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Sepsis in the Surgical Patient- Alastair Glossop
1. Sepsis in the surgical patient
Dr Alastair Glossop
Consultant in Anaesthesia and Intensive Care Medicine
Sheffield Teaching Hospitals NHS Foundation Trust
2. Why worry about sepsis?
• Leading cause of death in general ICUs
• Common
• Incidence is increasing:
• Affects 250 per 100,000 hospital inpatients
• 1 million cases of severe sepsis in 2010
3. Is it a problem in surgical patients?
• Yes it is
• 30% of severe sepsis occurs in surgical
patients
• Overall mortality 28.6%
• Elective surgery – 31%
• Emergency surgery – 39%
4. Why are surgeons such a problem?
The defence… The prosecution…
• Well trained • Work in a dirty
environment
• Decisive, incisive
• Insult and injury
• Obsessed with source predispose to sepsis
control • Surgery increases risk of
• Obsessed with asepsis infection elsewhere
• Close relationship with • Patients “go off” on
anaesthesia and ICU wards post op
5. What can we do to improve
this?
Start at the beginning...
6. Surviving sepsis campaign
• Committee established in 2003
• Tasked with producing evidence based
guidelines
• Reducing global mortality from sepsis
• Produced “care bundles” – targets to be
achieved at 6 and 24 hours
• Based on 5 “seminal” papers demonstrating
mortality benefit in sepsis
7.
8. Six hour goals…
• Resuscitation goals
• Also specified:
• antibiotics and source
control within 1 hour
• Lactate measurement
• Rivers protocol – level B
evidence
• Antibiotics within 1
hour – level E evidence
9. Twenty four hour goals…
Superseeded – no mortality benefit!
Superseeded – reduced mortality benefit
and increased complications!
Xigris withdrawn due to safety concerns!
Litigation being brought by families of
controls!
10. Despite being based on shaky
evidence, bundles seem to work
Early work suggested poor compliance
with bundles – 50% at 6 hours
Non compliance grt. 2 fold increase in
hospital mortality (p = 0.01)
NNT = 4
11. What really is important in reducing
mortality from sepsis?
Both Grade E recommendations
12.
13. Sepsis and Septic Shock:
An ID View Cellular dysfunction/tissue injury
Inflammatory response
Shock Threshold
Toxic burden
Microbial load
TIME
14. “An Injury Paradigm of Sepsis and Septic
Shock” Prof A Kumar, University of Manitoba
Antimicrobial
therapy
Cellular dysfunction/tissue injury
Inflammatory response
Shock Threshold
Toxic burden
Microbial load
TIME
15. “An Injury Paradigm of Sepsis
and Septic Shock” Prof A Kumar, University of Manitoba
earlier
antimicrobial
therapy
Shock Threshold
Cellular dysfunction/tissue injury
Inflammatory response
Toxic burden
Microbial load
TIME
17. “An Injury Paradigm of Sepsis and Septic
Shock” Prof A Kumar, University of Manitoba
Antimicrobial
therapy
+
Source control
Cellular dysfunction/tissue injury
Shock Threshold
Inflammatory response
Toxic burden
Microbial load
TIME
18. Audit of event timing from EWS 2 to theatre for the
deteriorating colorectal patient by stage
9 A: EWS 2 to SpR review
8
B: SpR review to Antibiotics
7
6 C: CT booking to scan
hours
5
4
D: CTscan to report
3 E: Scan to theatre booking
2
1 F: Booking to arrival
0
A B C D E F
19. Audit of event timing from EWS 2 to theatre for the
deteriorating colorectal patient by outcomes
25
20
15
Total time from
10
trigger to theatre
5
0
Survivors Non-
survivors
20.
21. The clock is ticking…
• Awareness of the
problem
• Early antibiotics
• Source control
alastair.glossop@sth.nhs.uk
