Sepsis
Wat is sepsis?
• Sepsis is een heftige immuunrespons op
bacterien / toxinen in de bloedbaan.
• Gekenmerkt door een systemi...
Wat gebeurt er bij sepsis?
• Sepsis bij circa 2% van de SEH patiënten
• Mortaliteit:
– 33% bij ernstige sepsis
– 59% bij s...
Systemic Inflammatory Response
Syndrome (SIRS)
Twee of meer criteria:
• Temperatuur >38˚C of <36˚C
• Hartslag >90/min
• Ad...
Stadia
Stadia sepsis
Sepsis

≥ 2 SIRS-verschijnselen met
verdenking op of aanwijzing voor
infectie.

Ernstige sepsis

seps...
Types of sepsis
• Sepsis:
– Two or more SIRS criteria, known or suspected infection
• Severe sepsis:
– Sepsis as above
– O...
Types of sepsis
• Septic shock:
– Severe sepsis
– Hypotension or raised lactate that does not improve with adequate
fluid ...
Wat gebeurt er bij (ernstige) sepsis?
• Lage perifere weerstand door lekkage van capillairen
en vasodilatatie
• Initieel h...
Waarom orgaanfalen?
Hoe meten we (ernstige) sepsis?
•
•
•
•
•
•

Verhoogde infectieparameters
Verhoogd lactaatgehalte
Verlaagde veneuze zuurst...
Hoe ernstig is sepsis?
Incidence of Severe Sepsis

Mortality of Severe Sepsis
250,000

250
200
150
100

200,000
Deaths/Yea...
Surviving Sepsis Campaign
A global program to:
• Reduce mortality rates
•Improve standards of care
•Secure adequate fundin...
6 Hour Resuscitation Bundle
• Early Identification
• Early Antibiotics and
Cultures
• Early Goal Directed
Therapy
Early Goal Directed Therapy
• Early goal-directed therapy (EGDT) is a
haemodynamic optimization protocol that is
proven to...
What’s the theory behind Early Goal
Directed Therapy?
In sepsis, circulatory insufficiency (intravascular volume
depletion...
Initial Resuscitation
Goals during first 6 hours:
•
•
•
•

Central venous pressure: 8–12 mm Hg
Mean arterial pressure  65...
Components of EGDT
• Fluid resuscitation and CVP monitoring
• MAP maintenance and vasopressors
• ScvO2 monitoring and bloo...
Fluid resuscitation and CVP
Monitoring
• Patients are usually fluid depleted – absolute
vs relative
• Fluid resuscitation ...
ScvO2
• Scvo2 – central venous oxygen saturation –
reflects tissue perfusion
6 - hour Severe Sepsis/
Septic Shock Bundle
•
•

•
•

• Vasopressors:
Early Detection:
– Hypotension not
– Obtain serum la...
Sepsis Resuscitation Bundle
1.
2.
3.
4.

5.
6.

Measure serum lactate
Blood cultures obtained prior to administration of a...
Sepsis in the Emergency Department
The Importance of Early Goal-Directed
Therapy for Sepsis Induced Hypoperfusion
NNT to prevent 1 event (death) = 6-8

Morta...
Antibiotics Administration
– Administration of an antimicrobial effective for isolated or suspected
pathogens within the f...
Conclusion
• Sepsis, severe sepsis and septic shock are a
serious cause of morbidity and mortality
• Early recognition of ...
Sepsis 05 12 definitief
Sepsis 05 12 definitief
Sepsis 05 12 definitief
Sepsis 05 12 definitief
Sepsis 05 12 definitief
Sepsis 05 12 definitief
Sepsis 05 12 definitief
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Sepsis 05 12 definitief

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Sepsis 05 12 definitief

  1. 1. Sepsis
  2. 2. Wat is sepsis? • Sepsis is een heftige immuunrespons op bacterien / toxinen in de bloedbaan. • Gekenmerkt door een systemische inflammatoire respons, SIRS. • Bij infecties in het bloed, urine, longen, hart, etc. • SIRS ook bij operatie en trauma • Continuum van SIRS – septische shock
  3. 3. Wat gebeurt er bij sepsis? • Sepsis bij circa 2% van de SEH patiënten • Mortaliteit: – 33% bij ernstige sepsis – 59% bij septische shock
  4. 4. Systemic Inflammatory Response Syndrome (SIRS) Twee of meer criteria: • Temperatuur >38˚C of <36˚C • Hartslag >90/min • Ademhalingsfrequentie > 20/min • Leuko’s > 12 of < 4
  5. 5. Stadia Stadia sepsis Sepsis ≥ 2 SIRS-verschijnselen met verdenking op of aanwijzing voor infectie. Ernstige sepsis sepsis met orgaanfalen zoals verwardheid, acute oligurie < 0,5 ml/kg, ARDS Septische shock sepsis met hypotensie ondanks adequate volumeresuscitatie (SBP < 90 mmHg of daling > 40 mmHg van baseline)
  6. 6. Types of sepsis • Sepsis: – Two or more SIRS criteria, known or suspected infection • Severe sepsis: – Sepsis as above – Organ dysfunction -Hypotension: systolic <90 mmHg, MAP <65 mmHg, or a decrease in 40 mmHg from usual reading -Lactate > 4mmol/L -Altered mental status -Hyperglycemia in the absence of diabetes -Hypoxemia, O2 < 93% -UOP <0.5 ml/kg/hr and/or raised urea or creatinine -Coagulopathy, INR >1.5
  7. 7. Types of sepsis • Septic shock: – Severe sepsis – Hypotension or raised lactate that does not improve with adequate fluid resuscitation • Multiple organ dysfunction: – Perfusion is compromised, ischemia and hypoxia of organs – Cardiovascular-Heart Failure, Neurological- change in LOC, Pulmonary-ARDS, Renal- Acute Renal Failure, Metabolic-acidosis, Hepatic- Liver Failure, Hematologic-Disseminated Intravascular Clotting
  8. 8. Wat gebeurt er bij (ernstige) sepsis? • Lage perifere weerstand door lekkage van capillairen en vasodilatatie • Initieel hoge cardiac output tot een kantelpunt • Inadequate weefselperfusie en weefselhypoxie • Gestoord zuurstofgebruik • Anaerobe verbranding en lactaatacidose • Oligurie • Verwardheid • Diffuus intravasale stolling
  9. 9. Waarom orgaanfalen?
  10. 10. Hoe meten we (ernstige) sepsis? • • • • • • Verhoogde infectieparameters Verhoogd lactaatgehalte Verlaagde veneuze zuurstofsaturatie Verlaagde bloeddruk Verlaagde urineproductie Diverse tekenen van orgaanfalen
  11. 11. Hoe ernstig is sepsis? Incidence of Severe Sepsis Mortality of Severe Sepsis 250,000 250 200 150 100 200,000 Deaths/Year Cases/100,000 300 150,000 100,000 50,000 50 0 AIDS* Colon Breast CHF† Severe Cancer§ Sepsis‡ †National 0 AIDS* Breast AMI† Cancer§ Severe Sepsis‡ Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association. 2000. ‡Angus DC et al. Crit Care Med. 2001;29(7):1303-1310.
  12. 12. Surviving Sepsis Campaign A global program to: • Reduce mortality rates •Improve standards of care •Secure adequate funding
  13. 13. 6 Hour Resuscitation Bundle • Early Identification • Early Antibiotics and Cultures • Early Goal Directed Therapy
  14. 14. Early Goal Directed Therapy • Early goal-directed therapy (EGDT) is a haemodynamic optimization protocol that is proven to reduce mortality in cases of severe sepsis/septic shock. • Early goal-directed therapy (EGDT) was proposed by Rivers et al in 2001. This protocol advocates aggressive treatment commencing in the emergency department to achieve certain haemodynamic goals. • This achieved a 16% absolute risk reduction for in-hospital mortality. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77.
  15. 15. What’s the theory behind Early Goal Directed Therapy? In sepsis, circulatory insufficiency (intravascular volume depletion, peripheral vasodilatation and myocardial depression), combined with an increased metabolic state could lead to an imbalance between oxygen demand and delivery, resulting in anaerobic metabolism and the potential development of multiple organ dysfunction syndrome.
  16. 16. Initial Resuscitation Goals during first 6 hours: • • • • Central venous pressure: 8–12 mm Hg Mean arterial pressure  65 mm Hg (≈95/50) Urine output  0.5 mL kg-1/hr-1 (≈40ml) Central venous (superior vena cava) [SvO2] saturation  70% Grade B
  17. 17. Components of EGDT • Fluid resuscitation and CVP monitoring • MAP maintenance and vasopressors • ScvO2 monitoring and blood transfusion + Intravenous antibiotics administration early
  18. 18. Fluid resuscitation and CVP Monitoring • Patients are usually fluid depleted – absolute vs relative • Fluid resuscitation can help to reduce the global tissue hypoxia, by increasing the cardiac output and improving oxygen delivery to the tissues • Continued fluid challenges of 500 ml
  19. 19. ScvO2 • Scvo2 – central venous oxygen saturation – reflects tissue perfusion
  20. 20. 6 - hour Severe Sepsis/ Septic Shock Bundle • • • • • Vasopressors: Early Detection: – Hypotension not – Obtain serum lactate level. responding to fluid – Titrate to MAP > 65 Early Blood Cx/Antibiotics: mmHg. – within 3 hours of • Septic shock or lactate > 4 presentation. mmol/L: – CVP and ScvO2 measured. Early EGDT: – CVP maintained >8 mmHg. Hypotension (SBP < 90, MAP – MAP maintain > 65 mmHg. < 65) or lactate > 4 mmol/L: – initial fluid bolus 20-40 ml of • ScvO2<70%with CVP > 8 crystalloid (or colloid equivalent) mmHg, MAP > 65 mmHg: per kg of body weight. – PRBCs if hematocrit < 30%. – Inotropes.
  21. 21. Sepsis Resuscitation Bundle 1. 2. 3. 4. 5. 6. Measure serum lactate Blood cultures obtained prior to administration of antibiotic From time of presentation, broad spectrum antibiotics must be administered within 3hrs of ED admission, or within 1hr of non-ED admission In the event that hypotension and/or serum lactate >4mmol a) Deliver initial minimum of 20ml/kg of crystalloid or colloid equivalent. b) Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain a MAP of ≥65mmHg. Consider insertion of urinary catheter (measure UOP) If hypotension persists and serum lactate >4mmol despite fluid resuscitation achieve a) CVP ≥8mmHg and b) (ScvO2) of ≥70%.
  22. 22. Sepsis in the Emergency Department
  23. 23. The Importance of Early Goal-Directed Therapy for Sepsis Induced Hypoperfusion NNT to prevent 1 event (death) = 6-8 Mortality (%) 60 50 Standard therapy EGDT 40 30 20 10 0 In28-day 60-day hospital mortality mortality mortality Adapted from Table 3, page 1374, with permission from Rivers E, Nguyen B, Havstad S, et al. (all Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-1377 patients)
  24. 24. Antibiotics Administration – Administration of an antimicrobial effective for isolated or suspected pathogens within the first hour of documented hypotension was associated with a survival rate of 79.9% – Each hour of delay in antimicrobial administration over the ensuing 6 hrs was associated with an average decrease in survival of 7.6%.(12) – Surviving Sepsis 2008 : “Begin IV antibiotics as early as possible and always within the first hour of recognizing severe sepsis and septic shock” Kumar et al, Intens Care Med 2009
  25. 25. Conclusion • Sepsis, severe sepsis and septic shock are a serious cause of morbidity and mortality • Early recognition of sepsis and activation of EGDT is crucial to improve the outcome • Airway maintenance, broad spectrum antibiotics, fluid resuscitation and blood pressure maintenance are the components of EGDT that should be carried out for better survival chance of the patients.

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