Sepsis ED Induction Teaching What is Sepsis ACCPSCCM

Sepsis ED Induction Teaching

What is Sepsis?

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

SIRS criteria • Temperature >38. 3 or <36 o. C • Heart rate >90 min-1 • Respiratory rate >20 min-1 • New Confusion • BM > 7. 7 (non diabetic) • White cells <4 or >12

ACCP/SCCM Consensus Definitions • Sepsis - 2 SIRS criteria AND proven/suspected infection • Severe Sepsis – Sepsis AND evidence of organ dysfunction/ hypoperfusion Bone RC et al. Chest. 1992; 101: 1644 -55

Criteria for organ dysfunction and hypoperfusion • New/increased O 2 requirement to maintain Sp. O 2 • • • >90% Cr >177µmol/l or <0. 5 ml/hr UO over 2 hours Bili > 34 µmol/l Plts < 100, INR >1. 5 or APTT >60 s SBP < 90 mm. Hg or MAP <65 mm. Hg SBP >40 mm. Hg lower than normal BP Lactate >2

ACCP/SCCM Consensus Definitions • Septic Shock – Sepsis AND hypotension despite adequate fluid resuscitation - SBP <90 mm. Hg or MAP <65 mm. Hg or lactate > 4 after “adequate” fluid resuscitation Bone RC et al. Chest. 1992; 101: 1644 -55

Why does Sepsis matter? • Incidence • - STEMI = 600, 000 per year - CVA = 115, 000 per year - Severe Sepsis/Septic shock = 40, 000 per year Mortality - STEMI = 4 -6% with treatment - CVA = 12% - Severe Sepsis =35% - Septic Shock = 50% http: //www. survivesepsis. org Dellinger RP et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008

Surviving Sepsis Campaign • International effort to improve awareness and outcomes • Evidence-based guidelines to the management of severe sepsis & septic shock • Development of SEPSIS SIX http: //www. survivesepsis. org Dellinger RP et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008

Severe Sepsis Screening Tool • Are any 2 of the following SIRS criteria present and new to your patient? • • • Temperature >38. 3 or <36 0 C Respiratory rate >20 min-1 Heart rate >90 bpm Acutely altered mental state White cells <4 x 109/l or >12 x 109/l Glucose>7. 7 mmol/l (if patient is not diabetic) If yes, patient has SIRS

• 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 Start SEPSIS SIX

SEPSIS SIX • High flow O 2 • Take blood cultures • IV Antibiotics (& source control) • IV fluid resuscitation • Measure Hb & lactate • Monitor urine output (consider catheter) • WITHIN 1 HOUR

Check for SEVERE SEPSIS/ SEPTIC SHOCK • BP • • Syst < 90 / Mean < 65 (after initial fluid challenge) Lactate > 4 mmol/l Urine output < 0. 5 ml/kg/hr for 2 hrs INR > 1. 5 a. PTT > 60 s Bilirubin > 34 μmol/l O 2 Needed to keep Sp. O 2 > 90% Platelets < 100 x 109/l Creatinine > 177 μmol/l or UO < 0. 5 ml/kg/hr Severe Sepsis/ Septic Shock Review immediately Senior Review +/- Critical Care Review

SSC • Adherence to SSC guidelines (including sepsis 6) leads to a reduction of 20% in mortality The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Levy MM et al. ; Intensive Care Med. 2010 Feb; 36(2): 222 -31

CEM Guidelines

Trust/Departmental Guidelines

Common Pitfalls (after Audit) • Identifying severe sepsis can be difficult – early • • lactate needed. Oxygen – high flow oxygen if severe sepsis/septic shock unless good reason not to. Senior Review – we can’t help if we don’t know Antibiotics – 7. 6% increased mortality with each hour delay Request urine output monitoring

Questions

Summary SEPSIS SIX • • • High flow O 2 Take blood cultures IV Antibiotics (& source control) IV fluid resuscitation Measure Hb & lactate Monitor urine output (consider catheter) • WITHIN 1 HOUR