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

1. Best Practice Interventions
in SEPSIS
By Kane Guthrie FCENA

2. Learning Point’s
• Case Study
• R/V evidence in sepsis care
• Approach to the septic patient
• Resuscitating & managing sepsis

3. SEPSIS
• Sepsis is a common life-
threatening 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. Meet Beryl

12. Beryl’s PMHx

13. Beryl’s PMHx

14. Her Legs

15. The Vital Signs
RR 32
Temp 38.4

16. Her Bloods
VBG 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

17. •Is Beryl Septic?

18. The Sepsis Cascade
• Temp >38°C or < 36°C
• Heart rate >90
• Resp Rate >20
SIRS • WCC <12 or >4
• 2 SIRS +
Sepsis • Confirmed or suspected infected infection
• Sepsis +
• Signs of End Organ Damage
Severe • Hypotension (SBP <90)
Sepsis • Lactate > 4 mmol
• Severe Sepsis with persistent:
• Hypotension
Septic • Signs of End Organ Damage
Shock • Lactate > 4 mmol

19. The Patho

20. The Patho
Distributive shock
↓
Myocardial depression
↓
Bone marrow suppression
↓
Activation of clotting cascade > DIC
↓
Organ dysfunction
↓
MODS
Death

22. 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

24. 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

25. Symptoms of Sepsis
• Cellulitis, wound, rash
• Dysuria, frequency, odour
• Abdominal pain/peritonism
• Cough/SOB
• Altered mental state
• Neck stiffness/headache

26. Sources of Infection
• Respiratory • 35%
• Urinary Tract • 35%
• Intra Abdominal • 10%
• Unknown • 10%
• Meningitis/septic • 10%
arthritis/skin/vascular
access devices

27. 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)

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

29. 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 !

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

32. The approach
• Airway
• Breathing
• Circulation
• Disability
• Environment
• Get help –MET, Dr R/V
• Ensure IV access
– Make sure canula patent, not infected

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

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

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

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

37. 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

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

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

40. When Fluids Fail
Need to improve hearts:
• Contractility
• Cardiac out
Use Vasopressors/Inotrope
• Noradrenaline
• Dopamine
• Vasopressin/Adrenaline

41. Which Pressor is Best?

42. Which Presspor is Best?
Noradrenaline seems to be popular ATM!

43. Time to be Invasive

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

45. 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

46. Kumar Study!

47. Before AB’s Check
• Allergies
• Clinical condition/likely source
– Renal function
• Local policy
• Previous antibiotics
• Cultures & sensitivities

48. Steroids: Fried or Foe?

49. Role of Roid’s

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

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

52. Source Control

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

54. Family
• High mortality
• Often elderly/comorbidities
• Discuss advanced care planning
– Patient & Family
– Describe likely outcomes
– Set realistic expectations

55. Complications of Sepsis

56. Resuscitation End Points
• ↑Systolic improving
• ↓CRT
• Warming of extremities
• Urine output ↑0.5mls/kg/hr
• Improving mental status
• Lactate normalisation

57. Forget all this….Get the App!
http://lifeinthefastlane.com/2013/01/techtool-thursday-013/

58. Forget all this….Get the App!
http://lifeinthefastlane.com/2013/01/techtool-thursday-013/

59. Forget all this….Get the App!
http://lifeinthefastlane.com/2013/01/techtool-thursday-013/

60. Questions

61. Take Home Points
Sepsis:
– Time sensitive disease
– Be suspicious & look for it
– When you find it – get help STAT
– Requires early intervention
• Antibiotics & fluids within 1 hour!

62. Thank you