Severe Sepsis

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Outline of the Surviving Sepsis Campaign to treat patients with severe sepsis.

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  • - Goal-directed therapy has been used for severe sepsis and septic shock. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. - International campaign: www.survivingsepsis.org
  • Severe Sepsis

    1. 2. <ul><li>21,000 cases per year </li></ul><ul><li>27% of ITU admissions </li></ul><ul><li>46% of bed days </li></ul>
    2. 3. <ul><li>Potentially 4-5 cases per month from MAU </li></ul><ul><li>More in CDU </li></ul><ul><li>About 60-70 severe sepsis cases per year </li></ul>
    3. 4. <ul><li>Several interventions are implemented together and result in a better outcome then when implemented individually </li></ul><ul><li>Every intervention in the bundle is based on irrefutable evidence and all elements in the bundle must be executed in the same place and time to ensure that clinical improvement occurs </li></ul>
    4. 5. <ul><li>New infection and any two: </li></ul><ul><li>Fever > 38.3 C </li></ul><ul><li>Hypothermia < 36 C </li></ul><ul><li>Chills and rigors </li></ul><ul><li>Tachycardia > 90 bpm </li></ul><ul><li>Tachypnoea > 20 bpm </li></ul><ul><li>Systolic BP < 90 mmHg </li></ul><ul><li>Headache or stiff neck </li></ul><ul><li>WBC > 12,000 or < 4,000 </li></ul><ul><li>Raised CRP </li></ul>
    5. 6. <ul><li>Acutely altered mental status </li></ul><ul><li>Systolic BP < 90 mmHg </li></ul><ul><li>SpO 2 < 90% on room air </li></ul><ul><li>Rising creatinine or > 176 μ mol/L or urine output < 0.5 ml/kg/hr for > 2 hours </li></ul><ul><li>Rising bilirubin or > 34 μ mol/L </li></ul><ul><li>INR > 1.5 or PTT > 60 sec </li></ul><ul><li>Platelets < 100,000 </li></ul><ul><li>Lactate > 2 mmol/L </li></ul>
    6. 7. <ul><li>To be accomplished as soon as possible and scored over the next 6 hours: </li></ul><ul><li>Measure serum lactate </li></ul><ul><li>Take blood cultures before administering antibiotics </li></ul><ul><li>Give broad spectrum antibiotics (<1 hour for ITU admissions, <3 hours for MAU admissions) </li></ul><ul><li>If hypotensive and/or lactate > 4 mmol/L: IV crystalloid at 20ml/kg and if MAP does not increase to >64 mmHg start vasopressors </li></ul><ul><li>If hypotension persists and/or lactate > 4 mmol/L: IV fluids to achieve CVP > 7 mmHg and ScvO2 > 70% </li></ul>
    7. 8. <ul><li>Blood cultures </li></ul><ul><li>IV broad spectrum antibiotics within 1 hour of diagnosis </li></ul><ul><li>Involve consultant and ITU </li></ul><ul><li>Start IV fluids </li></ul><ul><li>Catherterise bladder </li></ul><ul><li>Insert a central line and monitor CVP </li></ul><ul><li>Monitor response with lactate and BP </li></ul><ul><li>Monitor central venous oxygen saturation </li></ul><ul><li>Monitor glucose control </li></ul><ul><li>Monitor urine output (>= 0.5 ml/kg/hr) </li></ul><ul><li>Prophylactic LMWH and H 2 antagonists </li></ul><ul><li>ITU for vasopressors, inotropes and low dose steroids </li></ul><ul><li>Address source of infection </li></ul><ul><li>ALL TO BE COMPLETED WITHIN 2 HOURS OF ARRIVAL </li></ul>
    8. 9. <ul><li>To be accomplished as soon as possible and scored over the next 24 hours: </li></ul><ul><li>Low dose steroids </li></ul><ul><li>Drotecogin alfa </li></ul><ul><li>Maintain glucose control </li></ul><ul><li>For ventilated patients maintain inspiratory plateau pressures < 30 mmH2O </li></ul>
    9. 10. <ul><li>Lactate measurement is integral to the Sepsis Bundle </li></ul><ul><li>Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance </li></ul><ul><li>Lactate is a better prognostic measure than cytokines </li></ul>
    10. 11. <ul><li>16% reduction in mortality: </li></ul><ul><li>In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009) </li></ul>

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