the official training programme of the Surviving Sepsis Campaign

Objectives

• Understand the importance of sepsis• Be able to recognise the septic patient• Appreciate the importance of bundle-driven care• Contribute to the delivery of that care• Know when to refer to Outreach• Acknowledge the need to monitor performance

Is sepsis important?

• Risen by 329% in 20 years

• High mortality

• Worldwide 1400 deaths a day Angus D - more?

• Most common cause of death in ICU

• 30% of patients on UK ICU have it

39.8%How many of these patients die?

0

5

10

15

20

25

30

35

Lung1 Colon2 Breast3 Sepsis4

cancers

Annual

UK mortality

(2003),

thousands

1,2,3 www.statistics.gov.uk,,

4Intensive Care National Audit Research Centre (2005)

A U.K. Perspective

Identifying the Septic Patient

ACCP/SCCM Consensus Definitions

Infection– Inflammatory response to

microorganisms, or– Invasion of normally sterile

tissues

Systemic Inflammatory Response Syndrome (SIRS)– Systemic response to a

variety of processes

Sepsis– Infection plus 2 SIRS criteria

Severe Sepsis– Sepsis– Organ dysfunction

Septic shock– Sepsis– Hypotension despite fluid

resuscitation

Bone RC et al. Chest. 1992;101:1644-55. Identifying sepsis

now known as SSI

Step 1: What is SSI?

A systemic response to a nonspecific insultInfection, trauma, surgery, massive transfusion, etc

Defined as 2 of the following:

Temperature >38.3 or <36 0C

Heart rate >90 min-1

Respiratory rate >20 min-1

White cells <4 or >12

Acutely altered mental state

Hyperglycaemia (BM>6.6) in absence of DM

Identifying sepsis

SIRSSEVERE

SEPSIS

Step 2: What counts as an infection?

Pneumonia

Urinary Tract infection

Meningitis

Endocarditis

Device relatedCentral lineCannula

AbdominalPainDiarrhoeaDistensionUrgent laparotomy

Soft tissue/ musculoskeletal

CellulitisSeptic arthritisFasciitisWound infection

Identifying sepsis

Step 3: what is Sepsis?

SSI due to an infection

Identifying sepsis

Step 4: what is Severe Sepsis?

Sepsis with organ dysfunction, hypoperfusion or hypotension

CNS: Acutely altered mental statusCVS: Syst <90 or mean <65 mmHg

Resp: SpO2 >90% only with new/ more O2 Renal: Creatinine >175 mmol/l

or UO <0.5 ml/kg/hr for 2 hrsHepatic: Bilirubin >34 mmol/lBone marrow: Platelets <100Hypoperfusion: Lactate >2 mmol/lCoagulopathy: INR>1.5 or aPTT>60s

Identifying sepsis

What is shock?

Tissue perfusion is not adequate for the tissues’ metabolic requirements

Identifying sepsis

Septic Shock

Shock secondary to systemic

inflammatory response to a new

infection

Types of Shock

Cardiogenic

Neurogenic

Hypovolaemic

Anaphylactic

and…

Putting this together

The

Severe Sepsis Screening Tool

Are any 2 of the following present and new to the patient?

Temperature >38.3 or <36 0C

Heart rate >90 min-1

Respiratory rate >20 min-1

White cells <4 or >12 g/L

Acutely altered mental status

Hyperglycaemia (glucose>6.6mmol/L) (unless diabetic)

Screening Tool

Severe Sepsis Screening Tool

If yes, patient has SSI

Is the history suggestive of a new infection?

Pneumonia

UTI

Abdo pain/ diarrhoea/ distension/ urgent laparotomy

Meningitis

Cellulitis/ septic arthritis/ fasciitis/ wound infection

Endocarditis

Catheter (incl central venous) infection

Screening Tool

If yes, patient has SSI

If yes, patient has SEPSIS

Are any of the following present and new to the patient?

Blood pressure systolic <90 or mean <65 mmHg

New or increased O2 requirement to maintain SpO2>90%

Creatinine >177 mmol/l or UO <0.5 ml/kg/hr for 2 hrs

Bilirubin >34 mmol/l

Platelets <100

Lactate >2 mmol/l

Coagulopathy: INR>1.5 or aPTT>60s

Screening Tool

If yes, patient has SEPSIS

The patient has SEVERE SEPSISStart Severe Sepsis Care Pathway

Septic Shock

• Defined as• Systolic <90 mmHg• Mean <65 mmHg• Drop of >40 mmHg from patient’s normal systolic• Lactate >4 mmol/l

Treating the severely septic patient

The Surviving Sepsis Campaign Resuscitation Bundle

• Serum lactate measured• Blood cultures obtained prior to antibiotic administration.• From the time of presentation, broad-spectrum antibiotics

administered within 1 hour for all admissions• In the event of hypotension and/or lactate >4mmol/L (36mg/dL):

– Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)

– Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg.

• In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/L (36 mg/dl): – Achieve central venous pressure (CVP) of >8 mm Hg– Achieve central venous oxygen saturation (ScvO2) >70%

… within 6 hours of onset!

What you can do

•within 1 hour

•Then ensure Critical Care assistance if shocked to complete EGDT

Sepsis Six• Oxygen

• Blood Cultures

• Antibiotics

• Fluids

• Lactate & Hb

• Insert Catheter & monitor urine output

Sepsis Six• Oxygen

• Blood Cultures

• Antibiotics

• Fluids

• Lactate & Hb

• Insert Catheter & monitor urine output

At risk groups?

• Old• Young• Ill• Infections• Malignancy• Compromised organs• Immunocompromised• Post chemotherapy• Malnutrition• Invasive lines• How many of your patients are included?

Why are patients high risk?

• Multiple ‘at risk’ factors

• Underlying disease or condition

• Need for interventions – venflons, catheters, operations, etc.

• The hospital environment: MRSA, D&V, drug resistant bacteria, etc.

Summary

• Everyone has the potential to get sepsis

• Patients by definition have a high risk of sepsis

• Easy to identify – we know what we’re looking for

• Tools – MEWS, Clinical Acumen and Experience

• Sepsis Screening Tool

Questions