best practice in sepsis
DESCRIPTION
Presentation I gave to hospital surviving sepsis study day in March 2013TRANSCRIPT
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
Forget all this….Get the App!
http://lifeinthefastlane.com/2013/01/techtool-thursday-013/
Forget all this….Get the App!
http://lifeinthefastlane.com/2013/01/techtool-thursday-013/
Forget all this….Get the App!
http://lifeinthefastlane.com/2013/01/techtool-thursday-013/
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