SEPSIS3rd November 2011

Dr. Vimal Desai

What is sepsis?

Why should we be worried?

How to assess

How to manage

AIMS

What is sepsis?

Body’s response to infection

What is sepsis?

Why is it important?

Sepsis is common

SEPSIS KILLS!!! (36,800 deaths in UK in 2005)

Early intervention saves lives (in a study of over 15,000 patients across 30 countries over 2 years, mortality fell by 20%)

Why is it important?

SIRS

2 or more of... Temp >38oC or < 36oC

HR > 90

WCC >12 or <4

RR > 20 or PaCO2 < 4.2

SIRS

Sites of infection

Sites of infection

Chest Urine / ♀reproductive GI Biliary Cannula site Bone / joint / disc

CNS Endocarditis ENT Prosthesis Skin / soft tissue /

wound Other

SIRS + Infection = SEPSIS

Other causes of SIRS

Trauma Major surgery Blood transfusion Pancreatitis PE ACS

Other causes of SIRS

Surviving Sepsis Campaign

First hour care in sepsis or ‘sepsis six’

High flow oxygen Peripheral blood cultures IV antibiotics (as per local policy) Fluid resuscitate Serum lactate Measure hour fluid balance (?catheterise)

First hour care in sepsis or ‘sepsis six’

Next step...

Evidence of organ dysfunction

SBP < 90 / MAP < 65 / fall of 40mmHg Urine output < 0.5 ml / kg / h for adults INR > 1.5 Bilirubin > 34 Lactate > 2 O2 needed to keep SaO2 > 90% (new) Platelets < 100 Creatinine > 177 GCS < 14

Evidence of organ dysfunction

Sepsis + Organ Dysfunction = SEVERE SEPSIS

Mortality = 35%

PaO2 < 8 or SaO2 < 85% on 100% O2 or PaCO2 > 7 (>9 if chronic) or exhaustion

Stridor, tracheal tug or see-saw chest SBP < 90mmHg despite resuscitation pH < 7.15 or lactate > 6 (>4 after resus.) Seizures GCS < 9 Arrest EES > 8

Consider ITU referral if...

If severe sepsis results in SBP < 90 / MAP < 65 / a fall of 40mmHg or lactate > 4

↓

SEPTIC SHOCK

Mortality = 50%

Six hour resuscitation bundle

Further fluid resuscitation if indicated

Ensure Hb > 7 g / dl

If still shocked (low BP / ↓urine output / high lactate) insert central line and ensure CVP = 8-12mmHg; consider noradrenaline or dopamine

Check ScvO2; consider dobutamine if <70%

Six hour resuscitation bundle

APACHE II score ?Low tidal volume ventilation Ventilation care bundle Hydrocortisone ?vasopressin ?Activated protein C

ITU

Assessment of sepsis

Management of sepsis

Summary