2. Learning Point’s
• Case Study
• R/V evidence in sepsis care
• Approach to the septic patient
• Resuscitating & managing sepsis
3. SEPSIS
• Sepsis is a common life-
threatening condition that occurs
when a once localised
bacterial/fungal infection
becomes systemic& produces an
unregulated inflammatory
immune response.
4. Sepsis the Problem!
• Major public health problem
• High Mortality
• Comprises 12% of ICU admits
• Burden of death 3x that of national road toll
5. Sepsis Pitfalls
• Fail to recognise/screen for sepsis
• Under appreciate the mortality
• Failure to respect as Time Critical Illness
20. The Patho
Distributive shock
↓
Myocardial depression
↓
Bone marrow suppression
↓
Activation of clotting cascade > DIC
↓
Organ dysfunction
↓
MODS
Death
21.
22. The Hard Part!
End of the bed Look for:
Temperature changes
^ Pulse
New or changing pain
Changes in resp rate
↓ systolic BP
Conscious state (lethargy, anxiety, delirium)
Prolonged CRT
Urine output <30ml/hr
23.
24. Risk Factors!
• Imunocompromised
• Hx of fevers/rigors
• Recent surgery
• Recent invasive procedure
• Implanted medical device (CAPD)
• AGE >65
• Recent international travel (<1 month)
• H/O contact with transmissible disease
28. Lactate
• Reflects cellular hypoxia
– Hypoperfusion
• Rise’s early in shock development
• Lactate ^4mmol - panic value
• Repeat – assess lactate normalisation
29. Blood Cultures
• Taken when infection suspected
• Best during fever (high rate of capturing
organism)
• From IV & Invasive devices
• Before antibiotics
– But don’t delay Ab’s !
30.
31. The Goals of Sepsis Tx!
1. Respiratory support
2. Maintain circulating blood volume
3. Immediate antibiotic administration
4. Removal of source
32. The approach
• Airway
• Breathing
• Circulation
• Disability
• Environment
• Get help –MET, Dr R/V
• Ensure IV access
– Make sure canula patent, not infected
33. The Sepsis Six
1. Give Oxygen
2. Blood Cultures
3. IV antibiotics
4. Fluid challenge
5. Check lactate
6. Urine output
35. Give them O2
• Supplemental O2
– maximise O2 available
• Use High flow
– Cautious in COPD
• Aim for SPO2 >95%
36. When the Lungs Fail
• High risk of ARDS
• May require NIV
– CPAP or BiPAP for more support
• This fails = mechanical ventilation
37. Mechanical Ventilation in Sepsis
• Use low tidal volumes 6-8ml/kg/IBW
• Optimise your PEEP
• Keep plateau pressure <30
• Sit them up to 30°
• Check cuff pressure
• Avoid hyperoxia
38. Hypotension is Bad
• Sepsis = vascular depleted!
Results in:
• Peripheral hypoperfusion
• Myocardial dysfunction
All this = Hypotension
39. Fluid Resuscitation
• Start with fluid bolus:
• 20-40ml/kg
• Fluid choice
– Saline vs CSL
• Hb <70 give blood
• Look for: ↑BP, ↓HR, ↑Urine Output
40. When Fluids Fail
Need to improve hearts:
• Contractility
• Cardiac out
Use Vasopressors/Inotrope
• Noradrenaline
• Dopamine
• Vasopressin/Adrenaline
44. Renal Dose Dopamine
Myth that it prevents:
• Acute renal failure
• Does increase contractility slightly
• Limited evidence in low doses
• It works if ICU don’t want the patient!
45. Early Appropriate AB’s
• 1st dose within 1 hour
• Broad spectrum first
• Greatly reduces mortality
• Duration 7-10 days
• Consider antifungals/viral in special pop
53. Being Supportive
• Pressure area care
• Stress ulcer prophylaxis
• DVT prophylaxis
• Glucose control
• Family support
54. Family
• High mortality
• Often elderly/comorbidities
• Discuss advanced care planning
– Patient & Family
– Describe likely outcomes
– Set realistic expectations
61. Take Home Points
Sepsis:
– Time sensitive disease
– Be suspicious & look for it
– When you find it – get help STAT
– Requires early intervention
• Antibiotics & fluids within 1 hour!