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Case sepsis
- 1.
- 2. 63year old female ●PCCollapse/Generally Unwell Acute Confusion ●HPC Found collapsed on bathroom floor ● by neighbour/carer ● Not sure how long ● Lives alone Behaving confused, unable to stand unaided
- 3. Initial Observations ●GCS 13E4 V4 M5 ●HR 86, RR14, SATS 95% Bp195/90 ●BM 13.9 ●T 39.4
- 4. Collateral History ●Normally well ●Notconfused ●Recently treated for a UTI (4/7 prior) ●PMHX Learning disabilities Hypertension – NIDDM, – Rheumatic Heart Disease ● Meds Enalapril, Frusemide, Simvastatin, Metformin, Loratadine, Zopiclone
- 5. Examination ●T 38.7, pale,no rash, partial amputee ●HR125 BP187/97 ● RR 30 sats 100% on 02 Chest clear ●Bladder palpable ●GCS10 E4 V1 M5 not responding to commands, moving limbs ●Perla, Eyes deviated up to the right ●No neck stiffness
- 6. Investigations ●ECG Sr 125LAD, Intraventricular conduction delay ●ABGS pH 7.385 pCO2 3.16 pO2 23.5 HCO3 16.8 Base -9.6 (lactate 2.3) (AG 19.5) ●Urine +ve Nitrites, protein, blood, glucose
- 7. Differential Diagnosis ● SEPSIS URINARYTRACT PNEUMONIA SEPTIC ARTHRITIS INFECTIVE ENDOCARDITIS ● INTRACEREBRAL ● CVE ● SUBDURAL ● ABCESS ● KETOACIDOSIS
- 8. Management ●O2 by mask15 litres ●IV Cannulation and fluids ●Urinary Catheter ●Insulin sliding scale ●Broad spectrum antibiotic therapy ●ITU Referral
- 9. Time Course ●Origin 13.33 ●AmbulanceArrival 15.55 ●Initial Obs 16.10 ●ABGS 16.34 ●Broad spectrum antibiotic therapy 17.15 ●ITU 18.40
- 10. Surviving Sepsis Campaign ●Extent and Impact of problem ➢ 31,000 admissions to 240 adult ICU ➢ 27% of admissions ➢ Mortality 30 – 50% ➢ Burden ● International Collaboration 2002 - 2008 ● Guidelines / Bundles
- 11. Surviving Sepsis Campaign ●Definition of Sepsis ➢ Uncomplicated /SIRS ➢ Severe ➢ Septic shock ● SIRS ➢ Tº ➢ HR ➢ RR ➢ WCC
- 12. Surviving Sepsis Campaign ●Sepsis Resuscitation Bundle – 6hours – Serum Lactate – Blood Cultures – Antibiotics – Fluid resusctation CVP>8cm – ScVO2 > 70%
- 13. Surviving Sepsis Campaign ●Sepsis Management Bundle – 24 hours – Steroids – Recombinant Activated Protein C – Glucose control – Insp plateau pressure <30cm H20
- 14. Surviving Sepsis Campaign ●Implementation difficulties – Lack of recognition – Time and staffing – Need for specialised equipment and training – Lack of quality assurance measures – Lack of collaboration between specialities
- 15. Surviving Sepsis Campaign ●How to improve compliance – Education Interventions – Tools and Quality indicators – Collaboration – Sepsis preparation and organisation – Feedback
Editor's Notes
- #2 FIONN HAS ASKED ME TO SAY ALITTLE WORD ABOUT SEPSIS AND THECHALLENGES THAT WE AS A DEPARTMENT HAVE WITH IMPLEMENTING THE CURRENT GUIDELINES AS AN ILLUSTRATION I HAVE A CASE PRESENTATION AND it is A CASE ABOUT WHICH I GATHER THERE HAS BEEN SOME DISCUSSION WITH ICU REGARDING THE ISSUES
- #3 Ambulance, Origin 13.33 At scene 1342 Leftscene 15 39 At hosp 1555 Obs1610 IV nsaline 1000mls 16.10 ABGS 16.34 Urinary catheter 16.50 Ab therapy 1710 – 15 1v saline 1000mls 17.30 ITU 18.40; BIBA FOUND BY HER NEIGHBOUT COLLAPSED IN THE BATHROOM, HAVING VOMITED AND BEHAVING CONFUSED, NOT SURE HOW LONG SHEHAD BEEN THERE. SHE LIVED ALONE BUT HAD BEEN SEEN THE DAY BEFORE ABULANCE SHEET SAID CONFUSED, NOT VOCALISING UNABLE TO STAND UNAIDED CONFUSED MOVEMENT
- #8 THOUGHTS ON THE DIFFERENTIAL MY THOUGHTS WERE DIABETIC COULDNT IGNORE UTI
- #9 FIONN NOTE TAKING I WILL BE THE FIRST ONE TOADMIT THAT MY NOTE TAKING IN THIS CASE WAS RATHER LACKING TIMES ADMISSION REFERRAL
- #10 FIONN NOTE TAKING I WILL BE THE FIRST ONE TOADMIT THAT MY NOTE TAKING IN THIS CASE WAS RATHER LACKING TIMES ADMISSION REFERRAL
- #11 Although se[sis affects young and old extent is on the increase because of increased elderly pop , interventionz, antibiotic therapy 18million cases world wide Leading death in non coronaryicu Mortality very high International collaboration of european soc of icm, socoety of critical care medicine 100 countries and international sepsis forum Awareness, diagnosis,appropriate treatments and interventions, education Guidelines are systematic statements designed to assist doctors in diagnostic and therapeutic decision making Objective representation of how drs believe care should be given Instutute if healthcare improvement Database centered change measurement process Bundles A "bundle" is a group of therapies for a given disease that, when implemented together, may result in better outcomes than if implemented individually. In a bundle, the individual elements included are built around best evidence-based practices. The science supporting the individual treatment strategies in a bundle is sufficiently mature such that implementation of the approach should be considered either best practice or a reasonable and generally accepted practice.
- #12 · ··Systemic inflammatory response syndrome (SIRS). Defined by the presence of two or more of the following findings: · ··Body temperature < 36 °C (97 °F) or > 38 °C (100 °F) (··hypothermia or ··fever). · ··Heart rate > 90 beats per minute. · ··Respiratory rate > 20 breaths per minute or, on ··blood gas, a PaCO2 less than 32 ··mm Hg (4.3 ··kPa) (··tachypnea or ··hypocapnia due to ··hyperventilation). · ··White blood cell count < 4,000 cells/··mm3 or > 12,000 cells/mm3 (< 4 × 109 or > 12 × 109 cells/··L), or greater than 10% band forms (immature white blood cells). (··leukopenia, ··leukocytosis, or ··bandemia). · Sepsis. Defined as SIRS in response to a confirmed infectious process. Infection can be suspected or proven (by culture, stain, or ··polymerase chain reaction (PCR)), or a clinical syndrome pathognomonic for infection. Specific evidence for infection includes WBCs in normally sterile fluid (such as urine or ··cerebrospinal fluid (CSF)); evidence of a perforated ··viscus (free air on abdominal x-ray or CT scan; signs of ··acute peritonitis); abnormal chest x-ray (CXR) consistent with ··pneumonia (with focal opacification); or ··petechiae, ··purpura, or ··purpura fulminans. · Severe sepsis. Defined as sepsis with organ dysfunction, hypoperfusion, or hypotension. · ··Septic shock. Defined as sepsis with refractory arterial ··hypotension or hypoperfusion abnormalities in spite of adequate fluid resuscitation. Signs of systemic ··hypoperfusion may be either end-organ dysfunction or serum lactate greater than 4 mmol/L. Other signs include ··oliguria and ··altered mental status. Patients are defined as having ··septic shock if they have sepsis plus hypotension after aggressive fluid resuscitation (typically upwards of 6 liters or 40 ml/kg of ··crystalloid solution).
- #13 Antibiotics within 3 hours of edadmission and 1 hour or icu admission Abtherapy must be aprropriate > prompt 48 hour reevaluation If hypotensive orlactate > 4 give 20ml/kg bolus fluids or vasopressors to get amap >65
- #14 Antibiotics within 3 hours of edadmission and 1 hour or icu admission Abtherapy must be aprropriate > prompt 48 hour reevaluation If hypotensive orlactate > 4 give 20ml/kg bolus fluids or vasopressors to get amap >65
- #15 Inconsistency in the early diagnosis of severe sepsis and septic shock 2. Frequent inadequate volume resuscitation without defined endpoints 3. Late or inadequate use of antibiotics 4. Frequent failure to support the cardiac output when depressed 5. Frequent failure to control hyperglycemia adequately 6. Frequent failure to use low tidal volumes and pressures in acute lung injury 7. Frequent failure to treat adrenal inadequacy in refractory shock
- #16 Theseare often multifactorial and include group education, the use of the Institute for Healthcare Improvement toolkits to aid with incorporation of recommendations, close collaboration with other medical specialties such as critical care, standardized order sets, and collecting feedback