Sepsis is SIRS which is due to an infection Sepsis is a major cause of mortality, killing approximately 1,400 people worldwide every day. Surviving Sepsis Campaign (2008)

2. Sepsis is SIRS which is due to an
infection
Sepsis is a major cause of mortality, killing
approximately 1,400 people worldwide every
day,
Surviving Sepsis Campaign (2008)

3. Severe Sepsis:
A Growing Healthcare Challenge
Today
>750,000
cases of severe
sepsis/year
in the US*
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
*Angus DC. Crit Care Med 2001;29:1303-10
Future
200,000
2001 2025 2050
Year
600,000
500,000
400,000
300,000
200,000
100,000
Severe Sepsis Cases
US Population
Sepsis Cases
Total US Population/1,000

4. Severe Sepsis: Comparison With
Other Major Diseases
Incidence of Severe Sepsis Mortality of Severe Sepsis
300
250
200
150
100
50
0
AIDS* Colon Breast
Cancer§
CHF† Severe
Sepsis‡
Cases/100,000
250,000
200,000
150,000
100,000
50,000
0
Deaths/Year
AIDS* Severe
Sepsis‡
Breast AMI†
Cancer§
†National Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association.
2000. ‡Angus DC et al. Crit Care Med 2001

5. SIRS
INFECTION
PANCREATITIS
BURNS
TRAUMA
OTHER
SEPSIS
SEVERE
SEPSIS
SEPTIC
SHOCK
•Bacteria
•Fungus
•Parasites
•Virus
Adapted from: Bone RC et al. Chest 1992;101:1644-55
Opal SM et al. Crit Care Med 2000;28:S81-2

6.  Pneumonia 50%
 Urinary Tract
infection
 Device related
 Central line
 Cannula
 Meningitis
 Endocarditis
• Abdominal 25%
• Pain
• Diarrhoea
• Distension
• Urgent laparotomy
• Soft tissue/
musculoskeletal
• Cellulitis
• Septic arthritis
• Fasciitis
• Wound infection

7. Sepsis: Defining a Disease Continuum
Infection SIRS Sepsis
Severe
Sepsis
SIRS with a presumed or
confirmed infectious process
A clinical response arising from a nonspecific
insult, including  2 of the following:
•Temperature 38oC or 36oC
•HR 90 beats/min
•Respirations 20/min
•WBC count 12,000/mm3 or
4,000/mm3 or >10% immature neutrophils
SIRS : Systemic Inflammatory Response Syndrome
SEPTIC
SHOCK
The invasion and multiplication of
microorganisms such as bacteria,
viruses, and parasites that are not
normally present within the body.

8. Infection/ SIRS Sepsis
Trauma
Severe
Sepsis
Sepsis with 1 sign of organ
failure
Cardiovascular ( hypotension)
Lungs, ex: ARDS
Kidneys, ex : AKI
Liver
Digestive
Brain - confusion
SEPTIC
Shock
HYPOTENSION despite
adequate fluid
resuscitation/Requiring
Vasopressors or Inotropes

9.  35 year old male patient brought to ICU with 3
day old perforation, Posted for emergency
Laparatomy
 Has chills with fever
 Tachypneic- RR 40/mt, has respiratory distress,
 Tense abdomen, bilateral crepts,
 Spo2 Is on he 89% in on septic room air.
shock ?
 Pulse 130/mt well felt, BP 80/60 mm Hg,
Restless,
 Investigations
 WBC – 19,000 T.B 3.5, Enzymes Normal
 SC-2.0 INR 2.0, Platelets 1.2 lac
 Lactate 5.0 SCVO2 60%,

10.  Shock is defined as a life-threatening,
generalized maldistribution of blood flow
resulting in failure to deliver and/or utilize
adequate amounts of oxygen, leading to tissue
dysoxia.
 Hypotension [SBP < 90 mmHg, SBP decrease of
40 mmHg from baseline, or mean arterial
pressure (MAP) < 65 mmHg], while commonly
present, should not be required to define shock.
Shock requires evidence of inadequate tissue
perfusion on physical examination.

11. Definition of shock:
‘Tissue perfusion is not adequate for the tissues’ metabolic
requirements’
What it looks like
Low blood pressure Systolic < 90
Mean < 65
Drop from normal of > 40 mmHg
High lactate (beware anyone with lactate >2!) > 4 mmol/l
These patients do even worse!
Mortality upwards of 50%
Tissue
dysoxia

12. 1) Blood vessels dilate
Same volume of blood in
a smaller space
2) Capillaries ‘leak’
Water and solutes leave the circulation (seen as oedema)
Blood reduces in volume
Blood thickens (less water, same number of cells)
3) Cardiac function is impaired
histamine
bradykinin
interleukins
nitric oxide

13.  35 year old male patient brought to ICU with 3
day old perforation, Posted for emergency
Laparatomy
 Has chills with fever
 Tachypneic- RR 40/mt, has respiratory distress,
 Tense abdomen, bilateral crepts,
 Spo2 on 89% on room air.
 Pulse 130/mt well felt, BP 80/60 mm Hg,
Restless,
 Investigations
 WBC – 19,000 T.B 3.5, Enzymes Normal
 SC-2.0 INR 2.0, Platelets 1.2 lac
 Lactate 5.0 SCVO2 60%,
Severe SEPSIS

14. Severe Sepsis : Sepsis + > 1 organ dysfunction
Arterial hypotension
Tachycardia
Altered skin perfusion
Decreased U.O
Hyperlactatemia –
Altered WBC count
Increased CRP,
PCT concentrations
General signs & symptoms
Fever
Tachypnea
Positive fluid balance – edema
General inflammatory
reaction
Hemodynamic
alterations
Signs of organ dysfunction
Hypoxemia
Coagulation abnormalities
Altered mental status

15. • tachypnea 99%
• tachycardia 97%
• fever > 38°C 70%
• hypothermia < 36°C 13%
• metabolic acidosis 38%
• acute oliguria 54%
• acute encephalopathy 35%.
Brun-Buisson C, Doyon F, Carlet J et al Incidence, Risk Factors and Outcome of Severe Sepsis and Septic
Shock in Adults: A Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995

16. Acute Organ Dysfunction
Tachycardia
Hypotension
 CVP
 PAOP
Altered
Consciousness
Confusion
Psychosis
Tachypnea
PaO2 <70 mm Hg
SaO2 <90%
PaO2/FiO2 300
Jaundice
 Enzymes
 Albumin
 PT
Oliguria
Anuria
 Creatinine
 Platelets
 PT/APTT
 Protein C
 D-dimer
Balk. Crit Care Clin 2000;16:337-52

18. Crit Care Med 2004;32:858-73
www.NISE.cc

20. SSC 2004
SSC 2008
SSC 2012

21. GENERAL VARIABLES
INFLAMMATORY
VARIABLES
 Fever (> 38.3°C)
 Hypothermia (core temperature
< 36°C)
 Heart rate > 90/min–1 or more
than two SD above the normal
value for age
 Tachypnea
 Altered mental status
 Significant edema or positive
fluid balance (> 20 mL/kg over
24 hr)
 Hyperglycemia (plasma glucose
> 140 mg/dL or 7.7 mmol/L) in
the absence of diabetes
 Leukocytosis (WBC count >
12,000 μL–1)
 Leukopenia (WBC count <
4000 μL–1)
 Normal WBC count with
greater than 10% immature
forms
 Plasma C-reactive protein
more than two SD above the
normal value
 Plasma procalcitonin more than
two SD above the normal value

22. HEMODYNAMIC VARIABLES
ORGAN DYSFUNCTION
VARIABLES
 Arterial hypotension (SBP < 90
mm Hg, MAP < 70 mm Hg, or
an SBP decrease > 40 mm Hg
in adults or less than two SD
below normal for age)
 Arterial hypoxemia (Pao2/FIO2
< 300)
 Acute oliguria (urine output <
0.5 mL/kg/hr for at least 2 hrs
despite adequate fluid
resuscitation)
 Creatinine increase > 0.5 mg/dL
or 44.2 μmol/L
 Coagulation abnormalities (INR
> 1.5 or aPTT > 60 s)
 Ileus (absent bowel sounds)
 Thrombocytopenia (platelet
count < 100,000 μL–1)
 Hyperbilirubinemia (plasma total
bilirubin > 4 mg dL or 70 μmol/L)

23. TISSUE PERFUSION
VARIABLES
 Hyperlactatemia (>1mmol/L)
 Decreased capillary refill or
mottling

24. SEVERE SEPSIS DEFINITION = SEPSIS-INDUCED
TISSUE HYPOPERFUSION OR ORGAN DYSFUNCTION
(ANY OF THE FOLLOWING THOUGHT TO BE DUE TO
THE INFECTION)
 Sepsis-induced hypotension
 Lactate above upper limits laboratory normal
 Urine output < 0.5 mL/kg/hr for more than 2 hrs despite
adequate fluid resuscitation
 Acute lung injury with PaO2/FIO2 < 250 in the absence of
pneumonia as infection source
 Acute lung injury with PaO2/FIO2 < 200 in the presence of
pneumonia as infection source
 Creatinine > 2.0 mg/dL (176.8 μmol/L)
 Bilirubin > 2 mg/dL (34.2 μmol/L)
 Platelet count < 100,000 μL
 Coagulopathy (international normalized ratio > 1.5)

25. The
Severe Sepsis Screening
Tool

26. Are any 2 of the following SIRS criteria present and new to your patient?
Obs: Temperature > 38.3 or < 36 0C Respiratory rate > 20 min-1
Heart rate > 90 bpm Acutely altered mental state
Bloods: White cells < 4x109/l or > 12x109/l Glucose > 7.7 mmol/l
(if patient is not diabetic)
If yes,
patient has SIRS

27. Is this likely to be due to an infection?
For example
Cough/ sputum/ chest pain Dysuria
Abdo pain/ diarrhoea/ distension Headache with neck stiffness
Line infection Cellulitis/wound infection/septic
arthritis/ Endocarditis
If yes,
patient has SEPSIS

28. Senior staff: check for SEVERE SEPSIS
BP Syst < 90 / Mean < 65
(after initial fluid challenge)
Lactate > 2 mmol/l
Urine output < 0.5 ml/kg/hr for 2 hrs
INR > 1.5
aPTT > 60 s
Bilirubin > 34 μmol/l
O2 Needed to keep SpO2 > 90%
Platelets < 100 x 109/l
Creatinine > 177 μmol/l or UO < 0.5
ml/kg/hr
Severe Sepsis: Ensure Outreach and
Senior Doctor attend NOW!

29.  When your scoring system (e.g, MEWS) triggers
 On admission if you suspect infection
 Unexpected deterioration/ failure to recover
 Something is ‘just not right’
 High white cell count

30.  Everyone has the potential to get sepsis
 Easy to identify – we know what we’re looking for
 Tools – observations scoring, clinical acumen, experience
 Sepsis Screening Tool

31. Terima
Kasih