Code sepsis

1. CODE SEPSIS
By Kane Guthrie FCENA

2. Sepsis
• Why Code Sepsis
• R/V evidence in sepsis care
• Approach to the septic patient
• Resuscitating & managing sepsis

3. SEPSIS
• Sepsis is a common lifethreatening 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

6. The Current Code’s
Trauma
STEMI
Stroke

7. The Current Code’s
Trauma
STEMI
Stroke
7%
5%
8%
Mortality
Mortality
Mortality

8. Septic Shock Mortality

9. Septic Shock Mortality

11. Risk Factors!

12. Symptoms of Sepsis

13. Risk Assessment

14. Where to Look
• Respiratory
• 35%
• Urinary Tract
• 35%
• Intra Abdominal
• 10%
• Unknown
• 10%
• Meningitis/septic
• 10%
arthritis/skin/vascular
access devices

15. How to Look for Sepsis
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FBC, U&E, CRP,Coags, Lactate
Blood cultures x2 (Indwelling devices)
MSU
CXR
Swabs
Sputum
Consider – US, CT, LP (case specific)

16. Lactate
• Reflects cellular hypoxia
– Hypoperfusion
• Rise’s early in shock development
• Lactate ^4mmol - panic value
• Repeat – assess lactate normalisation

17. 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 !

19. The Game Plan

20. The Goals of Sepsis Tx!
1.
2.
3.
4.
Respiratory support
Maintain circulating blood volume
Immediate antibiotic administration
Removal of source

21. The approach
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•
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Airway
Breathing
Circulation
Disability
Environment
Senior DR to R/V
Ensure IV access

22. The Sepsis Six
1.
2.
3.
4.
5.
6.
Give Oxygen
Blood Cultures
IV antibiotics
Fluid challenge
Check lactate
Urine output

23. Respiratory Support
Hypoperfused tissue = oxygen depleted
↓
Respiratory rate increases
↓
Compensatory mechanism
↓
Results in metabolic acidosis

24. Give them O2
• Supplemental O2
– maximise O2 available
• Use High flow
– Cautious in COPD
• Aim for SPO2 >95%

25. When the Lungs Fail
• High risk of ARDS
• May require NIV
– CPAP or BiPAP for more support
• This fails = mechanical ventilation

26. Mechanical Ventilation in Sepsis
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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

27. Hypotension is Bad
• Sepsis = vascular depleted!
Results in:
• Peripheral hypoperfusion
• Myocardial dysfunction
All this = Hypotension

28. Fluid Resuscitation
• Start with fluid bolus:
• 20-40ml/kg
• Fluid choice
– Saline vs CSL
• Hb <70 give blood
• Look for: ↑BP, ↓HR, ↑Urine Output

29. When Fluids Fail
Need to improve hearts:
• Contractility
• Cardiac out
Use Vasoactives
• Noradrenaline
• Vasopressin
• Dopamine

30. Which Pressor is Best?

31. Which Pressor is Best?
Noradrenaline seems to be popular ATM!

32. Time to be Invasive

33. Renal Dose Dopamine
Myth that it prevents:
• Acute renal failure
• Does increase contractility slightly
• Limited evidence in low doses
• It works best if ICU don’t want the patient!

34. Early Appropriate AB’s
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1st dose within 1 hour
Broad spectrum first
Greatly reduces mortality
Duration 7-10 days
Consider antifungals/viral in special pop

35. Kumar Study!

36. Steroids: Friend or Foe?

37. Role of Roid’s

38. Role of Roid’s
Consider in vasopressor resistant shock

39. Source Control
Aim to:
• Control focus of infection
• Facilitate restoration of optimal A & P
Through:
• Drainage, debridement, removal

40. Source Control

41. Being Supportive
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Pressure area care
Stress ulcer prophylaxis
DVT prophylaxis
Glucose control
Family support

42. Complications of Sepsis

43. Questions

44. Take Home Points
Sepsis:
– Time sensitive disease
– Be suspicious & look for it
– Requires early intervention
• Antibiotics & fluids within 1 hour!