sepsis septic shock POCUS critical care ICU

1. HOW
to optimize source control ?
Dr Hossam Afify
MD , PhD , SFCCM , EDIC
Adult critical care consultant ( KAMC , KSA)

2. NO COI

3. Introduction
• there is consensus that antibiotic therapy and source control are the
major therapies for severe infections,
• source control has been consistently ignored by many studies, and its
exact role, particularly the timing and methodology used, remains
uncertain.
• Source control is receiving only limited attention in the first hour of
sepsis treatment, disproportional to its impact on outcome.

4. The objectives
• clarifing the importance of proper source control
• Understanding the proper ways by which we can control the sepsis
• Explaininig how is the team work and plan decrease mortality
• Finally , the role of point of care ultrasound ?

5. You obliged to
know
But
Not obliged to
follow

9. Figure it out Early recognition
Fill the tank Fluid resuscitation
Fluid responsiveness
Fight the bugs Propper ABX
Source control
Fix the perfusion Monitoring : lactate , MAP , organ function
Intervention :- vasopressors +/- inotropic
Source control

10. THEY recommend that as regard source control
specific anatomic diagnosis of infection requiring
emergent source control the identified or excluded as rapidly as
possible
in patients with sepsis or septic shock, and that any required source
control intervention be implemented as soon as medically and
logistically practical after the diagnosis is made (BPS).
We recommend prompt removal of intravascular access devices that
are a possible source of sepsis or septic shock after other vascular
access has been established (BPS).

11. Impact on survival
• The impact of source control seems
to be unrelated to the
administration of appropriate
antibiotics.
• Several studies found that both are
independent predictors of
mortality
• (Bloos et al. 2015; Tellor et al. 2015),
• but there is consensus that without
adequate source control, antibiotic
therapy may have little if any effect

12. Impact on survival
• Conclusions:
• A delay in source control beyond 6
hours may have a major impact on
patient mortality.
• Adequate AT is associated with
improved patient outcome
• but compliance with guideline
recommendation requires
improvement.

13. Impact on survival
MEDUSA trial , 2017
• In conclusion,
• findings confirm that delay in anti-
microbial therapy and source
control was associated with
increased mortality

16. Who?
When?
How?

17. Infection
source
Source
control
Doctors
enemy
Who for
source control
?
How to
control this
source ?
When we
should
control this
source ?

18. Infection
source
1-What patients for source control

19. 1-What patients for source control
Source of infection
Not amenable for
source control
measures
Meningitis
Sinusitis
Pneumonia
Infectious
diarrhea
Cellulitis
Amenable for source
control measures
Para-pnumonic
effusion
Acalcular
cholecystitis
Abscess
Git ischemia
and perforation
Pyelonephrit
is with
obstruction
Line
associated
infection
Examine
all
holes and
backs

20. Source
control
2- How to control ?

21. 2- How to control ?
Ideal source
control
method ?
What is the ideal source control method
1. Effective ( debridement , drainage , de-
obstruction , restore the function and
anatomy )
2. In no time
3. Without need of surgeon or anesthesia
4. Without need of consent
5. Without need of transportation
6. Without physiological derangements

22. 2- How to control ?

23. 2- How to control ?
Drainage Debridement Restoration
of anatomy
and function
Consent and
conflict
Time to
procedure
transportation Physiological
derangement
Definitive
(open
surgery)
+++ +++ +++ +++ +++ yes +++
Debridement ++ ++ 0 ++ ++ yes ++
Drainage ++ + 0 + + No +
Device
removal
+ 0 0 +/- + No +/-
De-
obstruction
++ 0 ++ ++ ++ yes +

24. Doctors enemy
3- when we should control ?

25. • The SSC guidelines
• recommend controlling the
source of the infection as
soon as medically and
logistically practical after
the diagnosis is made
• with the suggestion to do so
within a 6-12-hour window
after diagnosis
Rhodes et al. 2017
3- when we should control ?

26. • whereas the English Royal
College of Surgeons
• recommends controlling
the source of the infection
within 6 hours in patients
with sepsis and immediately
in patients with septic shock
Royal College of Surgeons of
England 2011
3- when we should control ?

27. • The latest update of the
Surgical Infection Society
guideline on intra-abdominal
infections cites
• 24 hours as the window in
which the source needs to be
controlled,
• unless when patients have
sepsis or septic shock, when
the intervention needs to be
undertaken in a more urgent
manner
• (Mazuski et al. 2017).
3- when we should control ?

28. • Conclusion
• The target time for a favorable outcome
may be less than 6 hours from
admission.
• To improve the outcome of patients, we
should not delay surgical source control
procedures assisted by EGDT if patients
have the complication of septic shock.
3- when we should control ?

29. Delay in
source
control !!!!

30. Delay in source
control !!!!
• in 2017 there were 48.9 million cases and
11 million sepsis-related deaths
worldwide, which accounted for almost
20% of all global deaths

32. Analysis of the delay
Delay of the diagnosis
• Underestimate the sepsis
• No formal clinical assessment in
sepsis patients
• Reluctance to use the POCUS
• Use the improper diagnostic tool
• (ct abdomen without contrast to
r/o abdominal sepsis)
Correction
• Continuous education
• Formal local guideline for sepsis
management
• Optimize the use of POCUS
• Multi-discplinary approach

33. Analysis of the delay
Delay of intervention
• Availability of ER theatre
• Availability of IR 24/7
• Availability of source control
oriented surgical team
• Instability of the patient
• Complexity of the conditions

34. Sepsis team
• The management of such patients in-
volves multiple elements, including
(tasks)
1. insertion of intravenous/arterial lines and
2. setting up of hemodynamic monitoring
systems,
3. blood sampling for cultures and laboratory
testing,
4. administration of antibiotics, fluid
resuscitation, and administration of
vasoactive agents for cardiovascular
support, all of which need to be started as
soon as possible

35. Sepsis team
• patients with severe sepsis can be
better managed by a team that
includes several doctors and nurses as a
minimum, but also possibly an
infectious diseases specialist,
radiographers, phlebotomist,
pharmacist, and surgeon, depending on
local resources

36. Sepsis team
• In such teams, each member will
have their own predefined role to
insure that all the essential aspects
of initial management are covered.
• One member of the team would be
clearly identified as the leader to
direct and coordinate the overall
management process.

37. Sepsis team
• The ‘sepsis team’ should be available
24/7

38. Sepsis team
• dedicated ‘shock room’ rather than a mobile
sepsis team, which is
1. staffed permanently by a team of nurses and doc- tors
trained in shock management, including septic shock,
2. and is equipped with all the necessary monitoring
devices, intravascular lines and phlebotomy
equipment, a ventilator ready for use, and essential
intravenous solutions and drugs.

39. Not only the team but also the plan

40. Case Break

41. • 50 y leukemic patient on mechanical ventilation because HAP
• at 3:00 AM he developed new onset of hypotension , no clear source
of sepsis but his abdomen is markedly tense and tender
• however the adequate resuscitation and broad spectrum ABX he
remained refractory shocked and rising lactate
• Vasopressors + hydrocortisone started
• POCUS : free turbid Intra abdominal fluid , normal LV and RV size and
function
• One hour later he became anuric , hypothermic and HAGMA
• WHAT IS BEST MANAGMNT PLAN ?
Case

42. What is the best the answer ?
a) Discuss code status
b) Support patient by all vasopressors , bicarb infusion and discuses
the case with surgery team after morning endorsement
c) Send patient for pan CT to search for diagnosis of the source
d) OR … it is possible perforated viscus : for exploration , lavage ,
resection and re-anestemosis
e) OR … it is possible perforated viscus : for exploration , lavage ,
colostomy , packing and temporary closing , send him back to ICU
for further support then discuss with his plan of definitive surgery

43. Surg Clin North Am. 2012 Apr;92(2):243-57, viii. doi:
10.1016/j.suc.2012.01.006. Epub 2012 Jan 26

44. Damage control surgery in sepsis
Action Venue Goals
Stage 0 Initial Resuscitation +
Hypothermia
Acidosis
coagulopathy
ER
ICU
1. Adequate tissue perfusion
2. Adequate preload
3. Adequate systemic pressure
Stage 1 Initial laparotomy ER
theater
OR
(main)
1. Reresection without re-anestemosis
2. Temporary drainage
3. Abdominal packing
4. Temporary abdominal closure
Stage 2 Subsequent resuscitation ICU 1. Optimize fluid resuscitation
2. Protective lung strategy
3. Optimum nutrional support
4. Abdominal compartmental syndrome
Stage 3 Subsequent surgeries OR 1. Control of the septic source( if not done at the initial operation)
2. On-demand vs planned
Stage 4 Definitive Abdominal Wall
Closure
OR 1. Re-anstmosis
2. Definitive abdominal closure

45. • The patient came from OR exploration , lavage , colostomy , packing
and temporary closing , send him back to ICU for further support ,
stable Hemodynamics , improving metabolic acidosis
• After 3 days , he started to worse again , more drop of blood pressure
and leukocytosis with worsen the oxygenation
Same Case
What's your plan ?

46. The answer ?
• Discuss code status
• Support patient by all vasopressors , bicarb infusion and discuses the
case with surgery team after morning endorsement
• Send full septic screen , start vancomycin
• Start vancomycin , remove the central line , book for pleural drainage
whenever possible
• Start vancomycin , remove the central line now , pleural drainage
within 6 hours POCUS guided , call the surgeon for possible
debridement ASAP

47. Role of
POCUS is
septic shock

48. Role of POCUS in sepsis
• targeted abdominal POCUS is quick and easy to perform
with 83% percent of emergency studies being completed in
less than 10 minutes.
• It can also be easily taught to learners.
• After a focused training course, novice ultrasound users
with no prior ultrasound experience were able to attain
moderate to perfect degree of agreement with
experienced radiologists when looking at characteristics of
biliary ultrasound.
• POCUS is also effective in decreasing the length of stay of
patients in the emergency department when compared
with those who received a radiologist performed
ultrasound with the length of stay decreasing by 11%
during daytime hours and up to 20% during afterhours.

49. The role of POCUS in sepsis ( 3D )
a) Diagnose
a) Septic or no?
b) If septic where is the source?
b) Deranged physiology correction
a) USG-fluid management
b) USG-CVL
c) Drain
a) USG- pleural drain insertion
b) USG- cholecystostomy drain
c) USG- Ascitic drain
d) USG- arthrocentesis
e) USG- LP

50. The role of POCUS in sepsis
a) Diagnose
a) Septic or no?
b) If septic where is the source?
b) Deranged physiology correction
a) USG-fluid management
b) USG-CVL
c) Drain
a) USG- pleural drain insertion
b) USG- cholecystostomy drain
c) USG- Ascitic drain
d) USG- arthrocentesis
e) USG- LP

51. The role of POCUS in sepsis
a) Diagnose
a) Septic or no?
b) If septic where is the source?
b) Deranged physiology correction
a) USG-fluid management
b) USG-CVL
c) Drain
a) USG- pleural drain insertion
b) USG- cholecystostomy drain
c) USG- Ascitic drain
d) USG- arthrocentesis
e) USG- LP

52. The role of POCUS in sepsis
a) Diagnose
a) Septic or no?
b) If septic where is the source?
b) Deranged physiology correction
a) USG-fluid management
b) USG-CVL
c) Drain
a) USG- pleural drain insertion
b) USG- cholecystostomy drain
c) USG- Ascitic drain
d) USG- arthrocentesis
e) USG- LP

53. WHERE IS THE SOURCE ( POCUS approach)
Assess the heart Assess the lung
Assess the abdomen Assess the soft tissue

54. Cardiac
• Transthoracic echocardiography shows 84%
sensitivity for vegetations of more than 10
mm in size.
• Recent case reports have highlighted how
POCUS can identify endocarditis and
facilitate rapid management of septic
patients with relatively large vegetations .
• Bugg CW, Berona K. Point-of-Care Ultrasound Diagnosis of Left-
Sided Endocarditis. West J Emerg Med. 2016;17(3):383.

55. LUNG
• In early pneumonia, B lines and areas of
subpleural consolidation can be
identified;
• in later stages of pneumonia,
hepatisation, the shred sign, air, dynamic
bronchograms as well as associated
pleural effusions or empyemas can be
identified
• Llamas-Alvarez AM, Tenza-Lozano EM, Latour-Perez J. Accuracy of Lung
Ultrasonography in the Diagnosis of Pneumonia in Adults: Systematic Review and
Meta-Analysis. Chest. 2017;151(2):374-82.

56. Abodomen
• acalculia cholecystitis POCUS has also been
assessed for the diagnosis of acute cholecystitis
and found to be highly sensitive and specific
(87% and 82%) when the criteria of gallstones
plus an additional finding of a sonographic
Murphy’s sign, gallbladder wall thickness, or
pericholecystic fluid is used for assessment.
• Results of POCUS for biliary disease have been
shown to be similarly accurate to findings of
radiologist performed ultrasounds (sensitivity
83% and specificity 86%).
• Hilsden R, et al. Trauma Surg Acute Care Open 2018;3:e000164.
doi:10.1136/tsaco-2018-000164

57. Abodomen
• When the appendix is visualised, POCUS has
a sensitivity of nearly 100 % and specificity
of 80–90 %
• In suspected appendicitis, POCUS could be
especially useful in pregnant and paediatric
patients.
• Lam SH, Grippo A, Kerwin C, Konicki PJ,
Goodwine D, Lambert MJ. Bedside
ultrasonography as an adjunct to routine
evaluation of acute appendicitis in the
emergency department. West J Emerg
Med. 2014;15(7):808-15.

58. Abodomen
• Diverticulitis can be appreciated on
ultrasound by colonic oedema, sometimes
producing an image called the “pseudo
kidney” sign (as it resembles a kidney).
• There are few reports on use of POCUS for
diverticulitis; however, it can be useful as a
rule in test
• Abboud ME, Frasure SE, Stone MB. Ultrasound
diagnosis of diverticulitis. World J Emerg Med.
2016;7(1):74-6.

59. Abodomen
• Rosen et al. first described the use of
ultrasound in the emergency department
for flank pain in 1997
• POCUS for hydronephrosis has a sensitivity
of 72–83.3% and a varying specificity,
similar to radiology-performed
ultrasonography
• Rosen CL, Brown DF, Sagarin MJ, Chang Y, McCabe CJ,
Wolfe RE. Ultrasonography by emergency physicians in
patients with suspected ureteral colic. J Emerg Med.
1998;16(6):865-70.

60. Soft tissue infection
• Musculoskeletal POCUS is the next step, especially if no obvious source of
infection has yet been identified.
• Cellulitis is the most common type of soft tissue infection.
• A cobblestone-like appearance on ultrasound, although not specific, indicates
inflamed tissue and combined with the clinical examination, can be helpful in
diagnosis of cellulitis.
• In occult abscess, POCUS has been shown to alter patient management in up
to half of patients .
• POCUS can also identify necrotising fasciitis and expedite management.
• Tayal VS, Hasan N, Norton HJ, Tomaszewski CA. The effect of soft- tissue ultrasound on the management of cellulitis
in the emergency department. Acad Emerg Med. 2006;13(4):384-8

61. Take Home Messages
THM
•Patient assessment
•Players
•Plan
•POCUS
•Policy and protocol
Extended one hour
bundle

62. Any Question

63. THANK YOU