Re: [Sepsis Groups] Vasopressor administration

[Pamela Green]

Our Sepsis protocol at HMH uses "Initiate Vasopressors for persistent 
Hypotension <90 syst or MAP<65 after initial Fluid Resuscitation of 30 ml/kg".  
Either measure meets the Bundle compliance Goals of therapy. Pam
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Tara Miller
Sent: Thursday, April 19, 2018 9:39 AM
To: 'sepsisgroups@lists.sepsisgroups.org' <sepsisgroups@lists.sepsisgroups.org>
Subject: [Sepsis Groups] Vasopressor administration

Pam Green BSN RN CCRN
Clinical Informatics

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Is anyone having issues with patients who have persistent hypotension after 
fluids defined as SBP < 90, but they still have a MAP of > or equal to 65 and 
no vasopressors being ordered? My facility's vasopressor orders read to 
initiate when the MAP is < 65. We have had two patients who did not meet that 
criteria until after the 6 hour window was up for vasopressors.

Are other facility's changing their practice to start pressors for SBP < 90?

Thanks.

Tara R Miller, RN
Team Leader, Quality Management
Mobile Infirmary Medical Center
Office: 435-5109
Cell: 605-8270

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[Sepsis Groups] Vasopressor administration

[Tara Miller]

Is anyone having issues with patients who have persistent hypotension after 
fluids defined as SBP < 90, but they still have a MAP of > or equal to 65 and 
no vasopressors being ordered? My facility's vasopressor orders read to 
initiate when the MAP is < 65. We have had two patients who did not meet that 
criteria until after the 6 hour window was up for vasopressors.

Are other facility's changing their practice to start pressors for SBP < 90?

Thanks.

Tara R Miller, RN
Team Leader, Quality Management
Mobile Infirmary Medical Center
Office: 435-5109
Cell: 605-8270

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[Sepsis Groups] Vasopressor Administration Answer from QualityNet

[Myran, Robin]

FYI...



 Subject

Vasopressor Administration



 Discussion Thread

 Response Via Email (Bob Dickerson)

12/14/2015 06:42 PM

Hi Robin,



Thank you for your questions.



Most patients that are going to respond to crystalloid fluids will
exhibit a response after 30 mL/kg. There are some that respond to less,
some that require more and many that do not respond.



It is virtually impossible to build a measure that takes into account
every possible variation in how patients may respond. As such the
measure was designed to account for the majority of cases. If in the
clinical judgment of the treating physician they feel that giving more
crystalloid fluids as opposed to starting vasopressors is in the best
interest of the patient and not doing so may be detrimental to the
patient then clinical judgment should be used.



I hope this helps.

 Auto-Response

10/30/2015 04:56 PM

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on QualityNet. A recording
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Provider call are available for review. The recording
  and slides
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 Customer By Web Form (Robin Myran)

10/30/2015 04:56 PM

The sepsis protocol at our hospital includes the administration of 30
cc/kg crystalloid for hypotension or lactate >=4. If the patient remains
hypotensive after the initial bolus, we have the option of administering
an additional 30 cc/kg. Often this second bolus works to achieve a
sustained MAP >=65.

According to the specifications manual for SEP-1, we *must* start a
vasopressor by the 6th hour if the patient remains hypotensive in the
hour after the initial bolus is complete, correct? The Surviving Sepsis
Campaign's recommendations include "a minimum of 30 mL/kg of
crystalloids" and that "greater amounts of fluid may be needed in some
patients." They go on to say that "fluid administration is continued as
long as there is hemodynamic improvement". My physicians will always go
to more fluids first (if the patient remains fluid responsive) before
starting vasopressors. Can you provide additional
information/clarification so I can educate my physicians?



 Question Reference #151030-000140

Escalation Level:

5 Business Days

Product Level 1:

Inpatient Quality Reporting

Date Created:

10/30/2015 04:56 PM

Last Updated:

12/14/2015 06:42 PM

Status:

Solved

Discharge Period:

10/01/2015 - 06/30/2016

CCN:








Robin Myran, MSN, RN, PCCN

Sepsis Coordinator

Hoag Memorial Hospital Presbyterian

One Hoag Drive

Newport Beach, CA 92658

Office: (949) 764-4588

Fax: (949) 764-5387

Cell: (949) 300-9137

robin.my...@hoag.org 




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Thank you,

Hoag Memorial Hospital Presbyterian and its Affiliates

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Re: [Sepsis Groups] Vasopressor Administration

[Townsend, Sean, M.D.]

Did you look at nursing documentation?

On Nov 4, 2015, at 7:58 AM, Mary Draper <mary.dra...@johnmuirhealth.com> wrote:

I have a case where the patient met the criteria for severe sepsis and septic 
shock on admission to the ED, lactate >4, BP < 90, required intubation from 
aspiration.  There wasn't any documentation of an infection or severe sepsis 
and septic shock until the next day at 0229.
Do I have to use the physician documented time or can I use the criteria that 
ruled the patient in on admission?
Appreciate any thoughts or feedback.
Thanks


Mary Draper RN BSN
Coordinator Quality Improvement
Peer Review Support CV/CT
Quality Management
Office (925) 674-2045
Cell (925) 451-8792
Fax (925) 674-2373
mary.dra...@johnmuirhealth.com

“O, let us always have a mountain within our soul, 
 with a peak so high that we never quite reach the top…
 For then we will always strive for greater things 
 And will not be content  with merely climbing hills.” Ardath Rodale


-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Monday, November 02, 2015 10:28 AM
To: Myran, Robin
Cc: Sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] Vasopressor Administration

The decision to measure the application of vasopressors is unfortunate in my 
view.

However, since it is measured, it is important to recall that the any time a 
vasopressor is applied, the goal is to wean it, not maintain it.  Thus while 
the measure checks to see that vasopressors were applied (ostensibly to prevent 
imminent cardiovascular collapse) they can be immediately weaned to off as long 
as MAP > 65, perhaps with additional fluids.

On Nov 2, 2015, at 9:52 AM, Myran, Robin 
<robin.my...@hoag.org<mailto:robin.my...@hoag.org>> wrote:

All –

I submitted this question through QualityNet, but was interested in your 
thoughts…

The sepsis protocol at our hospital includes the administration of 30 cc/kg 
crystalloid for hypotension or lactate >=4. If the patient remains hypotensive 
after the initial bolus, we have the option of administering an additional 30 
cc/kg. Often this second bolus works to achieve a sustained MAP >=65.

According to the specifications manual for SEP-1, we *must* start a vasopressor 
by the 6th hour if the patient remains hypotensive in the hour after the 
initial bolus is complete, correct? The Surviving Sepsis Campaign's 
recommendations include "a minimum of 30 mL/kg of crystalloids" and that 
"greater amounts of fluid may be needed in some patients." They go on to say 
that "fluid administration is continued as long as there is hemodynamic 
improvement". My physicians will always go to more fluids first (if the patient 
remains fluid responsive) before starting vasopressors. Can you provide 
additional information/clarification so I can educate my clinicians?


Robin Myran, MSN, RN, PCCN
Sepsis Coordinator
Hoag Memorial Hospital Presbyterian
One Hoag Drive
Newport Beach, CA 92658
Office: (949) 764-4588
Fax: (949) 764-5387
Cell: (949) 300-9137
robin.my...@hoag.org<mailto:jodi.caggi...@hoag.org>


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distribution or copying of this communication is strictly prohibited and may 
subject you to criminal or civil penalties. If you have received this 
communication in error, please notify the sender by replying to the message and 
delete the material from any computer. Thank you, Hoag Memorial Hospital 
Presbyterian and its Affiliates

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Re: [Sepsis Groups] Vasopressor Administration

[Nancy Fulmer]

I would like to hear a response to this question too.I tried to post the 
same
question to Qnet but I can't log on for some reason.



Nancy Fulmer, RRT, RN
Performance Improvement
University Health Care System
1350 Walton Way
Augusta, Ga. 30901
Office (706) 774-8245
Fax (706) 774-7640





From:   "Myran, Robin" <robin.my...@hoag.org>
To: <Sepsisgroups@lists.sepsisgroups.org>
Date:   11/02/2015 12:53 PM
Subject:    [Sepsis Groups] Vasopressor Administration
Sent by:"Sepsisgroups" <sepsisgroups-boun...@lists.sepsisgroups.org>



All –

I submitted this question through QualityNet, but was interested in your 
thoughts…

The sepsis protocol at our hospital includes the administration of 30 cc/kg
crystalloid for hypotension or lactate >=4. If the patient remains hypotensive 
after
the initial bolus, we have the option of administering an additional 30 cc/kg. 
Often
this second bolus works to achieve a sustained MAP >=65.

According to the specifications manual for SEP-1, we *must* start a vasopressor 
by
the 6th hour if the patient remains hypotensive in the hour after the initial 
bolus
is complete, correct? The Surviving Sepsis Campaign's recommendations include "a
minimum of 30 mL/kg of crystalloids" and that "greater amounts of fluid may be 
needed
in some patients." They go on to say that "fluid administration is continued as 
long
as there is hemodynamic improvement". My physicians will always go to more 
fluids
first (if the patient remains fluid responsive) before starting vasopressors. 
Can you
provide additional information/clarification so I can educate my clinicians?


Robin Myran, MSN, RN, PCCN
Sepsis Coordinator
Hoag Memorial Hospital Presbyterian
One Hoag Drive
Newport Beach, CA 92658
Office: (949) 764-4588
Fax: (949) 764-5387
Cell: (949) 300-9137
robin.my...@hoag.org



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is
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received this communication in error, please notify the sender by replying to 
the
message and delete the material from any computer. Thank you, Hoag Memorial 
Hospital
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Re: [Sepsis Groups] Vasopressor Administration

[Townsend, Sean, M.D.]

The decision to measure the application of vasopressors is unfortunate in my 
view.

However, since it is measured, it is important to recall that the any time a 
vasopressor is applied, the goal is to wean it, not maintain it.  Thus while 
the measure checks to see that vasopressors were applied (ostensibly to prevent 
imminent cardiovascular collapse) they can be immediately weaned to off as long 
as MAP > 65, perhaps with additional fluids.

On Nov 2, 2015, at 9:52 AM, Myran, Robin 
> wrote:

All –

I submitted this question through QualityNet, but was interested in your 
thoughts…

The sepsis protocol at our hospital includes the administration of 30 cc/kg 
crystalloid for hypotension or lactate >=4. If the patient remains hypotensive 
after the initial bolus, we have the option of administering an additional 30 
cc/kg. Often this second bolus works to achieve a sustained MAP >=65.

According to the specifications manual for SEP-1, we *must* start a vasopressor 
by the 6th hour if the patient remains hypotensive in the hour after the 
initial bolus is complete, correct? The Surviving Sepsis Campaign's 
recommendations include "a minimum of 30 mL/kg of crystalloids" and that 
"greater amounts of fluid may be needed in some patients." They go on to say 
that "fluid administration is continued as long as there is hemodynamic 
improvement". My physicians will always go to more fluids first (if the patient 
remains fluid responsive) before starting vasopressors. Can you provide 
additional information/clarification so I can educate my clinicians?


Robin Myran, MSN, RN, PCCN
Sepsis Coordinator
Hoag Memorial Hospital Presbyterian
One Hoag Drive
Newport Beach, CA 92658
Office: (949) 764-4588
Fax: (949) 764-5387
Cell: (949) 300-9137
robin.my...@hoag.org


Please note that the information contained in this message and any files 
transmitted with it are privileged and confidential and are protected from 
disclosure under the law, including the Health Insurance Portability and 
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recipient, or an employee or agent responsible for delivering this message to 
the intended recipient, you are hereby notified that any dissemination, 
distribution or copying of this communication is strictly prohibited and may 
subject you to criminal or civil penalties. If you have received this 
communication in error, please notify the sender by replying to the message and 
delete the material from any computer. Thank you, Hoag Memorial Hospital 
Presbyterian and its Affiliates

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[Sepsis Groups] Vasopressor Administration

[Myran, Robin]

All -



I submitted this question through QualityNet, but was interested in your
thoughts...



The sepsis protocol at our hospital includes the administration of 30
cc/kg crystalloid for hypotension or lactate >=4. If the patient remains
hypotensive after the initial bolus, we have the option of administering
an additional 30 cc/kg. Often this second bolus works to achieve a
sustained MAP >=65.

According to the specifications manual for SEP-1, we *must* start a
vasopressor by the 6th hour if the patient remains hypotensive in the
hour after the initial bolus is complete, correct? The Surviving Sepsis
Campaign's recommendations include "a minimum of 30 mL/kg of
crystalloids" and that "greater amounts of fluid may be needed in some
patients." They go on to say that "fluid administration is continued as
long as there is hemodynamic improvement". My physicians will always go
to more fluids first (if the patient remains fluid responsive) before
starting vasopressors. Can you provide additional
information/clarification so I can educate my clinicians?





Robin Myran, MSN, RN, PCCN

Sepsis Coordinator

Hoag Memorial Hospital Presbyterian

One Hoag Drive

Newport Beach, CA 92658

Office: (949) 764-4588

Fax: (949) 764-5387

Cell: (949) 300-9137

robin.my...@hoag.org 




Please note that the information contained in this message and any files
transmitted with it are privileged and confidential and are
protected from disclosure under the law, including the Health Insurance
Portability and Accountability Act (HIPAA). If the reader of this
message is not the intended recipient, or an employee or agent
responsible for delivering this message to the intended recipient, you
are hereby notified that any dissemination, distribution or copying of
this communication is strictly prohibited and may subject you to
criminal or civil penalties. If you have received this communication in
error, please notify the sender by replying to the message and delete
the material from any computer.

Thank you,

Hoag Memorial Hospital Presbyterian and its Affiliates

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