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Best Practice in Sepsis

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Presentation I gave to hospital surviving sepsis study day in March 2013

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Best Practice in Sepsis

  1. 1. Best Practice Interventions in SEPSIS By Kane Guthrie FCENA
  2. 2. Learning Point’s• Case Study• R/V evidence in sepsis care• Approach to the septic patient• Resuscitating & managing sepsis
  3. 3. SEPSIS • Sepsis is a common life-threatening condition that occurs when a once localised bacterial/fungal infectionbecomes systemic& produces an unregulated inflammatory immune response.
  4. 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. 5. Sepsis Pitfalls• Fail to recognise/screen for sepsis• Under appreciate the mortality• Failure to respect as Time Critical Illness
  6. 6. The Current Code’sTrauma STEMI Stroke
  7. 7. The Current Code’sTrauma STEMI Stroke 7% 5% 8%Mortality Mortality Mortality
  8. 8. Septic Shock Mortality
  9. 9. Septic Shock Mortality
  10. 10. Meet Beryl
  11. 11. Beryl’s PMHx
  12. 12. Beryl’s PMHx
  13. 13. Her Legs
  14. 14. The Vital Signs RR 32 Temp 38.4
  15. 15. Her BloodsVBG Routine Bloods• PH: 7.18 • HB: 92• Pao2: 20 • WCC: 23• Pco2: 44 • K: 4.9• Bic: 14 • Sodium: 124• Lactate: 5.2 • Creatinine: 220 • CRP: 180
  16. 16. •Is Beryl Septic?
  17. 17. The Sepsis Cascade • Temp >38°C or < 36°C • Heart rate >90 • Resp Rate >20SIRS • WCC <12 or >4 • 2 SIRS +Sepsis • Confirmed or suspected infected infection • Sepsis + • Signs of End Organ DamageSevere • Hypotension (SBP <90)Sepsis • Lactate > 4 mmol • Severe Sepsis with persistent: • HypotensionSeptic • Signs of End Organ DamageShock • Lactate > 4 mmol
  18. 18. The Patho
  19. 19. The Patho Distributive shock ↓ Myocardial depression ↓ Bone marrow suppression ↓Activation of clotting cascade > DIC ↓ Organ dysfunction ↓ MODS Death
  20. 20. The Hard Part!End of the bed Look for:Temperature changes^ PulseNew or changing painChanges in resp rate↓ systolic BPConscious state (lethargy, anxiety, delirium)Prolonged CRTUrine output <30ml/hr
  21. 21. Risk Factors!• Imunocompromised• Hx of fevers/rigors• Recent surgery• Recent invasive procedure• Implanted medical device (CAPD)• AGE >65• Recent international travel (<1 month)• H/O contact with transmissible disease
  22. 22. Symptoms of Sepsis• Cellulitis, wound, rash• Dysuria, frequency, odour• Abdominal pain/peritonism• Cough/SOB• Altered mental state• Neck stiffness/headache
  23. 23. Sources of Infection• Respiratory • 35%• Urinary Tract • 35%• Intra Abdominal • 10%• Unknown • 10%• Meningitis/septic • 10% arthritis/skin/vascular access devices
  24. 24. How to Look for Sepsis• FBC, U&E, CRP,Coags, Lactate• Blood cultures x2 (Indwelling devices)• MSU• CXR• Swabs• Sputum• Consider – US, CT, LP (case specific)
  25. 25. Lactate• Reflects cellular hypoxia – Hypoperfusion• Rise’s early in shock development• Lactate ^4mmol - panic value• Repeat – assess lactate normalisation
  26. 26. 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 !
  27. 27. The Goals of Sepsis Tx!1. Respiratory support2. Maintain circulating blood volume3. Immediate antibiotic administration4. Removal of source
  28. 28. The approach• Airway• Breathing• Circulation• Disability• Environment• Get help –MET, Dr R/V• Ensure IV access – Make sure canula patent, not infected
  29. 29. The Sepsis Six1. Give Oxygen2. Blood Cultures3. IV antibiotics4. Fluid challenge5. Check lactate6. Urine output
  30. 30. Respiratory SupportHypoperfused tissue = oxygen depleted ↓ Respiratory rate increases ↓ Compensatory mechanism ↓ Results in metabolic acidosis
  31. 31. Give them O2• Supplemental O2 – maximise O2 available• Use High flow – Cautious in COPD• Aim for SPO2 >95%
  32. 32. When the Lungs Fail• High risk of ARDS• May require NIV – CPAP or BiPAP for more support• This fails = mechanical ventilation
  33. 33. Mechanical Ventilation in Sepsis• 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
  34. 34. Hypotension is Bad• Sepsis = vascular depleted!Results in:• Peripheral hypoperfusion• Myocardial dysfunctionAll this = Hypotension
  35. 35. Fluid Resuscitation• Start with fluid bolus:• 20-40ml/kg• Fluid choice – Saline vs CSL• Hb <70 give blood• Look for: ↑BP, ↓HR, ↑Urine Output
  36. 36. When Fluids FailNeed to improve hearts:• Contractility• Cardiac outUse Vasopressors/Inotrope• Noradrenaline• Dopamine• Vasopressin/Adrenaline
  37. 37. Which Pressor is Best?
  38. 38. Which Presspor is Best?Noradrenaline seems to be popular ATM!
  39. 39. Time to be Invasive
  40. 40. Renal Dose DopamineMyth that it prevents:• Acute renal failure• Does increase contractility slightly• Limited evidence in low doses• It works if ICU don’t want the patient!
  41. 41. Early Appropriate AB’s• 1st dose within 1 hour• Broad spectrum first• Greatly reduces mortality• Duration 7-10 days• Consider antifungals/viral in special pop
  42. 42. Kumar Study!
  43. 43. Before AB’s Check• Allergies• Clinical condition/likely source – Renal function• Local policy• Previous antibiotics• Cultures & sensitivities
  44. 44. Steroids: Fried or Foe?
  45. 45. Role of Roid’s
  46. 46. Role of Roid’sConsider in vasopressor resistant shock
  47. 47. Source ControlAim to:• Control focus of infection• Facilitate restoration of optimal A & PThrough:• Drainage, debridement, removal
  48. 48. Source Control
  49. 49. Being Supportive• Pressure area care• Stress ulcer prophylaxis• DVT prophylaxis• Glucose control• Family support
  50. 50. Family• High mortality• Often elderly/comorbidities• Discuss advanced care planning – Patient & Family – Describe likely outcomes – Set realistic expectations
  51. 51. Complications of Sepsis
  52. 52. Resuscitation End Points• ↑Systolic improving• ↓CRT• Warming of extremities• Urine output ↑0.5mls/kg/hr• Improving mental status• Lactate normalisation
  53. 53. Forget all this….Get the App! http://lifeinthefastlane.com/2013/01/techtool-thursday-013/
  54. 54. Forget all this….Get the App! http://lifeinthefastlane.com/2013/01/techtool-thursday-013/
  55. 55. Forget all this….Get the App! http://lifeinthefastlane.com/2013/01/techtool-thursday-013/
  56. 56. Questions
  57. 57. Take Home PointsSepsis: – Time sensitive disease – Be suspicious & look for it – When you find it – get help STAT – Requires early intervention • Antibiotics & fluids within 1 hour!
  58. 58. Thank you

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