Surviving Sepsis


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Surviving Sepsis

  1. 1. the official training programme of the Surviving Sepsis Campaign
  2. 2. Objectives <ul><li>Understand the importance of sepsis </li></ul><ul><li>Be able to recognise the septic patient </li></ul><ul><li>Appreciate the importance of bundle-driven care </li></ul><ul><li>Contribute to the delivery of that care </li></ul><ul><li>Know when to refer to Outreach </li></ul><ul><li>Acknowledge the need to monitor performance </li></ul>
  3. 3. Is sepsis important? <ul><li>Risen by 329% in 20 years </li></ul><ul><li>High mortality </li></ul><ul><li>Worldwide 1400 deaths a day Angus D - more? </li></ul><ul><li>Most common cause of death in ICU </li></ul><ul><li>30% of patients on UK ICU have it </li></ul>
  4. 4. <ul><li>How many of these patients die? </li></ul>39.8%
  5. 5. Lung 1 Colon 2 Breast 3 Sepsis 4 cancers Annual UK mortality (2003), thousands 1,2,3,, 4 Intensive Care National Audit Research Centre (2005) A U.K. Perspective
  6. 6. Identifying the Septic Patient
  7. 7. ACCP/SCCM Consensus Definitions <ul><li>Infection </li></ul><ul><ul><li>Inflammatory response to microorganisms, or </li></ul></ul><ul><ul><li>Invasion of normally sterile tissues </li></ul></ul><ul><li>Systemic Inflammatory Response Syndrome (SIRS) </li></ul><ul><ul><li>Systemic response to a variety of processes </li></ul></ul><ul><li>Sepsis </li></ul><ul><ul><li>Infection plus </li></ul></ul><ul><ul><li> 2 SIRS criteria </li></ul></ul><ul><li>Severe Sepsis </li></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Organ dysfunction </li></ul></ul><ul><li>Septic shock </li></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Hypotension despite fluid resuscitation </li></ul></ul>Bone RC et al. Chest. 1992;101:1644-55 . Identifying sepsis now known as SSI
  8. 8. Step 1: What is SSI? A systemic response to a nonspecific insult Infection, trauma, surgery, massive transfusion, etc Defined as  2 of the following : Temperature >38.3 or <36 0 C 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 SIRS SEVERE SEPSIS
  9. 9. Step 2: What counts as an infection? Pneumonia Urinary Tract infection Meningitis Endocarditis Device related Central line Cannula Abdominal Pain Diarrhoea Distension Urgent laparotomy Soft tissue/ musculoskeletal Cellulitis Septic arthritis Fasciitis Wound infection Identifying sepsis
  10. 10. Step 3: what is Sepsis? <ul><li>SSI due to an infection </li></ul>Identifying sepsis
  11. 11. Step 4: what is Severe Sepsis? <ul><li>Sepsis with organ dysfunction, hypoperfusion or hypotension </li></ul><ul><li>CNS: Acutely altered mental status </li></ul><ul><li>CVS: Syst <90 or mean <65 mmHg </li></ul><ul><li>Resp: SpO 2 >90% only with new/ more O 2 </li></ul><ul><li>Renal: Creatinine >175 mmol/l </li></ul><ul><li>or UO <0.5 ml/kg/hr for 2 hrs </li></ul><ul><li>Hepatic: Bilirubin >34 mmol/l </li></ul><ul><li>Bone marrow: Platelets <100 </li></ul><ul><li>Hypoperfusion: Lactate >2 mmol/l </li></ul><ul><li>Coagulopathy: INR>1.5 or aPTT>60s </li></ul>Identifying sepsis
  12. 12. What is shock? <ul><li>Tissue perfusion is not adequate for the tissues’ metabolic requirements </li></ul>Identifying sepsis <ul><li>Types of Shock </li></ul><ul><ul><ul><ul><li>Cardiogenic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Neurogenic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypovolaemic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anaphylactic and… </li></ul></ul></ul></ul>Septic Shock Shock secondary to systemic inflammatory response to a new infection
  13. 13. Putting this together <ul><li>The </li></ul><ul><li>Severe Sepsis Screening Tool </li></ul>
  14. 14. Are any 2 of the following present and new to the patient? Temperature >38.3 or <36 0 C 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
  15. 15. 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
  16. 16. 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 SEPSIS Start Severe Sepsis Care Pathway
  17. 17. Septic Shock <ul><li>Defined as </li></ul><ul><ul><ul><li>Systolic <90 mmHg </li></ul></ul></ul><ul><ul><ul><li>Mean <65 mmHg </li></ul></ul></ul><ul><ul><ul><li>Drop of >40 mmHg from patient’s normal systolic </li></ul></ul></ul><ul><ul><ul><li>Lactate >4 mmol/l </li></ul></ul></ul>
  18. 18. <ul><li>Treating the severely septic patient </li></ul>
  19. 19. The Surviving Sepsis Campaign Resuscitation Bundle <ul><li>Serum lactate measured </li></ul><ul><li>Blood cultures obtained prior to antibiotic administration. </li></ul><ul><li>From the time of presentation, broad-spectrum antibiotics administered within 1 hour for all admissions </li></ul><ul><li>In the event of hypotension and/or lactate >4mmol/L (36mg/dL): </li></ul><ul><ul><li>Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent) </li></ul></ul><ul><ul><li>Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. </li></ul></ul><ul><li>In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/L (36 mg/dl): </li></ul><ul><ul><li>Achieve central venous pressure (CVP) of > 8 mm Hg </li></ul></ul><ul><ul><li>Achieve central venous oxygen saturation (ScvO2) > 70% </li></ul></ul>… within 6 hours of onset!
  20. 20. What you can do <ul><li>within 1 hour </li></ul><ul><li>Then ensure Critical Care assistance if shocked to complete EGDT </li></ul>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
  21. 22. At risk groups? <ul><li>Old </li></ul><ul><li>Young </li></ul><ul><li>Ill </li></ul><ul><li>Infections </li></ul><ul><li>Malignancy </li></ul><ul><li>Compromised organs </li></ul><ul><li>Immunocompromised </li></ul><ul><li>Post chemotherapy </li></ul><ul><li>Malnutrition </li></ul><ul><li>Invasive lines </li></ul><ul><li>How many of your patients are included? </li></ul>
  22. 23. Why are patients high risk? <ul><li>Multiple ‘at risk’ factors </li></ul><ul><li>Underlying disease or condition </li></ul><ul><li>Need for interventions – venflons, catheters, operations, etc. </li></ul><ul><li>The hospital environment: MRSA, D&V, drug resistant bacteria, etc. </li></ul>
  23. 24. Summary <ul><li>Everyone has the potential to get sepsis </li></ul><ul><li>Patients by definition have a high risk of sepsis </li></ul><ul><li>Easy to identify – we know what we’re looking for </li></ul><ul><li>Tools – MEWS, Clinical Acumen and Experience </li></ul><ul><li>Sepsis Screening Tool </li></ul>
  24. 25. the official training programme of the Surviving Sepsis Campaign Questions