Presentation at the SRMO weekly teaching for Shellharbour Hospital ED - by Dr Mahsa Fateminayyeri, MD - trainee, who covers an approach to sepsis in the ED setting, and highlights the value of a sepsis pathway to expedite antibiotic treatment and provide early resuscitation in order to promote good outcomes

1. Dr Mahsa
FATEMINAYYERI
MD
Shellharbour ED SRMO Teaching
8/4/2022

2. What is the first
thing, that comes
to your mind
when you hear
the word sepsis?

3. When do you
consider/think
about sepsis?

4. How often do you use sepsis pathway?

5. Case - 1
• Mr B.
• 85 years old
• BIBA From home – was well yesterday
• CC: fall / confusion, fever neck pain and abdominal pain, mild cough
• PMHx: AF, AVR, CCF on fluid restriction 1.5 lit/day , alcoholic cirrhosis
, C2, T2, T3 fracture

6. Physical examination
• GCS:14/15
• Dehydrated
• BP: 102/58
• HR:104
• RR:26
• Sat:91%
• Temp:36
• Neck tenderness
• Chest: crackle on right basal lung
• Abdomen: generalised tenderness
without rebound or guarding
What is most likely Dx?
What are other DDx?
What do you do next?

7. • IVF  boluses of 250mL
• Blood tests and culture
• VBG
• Brain & cervical spine CT
• CXR
• UDT

8. Lab findings
• Hb 136, Wcc 12.8 plt 76
• Na 141, K 5.1, Cr 127 (Gfr 44)
• Bili 45 (high)
• Tprot 75
• Alp 172, ggt 346, Alt45
• INR 1.4
• CRP 58
• VBG
• ph 7.31 pCO 35, HCO 17 BE - 7.4
• lactate 9.7
• UDT: trace haemolysed blood
• Investigations:
• CT brain - cerebral atrophy, nil
intracranial bleeds
• CT C spine - chronic dens
fracture, chronic T2
compression fracture
• CXR: consolidation on right
basal lung

9. Progress:
Escalated by nurse
Hypotensive  83/48
Febrile  38.8
Tachycardic  HR:102
RR: 20 sat: 92% room air
• Transferred to resus
• Fluid
• pressor
• IV AB with possible pneumonia:
• Ceftriaxone + Azithro
• CT abdo - cirrhosis and portal
hypertension with
splenomegaly, nil ascites
• CT chest - right lower lobe
consolidation with effusion,
emphysematous changes

10. progress
Still tachycardic
Hypotensive, needs pressor
not oxygen dependant, O2 sats
92% on RA, and RR 20, crackles
in R base
- CT scan showed consolidation R
base

11. Other causes off sepsis?
• Neck tenderness
• Prosthetic Aortic valve
• elevated bilirubin, mild diffuse
tenderness in abdo
• ACD:
oNot for CPR, intubation
oPalliative care
oFor ICU if reversible cause
• What would you do?

12. • Tazocin was started
• Admit in HDU
• ICU reg advice:
- Add IV gentamycin and Vancomycin
- Albumin 4% 500mls over 3 hours
- repeat VBG after this
• Positive Blood culture for
S.Aureus
• commence on fluclox 2g Q4H for IE
• No furthure investigations as patient was not for
active treatment

13. Case - 2
• A 7-month female infant
• BIB mom due to 3days of fever and lethargy
• Mum worried about smelly urine
• 3rd day post vaccination
• History of probable UTIs
• Term baby
• Was born through C/S due to breech
presentation
• Lives with mum
• Normal development
• Examination:
• sleeping in mom's cuddle, responsive on
examination
• normal wet nappies
• HR 152, cap refil <3 seconds
• RR:24
• Sat:99%
• Temp:37.3
• Right TM: erythematus, no effusions
• No lymphadenopathy
• chest and abdo: NAD
What would you do?

14. • Paediatric consult due to prolonged fever
review patient in TWH and make decision about bloods
Was transferred by own car
• UDT: clear
• bloods
• Consider LP/abx if deteriorating or specific concern for neurological infection

15. • Observed over night at
TWH
• Discharged
• likely viral illness

16. Case - 3
• 76F from home
• Had a fall last night- rolled out of bed
• Fever
• GP: started cephalexin due to UTI
• Presented to ED as :
• Got deteriorated
• unwell & rigor
• An episode of diarrhoea
• PMHx:
• Chronic kidney disease Stage 3 due to HTN
• HTN
• Hospital admission in 2018 with E coli septicaemia
• Hospital admission in March 2018 with E coli
septicaemia
• DVT following sepsis and hospital admission

17. Physical examination:
• BP: 100/60
• HR: 130
• RR:26
• Sat:97% room air
• Temp: 38
• Tongue dry
• Normal JVP
• Chest left basal crackle, cleared with coughing
• Abdomen NAD
• Calves soft, nontender, nil pedal oedema, nil
cellulitic changes
-------------------------------------------
• Lactate 3.3
• UA +++leuks

19. • WCC 12.10 x10^9/L
• Hb 129 g/L
• Plt 199 x10^9/L
• CRP 243 mg/L
• Cr 147 umol/L
• eGFR 30 mL/min/1.73m2
• Na 130
• ECG: sinus tachycardia, HR 130, no ST changes
• Impression and Plan
• sepsis
• likely source : urine
• started fluid resuscitation ( 2 L)
• IVAB ( ampicillin+ getamicin)

20. Case - 4

22. Perth Children's
Hospital death of
seven-year-old girl
waiting 2 hours in
WR

23. AIMS of the Sepsis Pathway
• Recognise sepsis early
• Initiate appropriate management including early administration of
intravenous antibiotics, preferably within 1 hour of sepsis recognition.
• Escalate early to senior clinicians and critical care support in patients
with suspected/confirmed sepsis
• Provide appropriate follow up management to ensure sepsis is
treated adequately or pathway is ceased if not required.

24. Recognition of sepsis

25. Definition of sepsis ???

26. • infection and acute, life threatening
organ dysfunction
• Prompt recognition and
treatment of these syndromes
is vital, because appropriate
resuscitation and organ
support, together with rapid
initiation of antibiotic therapy,
reduces mortality
• Septic shock = vasodilatory or
distributive shock
• sepsis despite adequate fluid
resuscitation, require
vasopressors to maintain a mean
arterial pressure (MAP) ≥65
mmHg and have a lactate >2
mmol/L

27. patients with
suspected infection
who are at risk of
sepsis but do not have
sepsis or septic shock
• Closely monitor, in case of
deterioration
• Collect blood samples, as well as
appropriate samples from sites
considered to be a potential
source of infection. Depending on
the clinical scenario, it may be
appropriate to start antibiotic
therapy while awaiting the results
of testing; antibiotic choice is
guided by the suspected source
of infection

28. • In patients with sepsis or
septic shock, start therapy
within 1 hour of
presentation to medical
care or, for ward-based
patients, development of
sepsis or septic shock

31. • There are no clear guidelines to help the clinician
identify the presence of infection or to causally link an
identified organism with sepsis. In our experience, for
this component of the diagnosis, the clinician is reliant
upon clinical suspicion derived from the signs and
symptoms of infection as well as supporting radiologic
and microbiologic data and response to therapy

32. Suspected site Symptoms/signs* Initial microbiologic evaluation¶
Upper respiratory tract Pharyngeal inflammation plus exudate ± swelling and
lymphadenopathy
Throat swab for aerobic culture
Lower respiratory tract Productive cough, pleuritic chest pain, consolidative
auscultatory findings
Sputum of good quality, rapid influenza testing, urinary
antigen testing (eg, pneumococcus, legionella; not
recommended in children), quantitative culture of
protected brush or bronchoalveolar lavage
Urinary tract Urgency, dysuria, loin, or back pain Urine culture and microscopy showing pyuria
Vascular catheters: arterial, central venous Redness or drainage at insertion site Culture of blood (from the catheter and a peripheral
site), culture catheter tip (if removed)
Indwelling pleural catheter Redness or drainage at insertion site Culture of pleural fluid (through catheter)
Wound or burn Inflammation, edema, erythema, discharge of pus Gram stain and culture of draining pus, wound culture
not reliable
Skin/soft tissue Erythema, edema, lymphangitis Culture blister fluid or draining pus; role of tissue
aspirates not proven
Central nervous system Signs of meningeal irritation CSF cell count, protein, glucose, Gram stain,
and cultureΔ
Gastrointestinal Abdominal pain, distension, diarrhea, and vomiting Stool culture for Salmonella, Shigella, or
Campylobacter; detection of Clostridium difficile toxin

33. Intra-abdominal Specific abdominal symptoms/signs Aerobic and anaerobic culture of percutaneously or
surgically drained abdominal fluid collections
Peritoneal dialysis (PD) catheter Cloudy PD fluid, abdominal pain Cell count and culture of PD fluid
Genital tract Women: Low abdominal pain, vaginal discharge
Men: Dysuria, frequency, urgency, urge incontinence,
cloudy urine, prostatic tenderness
Women: Endocervical and high vaginal swabs onto
selective media
Men: Urine Gram stain and culture
Bone Pain, warmth, swelling, decreased use Blood cultures, MRI, bone cultures at surgery or by
interventional radiology
Joint Pain, warmth, swelling, decreased range of motion Arthrocentesis with cell counts, Gram stain, and culture

34. Lab findings
●Leukocytosis (white blood cell [WBC] count >12,000 microL–1) or
leukopenia (WBC count <4000 microL–1).
●Normal WBC count with greater than 10 percent immature forms.
●Hyperglycemia (plasma glucose >140 mg/dL or 7.7 mmol/L) in the
absence of diabetes.
●Plasma C-reactive protein more than two standard deviations above
the normal value.
●Arterial hypoxemia (arterial oxygen tension [PaO2]/fraction of
inspired oxygen [FiO2] <300).
●Acute oliguria (urine output <0.5 mL/kg/hour for at least two hours
despite adequate fluid resuscitation).
●Creatinine increase >0.5 mg/dL or 44.2 micromol/L.
●Coagulation abnormalities (international normalized ratio [INR]
>1.5 or activated partial thromboplastin time [aPTT] >60
seconds).
●Thrombocytopenia (platelet count <100,000 microL–1).
●Hyperbilirubinemia (plasma total bilirubin >4 mg/dL or 70
micromol/L).
●Adrenal insufficiency (eg, hyponatremia, hyperkalemia), and
the euthyroid sick syndrome can also be found in sepsis.
●Hyperlactatemia (higher than the laboratory upper limit of
normal) (eg, >2 mmol/L)
●Plasma procalcitonin – Elevated serum procalcitonin
levels are associated with bacterial infection and sepsis

35. • Life-threatening organ dysfunction is indicated by the following features, and these are associated with a significant
risk of deterioration or death:
 impaired consciousness
 tachypnoea (respiratory rate 22 breaths/minute or more) or hypoxaemia
 hypotension (systolic blood pressure less than 90 mmHg)
• blood lactate concentration more than 2 mmol/L
• Life-threatening organ dysfunction is also indicated by the following features:
 poor peripheral perfusion or mottled skin
 acute oliguria or elevated serum creatinine (above baseline)
 low platelet count
 elevated serum bilirubin (above baseline).
 note that the lactate and blood pressure targets are not applicable to children

36. qSOFA
• The qSOFA score (also known
as quickSOFA) is a bedside
prompt that may identify
patients with suspected
infection who are at greater
risk for a poor outcome
outside the intensive care
unit (ICU).
• it was originally designed not
as a diagnostic tool but
rather as a predictive tool
that calculates the risk of
death from sepsis

37. AIMS of the Sepsis Pathway
• Recognise sepsis early
• Initiate appropriate management including early administration of
intravenous antibiotics, preferably within 1 hour of sepsis recognition.
• Escalate early to senior clinicians and critical care support in patients
with suspected/confirmed sepsis
• Provide appropriate follow up management to ensure sepsis is
treated adequately or pathway is ceased if not required.

38. Priorities in
treatment
ABC
Restore haemodynamic:
- N/S given at 30 mL/kg (actual body weight)
- Pressors : not responding to IVF / pulmonary oedema
Antibiotic within an hour

39. resusitation
• In patients with sepsis or septic shock, start therapy within 1 hour of presentation to medical care
or, for ward-based patients, development of sepsis or septic shock. Initial therapy includes:
 measuring blood lactate concentration [Note 4] [Note 5]. If initial lactate concentration is more
than 2 mmol/L, measure again within 2 to 4 hours
• beginning rapid administration of intravenous fluids to manage hypotension or a blood lactate
concentration more than 2 mmol/L. If the patient is hypotensive during or after fluid resuscitation,
give a vasopressor to maintain a mean arterial blood pressure of at least 65 mmHg
• It is important to establish whether an advance care plan is in
place and whether therapy for sepsis and septic shock is
consistent with the expressed goals of the patient

40. Targets of IVF
• MAP> 65
• Urine out put >0.5mL/kg/Hr
• As a consequence
• Improving mental status
• Improving lactate  poor marker of tissue perfusion after restoring of
perfusion

41. How to work
up sepsis?
Identify the cause
• Thorough exam
• Blood culture
• Urine culture
• Other relevant cultures
• CXR
• Abdominal imaging
CT/US
Identify complications
• CBC: anemia/
thrombocytopenia
• UEC
• Coags :DIC
• LFT
• VBG / Lactate
• Troponin : demand
hypoperfusion
• ECG : arrythmia
• CXR: ARDS
• echo

42. Antibiotics
Unknown source
gentamicin intravenously over 3 to 5 minutes + flucloxacillin 2 g intravenously, 4-hourly +
if the patient has septic shock or is at increased risk of MRSA infection: vancomycin 25 to 30 mg/kg
intravenously, as a loading dose+
if Neisseria meningitidis infection is suspected: ceftriaxone 2 g intravenously, 12-hourly or cefotaxime 2 g
intravenously, 6-hourly
• Typical features of N. meningitidis
infection include fever, meningitis
symptoms and a nonblanching, purpuric
rash.
• Leg pain, cold extremities and abnormal
skin colour may also occur. Increasingly,
N. meningitidis infection has an atypical
presentation—gastrointestinal symptoms
may predominate, as well as other
nonspecific features.
• Purpuric rash and meningitis symptoms
may be absent
• MRSA:
• Risk factors for infection with MRSA include:
• residence in an area with a high prevalence of MRSA
 previous colonisation or infection with MRSA, particularly if recent or
associated with the current episode of care [NB1]
 frequent stays, or a current prolonged stay, in a hospital with a high
prevalence of MRSA, particularly if associated with antibiotic exposure or
recent surgery
 residence in an aged-care facility with a high prevalence of MRSA,
particularly if the patient has had multiple courses of antibiotics
• current residence, or residence in the past 12 months, in a correctional
facility

43. children
• Cefotaxime or ceftriaxone can be used alone for children with sepsis,
or combined with vancomycin if the child has an increased risk of
MRSA infection
• For children 2 months or older with community-acquired septic
shock without an apparent source of infection:
• gentamicin intravenously over 3 to 5 minutes + either Cefotaxime or
Ceftriaxone + Vancomycine
• If meningitis is suspected, add to the above regimens:
• dexamethasone 0.15 mg/kg up to 10 mg intravenously, started before or with the first
dose of antibiotic, then 6-hourly
• If herpes simplex encephalitis is suspected, add to the above
regimens:
• aciclovir (child 12 years or younger: 500 mg/m2; child older than 12 years: 10 mg/kg)
intravenously, 8-hourly

49. Key Points
– Summary
Sepsis is a (preventable) killer
It affects both local and at all hospitals
Early recognition and initiation of therapy is
VITAL to prevent mortality and morbidity
Use a Sepis pathway , or be guided by the
evidence

50. Questions