best practice in sepsis

Best Practice Interventions in SEPSIS

By Kane Guthrie FCENA

Learning Point’s

• Case Study

• R/V evidence in sepsis care

• Approach to the septic patient

• Resuscitating & managing sepsis

SEPSIS

• Sepsis is a common life-threatening condition that occurs

when a once localised bacterial/fungal infection becomes

systemic & produces an unregulated inflammatory

immune response.

Sepsis the Problem!

• Major public health problem

• High Mortality

• Comprises 12% of ICU admits

• Burden of death 3x that of national road toll

Sepsis Pitfalls

• Fail to recognise/screen for sepsis

• Under appreciate the mortality

• Failure to respect as Time Critical Illness

The Current Code’s

The Current Code’s

Septic Shock Mortality

?

Septic Shock Mortality

25%

Meet Beryl

Beryl’s PMHx

Beryl’s PMHx

Her Legs

The Vital Signs

RR 32Temp 38.4

Her Bloods

VBG• PH: 7.18• Pao2: 20• Pco2: 44• Bic: 14• Lactate: 5.2

Routine Bloods• HB: 92• WCC: 23• K: 4.9• Sodium: 124• Creatinine: 220• CRP: 180

•Is Beryl Septic?

The Sepsis Cascade

The Patho

The Patho

Distributive shock

↓

Myocardial depression

↓

Bone marrow suppression

↓

Activation of clotting cascade > DIC

↓

Organ dysfunction

↓

MODS

Death

RECOGNISING

The Hard Part!End of the bed Look for:Temperature changes^ PulseNew or changing painChanges in resp rate↓ systolic BPConscious state (lethargy, anxiety, delirium)Prolonged CRTUrine output <30ml/hr

Risk Factors!

• Imunocompromised

• Hx of fevers/rigors

• Recent surgery

• Recent invasive procedure

• Implanted medical device (CAPD)

• AGE >65

• Recent international travel (<1 month)

• H/O contact with transmissible disease

Symptoms of Sepsis

• Cellulitis, wound, rash

• Dysuria, frequency, odour

• Abdominal pain/peritonism

• Cough/SOB

• Altered mental state

• Neck stiffness/headache

Sources of Infection

• Respiratory

• Urinary Tract

• Intra Abdominal

• Unknown

• Meningitis/septic

arthritis/skin/vascular

access devices

• 35%

• 35%

• 10%

• 10%

• 10%

How to Look for Sepsis

• FBC, U&E, CRP,Coags, Lactate• Blood cultures x2 (Indwelling devices)• MSU• CXR• Swabs • Sputum • Consider – US, CT, LP (case specific)

Lactate• Reflects cellular hypoxia

– Hypoperfusion

• Rise’s early in shock development

• Lactate ^4mmol - panic value

• Repeat – assess lactate normalisation

Blood Cultures

• Taken when infection suspected• Best during fever (high rate of capturing

organism)• From IV & Invasive devices• Before antibiotics

– But don’t delay Ab’s !

RESUSCITATION&

MANAGEMENT

The Goals of Sepsis Tx!

1. Respiratory support2. Maintain circulating blood volume3. Immediate antibiotic administration4. Removal of source

The approach

• Airway• Breathing• Circulation• Disability • Environment• Get help –MET, Dr R/V• Ensure IV access

– Make sure canula patent, not infected

The Sepsis Six

1. Give Oxygen2. Blood Cultures3. IV antibiotics4. Fluid challenge5. Check lactate6. Urine output

Respiratory Support

Hypoperfused tissue = oxygen depleted↓

Respiratory rate increases ↓

Compensatory mechanism↓

Results in metabolic acidosis

Give them O2

• Supplemental O2 – maximise O2 available

• Use High flow– Cautious in COPD

• Aim for SPO2 >95%

When the Lungs Fail

• High risk of ARDS

• May require NIV– CPAP or BiPAP for more support

• This fails = mechanical ventilation

Mechanical Ventilation in Sepsis

• Use low tidal volumes 6-8ml/kg/IBW• Optimise your PEEP• Keep plateau pressure <30• Sit them up to 30°• Check cuff pressure• Avoid hyperoxia

Hypotension is Bad

• Sepsis = vascular depleted!

Results in:• Peripheral hypoperfusion• Myocardial dysfunction

All this = Hypotension

Fluid Resuscitation

• Start with fluid bolus:• 20-40ml/kg• Fluid choice

– Saline vs CSL

• Hb <70 give blood

• Look for: ↑BP, ↓HR, ↑Urine Output

When Fluids Fail

Need to improve hearts:• Contractility• Cardiac out

Use Vasopressors/Inotrope• Noradrenaline• Dopamine• Vasopressin/Adrenaline

Which Pressor is Best?

Which Presspor is Best?

Noradrenaline seems to be popular ATM!

Time to be Invasive

Renal Dose Dopamine

Myth that it prevents:• Acute renal failure• Does increase contractility slightly• Limited evidence in low doses

• It works if ICU don’t want the patient!

Early Appropriate AB’s

• 1st dose within 1 hour• Broad spectrum first• Greatly reduces mortality• Duration 7-10 days• Consider antifungals/viral in special pop

Kumar Study!

Before AB’s Check

• Allergies• Clinical condition/likely source

– Renal function• Local policy • Previous antibiotics• Cultures & sensitivities

Steroids: Fried or Foe?

Role of Roid’s

Role of Roid’s

Consider in vasopressor resistant shock

Source Control

Aim to:• Control focus of infection• Facilitate restoration of optimal A & P

Through:• Drainage, debridement, removal

Source Control

Being Supportive

• Pressure area care• Stress ulcer prophylaxis• DVT prophylaxis• Glucose control• Family support

Family

• High mortality• Often elderly/comorbidities• Discuss advanced care planning

– Patient & Family– Describe likely outcomes– Set realistic expectations

Complications of Sepsis

Resuscitation End Points

• ↑Systolic improving• ↓CRT• Warming of extremities• Urine output ↑0.5mls/kg/hr• Improving mental status• Lactate normalisation

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Questions

Take Home Points

Sepsis:– Time sensitive disease– Be suspicious & look for it– When you find it – get help STAT– Requires early intervention

• Antibiotics & fluids within 1 hour!

Thank you