Post on 07-May-2015
the official training programme of the Surviving Sepsis Campaign
Objectives
• Understand the importance of sepsis• Be able to recognise the septic patient• Appreciate the importance of bundle-driven care• Contribute to the delivery of that care• Know when to refer to Outreach• Acknowledge the need to monitor performance
Is sepsis important?
• Risen by 329% in 20 years
• High mortality
• Worldwide 1400 deaths a day Angus D - more?
• Most common cause of death in ICU
• 30% of patients on UK ICU have it
39.8%How many of these patients die?
0
5
10
15
20
25
30
35
Lung1 Colon2 Breast3 Sepsis4
cancers
Annual
UK mortality
(2003),
thousands
1,2,3 www.statistics.gov.uk,,
4Intensive Care National Audit Research Centre (2005)
A U.K. Perspective
Identifying the Septic Patient
ACCP/SCCM Consensus Definitions
Infection– Inflammatory response to
microorganisms, or– Invasion of normally sterile
tissues
Systemic Inflammatory Response Syndrome (SIRS)– Systemic response to a
variety of processes
Sepsis– Infection plus 2 SIRS criteria
Severe Sepsis– Sepsis– Organ dysfunction
Septic shock– Sepsis– Hypotension despite fluid
resuscitation
Bone RC et al. Chest. 1992;101:1644-55. Identifying sepsis
now known as SSI
Step 1: What is SSI?
A systemic response to a nonspecific insultInfection, trauma, surgery, massive transfusion, etc
Defined as 2 of the following:
Temperature >38.3 or <36 0C
Heart rate >90 min-1
Respiratory rate >20 min-1
White cells <4 or >12
Acutely altered mental state
Hyperglycaemia (BM>6.6) in absence of DM
Identifying sepsis
SIRSSEVERE
SEPSIS
Step 2: What counts as an infection?
Pneumonia
Urinary Tract infection
Meningitis
Endocarditis
Device relatedCentral lineCannula
AbdominalPainDiarrhoeaDistensionUrgent laparotomy
Soft tissue/ musculoskeletal
CellulitisSeptic arthritisFasciitisWound infection
Identifying sepsis
Step 3: what is Sepsis?
SSI due to an infection
Identifying sepsis
Step 4: what is Severe Sepsis?
Sepsis with organ dysfunction, hypoperfusion or hypotension
CNS: Acutely altered mental statusCVS: Syst <90 or mean <65 mmHg
Resp: SpO2 >90% only with new/ more O2 Renal: Creatinine >175 mmol/l
or UO <0.5 ml/kg/hr for 2 hrsHepatic: Bilirubin >34 mmol/lBone marrow: Platelets <100Hypoperfusion: Lactate >2 mmol/lCoagulopathy: INR>1.5 or aPTT>60s
Identifying sepsis
What is shock?
Tissue perfusion is not adequate for the tissues’ metabolic requirements
Identifying sepsis
Septic Shock
Shock secondary to systemic
inflammatory response to a new
infection
Types of Shock
Cardiogenic
Neurogenic
Hypovolaemic
Anaphylactic
and…
Putting this together
The
Severe Sepsis Screening Tool
Are any 2 of the following present and new to the patient?
Temperature >38.3 or <36 0C
Heart rate >90 min-1
Respiratory rate >20 min-1
White cells <4 or >12 g/L
Acutely altered mental status
Hyperglycaemia (glucose>6.6mmol/L) (unless diabetic)
Screening Tool
Severe Sepsis Screening Tool
If yes, patient has SSI
Is the history suggestive of a new infection?
Pneumonia
UTI
Abdo pain/ diarrhoea/ distension/ urgent laparotomy
Meningitis
Cellulitis/ septic arthritis/ fasciitis/ wound infection
Endocarditis
Catheter (incl central venous) infection
Screening Tool
If yes, patient has SSI
If yes, patient has SEPSIS
Are any of the following present and new to the patient?
Blood pressure systolic <90 or mean <65 mmHg
New or increased O2 requirement to maintain SpO2>90%
Creatinine >177 mmol/l or UO <0.5 ml/kg/hr for 2 hrs
Bilirubin >34 mmol/l
Platelets <100
Lactate >2 mmol/l
Coagulopathy: INR>1.5 or aPTT>60s
Screening Tool
If yes, patient has SEPSIS
The patient has SEVERE SEPSISStart Severe Sepsis Care Pathway
Septic Shock
• Defined as• Systolic <90 mmHg• Mean <65 mmHg• Drop of >40 mmHg from patient’s normal systolic• Lactate >4 mmol/l
Treating the severely septic patient
The Surviving Sepsis Campaign Resuscitation Bundle
• Serum lactate measured• Blood cultures obtained prior to antibiotic administration.• From the time of presentation, broad-spectrum antibiotics
administered within 1 hour for all admissions• In the event of hypotension and/or lactate >4mmol/L (36mg/dL):
– Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)
– Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg.
• In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/L (36 mg/dl): – Achieve central venous pressure (CVP) of >8 mm Hg– Achieve central venous oxygen saturation (ScvO2) >70%
… within 6 hours of onset!
What you can do
•within 1 hour
•Then ensure Critical Care assistance if shocked to complete EGDT
Sepsis Six• Oxygen
• Blood Cultures
• Antibiotics
• Fluids
• Lactate & Hb
• Insert Catheter & monitor urine output
Sepsis Six• Oxygen
• Blood Cultures
• Antibiotics
• Fluids
• Lactate & Hb
• Insert Catheter & monitor urine output
At risk groups?
• Old• Young• Ill• Infections• Malignancy• Compromised organs• Immunocompromised• Post chemotherapy• Malnutrition• Invasive lines• How many of your patients are included?
Why are patients high risk?
• Multiple ‘at risk’ factors
• Underlying disease or condition
• Need for interventions – venflons, catheters, operations, etc.
• The hospital environment: MRSA, D&V, drug resistant bacteria, etc.
Summary
• Everyone has the potential to get sepsis
• Patients by definition have a high risk of sepsis
• Easy to identify – we know what we’re looking for
• Tools – MEWS, Clinical Acumen and Experience
• Sepsis Screening Tool
Questions