporting. The important relation- ship between the bundles and survival was confirmed in a pub- lication from this NYS initiative (16).    Paramount in the management of patients with sep- sis is the concept that sepsis is a medical emergency. As with polytrauma, acute myocardial infarction, and stroke, early identification and appropriate immediate management in the initial hours after development of sepsis improves outcomes (7-11, 14, 16-21). The guidelines state that these patients need urgent assessment and treatment, including initial fluid resus- citation while pursuing source control, obtaining further Iab- oratory results, and attaining more precise measurements of hemodynamic status. A guiding principle is that these complex patients need a detailed initial assessment and then ongoing re-evaluation of their response to treatment. The elements of the 2018 bundle, intended to be initiated within the first hour, are listed in Table I and presented in the following. Consis- tent with previous iterations of the SSC sepsis bundles, "time zero" or "time of presentation" is defined as the time of triage in the emergency department or, if referred from another care location, from the earliest chart annotation consistent with all eIements of sepsis (formerly severe sepsis) or septic shock ascertained through chart review. Because this new bundle is based on the 2016 Guidelines publication,the guidelines them- selves should be referred to for further discussion and evidence related to each element and to sepsis management as a whole.
HOUR-1 BUNDLE 
The most important change in the revision of the SSC bun- dles is that the 3-h and 6-h bundles have been combined into a single "hour-l bundle" with the explicit intention of begin- ning resuscitation and management immediateJy. We believe this reflects the clinical reality at the bedside of these seriously ill patients with sepsis and septic shock-that clinicians begin treatment immediately, especially in patients with hypoten- sion, rather than waiting or extending resuscitation measures over a longer period. More than 1 hour may be required for resuscitation to be completed, but initiation of resuscitation and treatment, such as obtaining blood for measuring lactate and blood cultures, administration of fluids and antibiotics, and in the case of life-threatening hypotension, initiation of vasopressor therapy, are all begun immediately.It is also impor- tant to note that there are no published studies that have evalu- ated the efIicacy in important subgroups,including burns and immunocompromised patients. This knowledge gap needs to be addressed in future studies specifically targeting these sub- groups. The elements inCILided in the revised bundle are taken from the Surviving Sepsis Campaign Guidelines, and the level of evidence in support of each element can be seen in Table 1 (12, 13). We believe the new bundle is an accurate reflection of actual clinical care.  Measure Lactate Level While serum lactate is not a direct measure of tissue perfu- sion (22), it can serve as a surrogate, as increases may repre- sent tissue hypoxia, accelerated aerobic glycolysis driven by excess beta-adrenergic stimulation, or other causes associated  with worse outcomes ( 23). Randomized controlled trials have  demonstrated a significant reduction in mortality with lactate- guided resuscitation (24-28).    If initial lactate is elevated ( 2mmolL), it should be remeasured within 2-4h to guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (24).  Obtain Blood Cultures 
Prior to Antibiotics Sterilization of cultures can occur within minutes of the first  dose of an appropriate antimicrobial (29, 30), so must be obtained before antibiotic administration  cultures to opti-  mize the identification of pathogens and improve outcomes (31, 32). Appropriate blood cultures include at least two sets (aerobic and anaerobic). Administration of appropriate anti- biotic therapy should not be delayed in order to obtain blood cultures.
Administer Broad-  Spectrum Antibiotics  Empiric broad-spectrum therapy with one or more intravenous antimicrobials to cover alI likely pathogens should be started immediately (21) for patients presenting with sepsis septic shock. Empiric antimicrobial therapy should be narrowed once pathogen identification and sensitivities are stablished, or discontinued if a decision is made that the patient does not have infection. The link between early administration of antibiotics for sus- pected infection and antibiotic stewardship remams an essen- tial aspect of high-quality sepsis management. If infection is subsequently proven not to exist, then antimicrobials should be discontinued. 
Administer IV Fluid
 Early effective fluid resuscitation is crucial for the stabilization of  sepsis-induced tissue hypoperfusion or septic shock. Given the  urgent nature of this medicaI emergency, initial fluid resuscita-  tion should begin immediately upon recognizing a patient with sepsis andor hypotension and elevated lactate, and compIeted within 3 hours of recognition. The guidelines recommend this should comprise a minimum of 30mLkg of intravenous crystalloid fluid. Although little literature includes controlled data to support this voIume, recent interventional studies have described this as usualpractice in the early stages of resuscitation, and observational evidence is supportive (7, 8). The absence of any clear benefit following the administration of colloid com- pared with crystalIoid solutions in the combined subgroups of sepsis, in conjunction with the expense of albumin, supports a strong recommendation for the use of crystalloid solutions in the initial resuscitation of patients with sepsis and septic shock. Because some evidence indicates that a sustained positive fluid balance during ICU stay is harmful (33-37), fluid administra- tion beyond initial resuscitation requires careful assessment of the likelihood that the patient remains fluid responsive.
Apply Vasopressors 
Urgent restoration of an adequate perfusion pressure to the vital organs is a key part of resuscitation. This should not be delayed. If blood pressure is not restored after initial fluid resuscitation, then vasopressors should be commenced within the first hour to achieve mean arterial pressure (MAP) of  65 mm Hg. The physiologic effects of vasopressors and com- bined inotropevasopressor selection in septic shock are out- lined in a large number of literature reviews (38-47).

Pitting Edema Scale

Pitting Edema Scale

Transfusion Reaction

Transfusion Reaction: Nursing Interventions
1. Stop the transfusion.
2. Change the intravenous (IV) tubing down to the IV site
and keep the IV line open with normal saline.
3. Notify the health care provider (HCP) and blood bank.
4. Stay with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.
5. Prepare to administer emergency medications as prescribed.
6. Obtain a urine specimen for laboratory studies (perform any other laboratory studies as prescribed).
7. Return blood bag, tubing, attached labels, and transfusion record to the blood bank.
8. Document the occurrence, actions taken, and the client’s response.
If the client exhibits signs of a transfusion reaction, the
nurse immediately stops the transfusion and changes the
IV tubing down to the IV site to prevent the entrance of addi-
tional blood solution into the client. Normal saline solution
is hung and infused to keep the IV line open in the event that
emergencymedications need to be administered. The HCP is
notified and the nurse also notifies the blood bank of the
occurrence. The nurse stays with the client and monitors
the client closely while other personnel obtain needed sup-
plies to treat the client. As prescribed by the HCP, the nurse
administers emergency medications such as antihistamines,
vasopressors, fluids, and corticosteroids. The nurse then
obtains a urine specimen for laboratorystudies and anyother
laboratorystudies as prescribed to check for free hemoglobin
indicating that red blood cells were hemolyzed. The blood
bag, tubing, attached labels, and transfusion record are
returned to the blood bank so that the blood bank can check
the items to determine the reason that the reaction occurred.
Finally the nurse documents the occurrence, actions taken,and the client’s response.
Reference
Ignatavicius, Workman (2016), pp. 824-825.

Safe Blood Transfusion

General Precautions
A large volume of refrigerated blood infused rapidly through a
central venous catheter into the ventricle of the heart can cause cardiac dysrhythmias.
No solution other than normal saline should be added to blood
components.
Medications are never added to blood components or piggy-backed into a blood transfusion.
To avoid the risk of septicemia, infusions (1 unit) should not
exceed the prescribed time for administration (2 to 4 hours
for packed red blood cells); follow evidence-based practice Guidelines and agency procedure.

The blood administration set should be changed with each unit
of blood, or according to agency policy, to reduce the risk of
septicemia.
Check the blood bag for the date of expiration; components
expire at midnight on the day marked on the bag unless oth-
erwise specified.
Inspect the blood bag for leaks, abnormal color, clots, and
bubbles.
Blood must be administered as soon as possible (within 20 to
30 minutes) after being received from the blood bank, because
this is the maximal allowable time out of monitored storage.
Never refrigerate blood in refrigerators other than those used in
blood banks; if the blood is not administered within 20 to
30 minutes, return it to the blood bank.
The recommended rate of infusion varies with the blood com-
ponent being transfused and depends on the client’s condi-
tion; generally blood is infused as quickly as the client’s
condition allows.
Components containing few red blood cells (RBCs) and plate-
lets may be infused rapidly, but caution should be taken
to avoid circulatory overload.
The nurse should measure vital signs and assess lung sounds
before the transfusion and again after the first 15 minutes
and every 30 minutes to 1 hour (per agency policy) until
1 hour after the transfusion is completed.
Client Assessment
Assess for any cultural or religious beliefs regarding blood
transfusions.
A Jehovah’s Witness cannot receive blood or blood products;
this group believes that receiving a blood transfusion has
eternal consequences.
Ensure that an informed consent has been obtained.
Explain the procedure to the client and determine whether the
client has ever received a blood transfusion or experienced
any previous reactions to blood transfusions.
Check the client’s vital signs; assess renal, circulatory, and
respiratory status and the client’s ability to tolerate intrave-
nously administered fluids.
If the client’s temperature is elevated, notify the health care pro-
vider (HCP) before beginning the transfusion; a fever maybe
a cause for delaying the transfusion in addition to masking a
possible symptom of an acute transfusion reaction.
Blood Bank Precautions
Blood will be released from the blood bank only to personnel
specified by agency policy.
The name and identification number of the intended recipient
must be provided to the blood bank, and a documented
permanent record of this information must be maintained.
Blood should be transported from the blood bank to only1client
at a time to prevent blood delivery to the wrong client.
Only 1 unit of blood should be transported at a time, even if the
client is prescribed to have more than 1 unit transfused.
Client Identity and Compatibility
Check the HCP’s prescription for the administration of the
blood product.
The most critical phase of the transfusion is confirming product
compatibility and verifying client identity.
Universal barcode systems for blood transfusions should be
used to confirm product compatibility, client identity, and
expiration.
Two licensed nurses (follow agency policy) need to check the
HCP’s prescription, the client’s identity, and the client’s
identification band or bracelet and number, verifying that
the name and number are identical to those on the blood
component tag.
At the bedside, the nurse asks the client to state his or her name,
and the nurse compares the name with the name on the
identification band or bracelet.
The nurse checks the blood bag tag, label, and blood requi-
sition form to ensure that ABO and Rh types are compat-
ible. The nurse uses the barcode scanning system per
agency policy.
If the nurse notes any inconsistencies when verifying client
identity and compatibility, the nurse notifies the blood bank
immediately.

Crisis

Nurses

Being a nurse means you will never be bored, you will always be frustrated, you will be surrounded by challenges, so much to do and so little time. You will carry immense responsibility and very little authority. You will step into people's lives and you will make a difference. Some will bless you, some will curse you. You will see people at their worst and at their best. You will never cease to be amazed at people's capacity for love, courage, and endurance. You will see life begin and end. You will experience resounding triumphs & devastating failures. You will cry a lot, you will laugh a lot. You will know what it is to be human, and to be humane.

As India struggles with doctor shortage, govt gives a push to nurse-led clinics

Click here for Details 👇👇
 India struggles with doctor shortage, govt gives a push to nurse-led clinics