Download - Best Practice in Sepsis
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Best Practice Interventions in SEPSIS
By Kane Guthrie FCENA
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Learning Point’s
• Case Study
• R/V evidence in sepsis care
• Approach to the septic patient
• Resuscitating & managing sepsis
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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.
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Sepsis the Problem!
• Major public health problem
• High Mortality
• Comprises 12% of ICU admits
• Burden of death 3x that of national road toll
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Sepsis Pitfalls
• Fail to recognise/screen for sepsis
• Under appreciate the mortality
• Failure to respect as Time Critical Illness
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The Current Code’s
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The Current Code’s
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Septic Shock Mortality
?
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Septic Shock Mortality
25%
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Meet Beryl
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Beryl’s PMHx
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Beryl’s PMHx
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Her Legs
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The Vital Signs
RR 32Temp 38.4
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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
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•Is Beryl Septic?
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The Sepsis Cascade
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The Patho
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The Patho
Distributive shock
↓
Myocardial depression
↓
Bone marrow suppression
↓
Activation of clotting cascade > DIC
↓
Organ dysfunction
↓
MODS
Death
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RECOGNISING
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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
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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
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Symptoms of Sepsis
• Cellulitis, wound, rash
• Dysuria, frequency, odour
• Abdominal pain/peritonism
• Cough/SOB
• Altered mental state
• Neck stiffness/headache
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Sources of Infection
• Respiratory
• Urinary Tract
• Intra Abdominal
• Unknown
• Meningitis/septic
arthritis/skin/vascular
access devices
• 35%
• 35%
• 10%
• 10%
• 10%
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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)
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Lactate• Reflects cellular hypoxia
– Hypoperfusion
• Rise’s early in shock development
• Lactate ^4mmol - panic value
• Repeat – assess lactate normalisation
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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 !
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RESUSCITATION&
MANAGEMENT
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The Goals of Sepsis Tx!
1. Respiratory support2. Maintain circulating blood volume3. Immediate antibiotic administration4. Removal of source
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The approach
• Airway• Breathing• Circulation• Disability • Environment• Get help –MET, Dr R/V• Ensure IV access
– Make sure canula patent, not infected
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The Sepsis Six
1. Give Oxygen2. Blood Cultures3. IV antibiotics4. Fluid challenge5. Check lactate6. Urine output
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Respiratory Support
Hypoperfused tissue = oxygen depleted↓
Respiratory rate increases ↓
Compensatory mechanism↓
Results in metabolic acidosis
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Give them O2
• Supplemental O2 – maximise O2 available
• Use High flow– Cautious in COPD
• Aim for SPO2 >95%
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When the Lungs Fail
• High risk of ARDS
• May require NIV– CPAP or BiPAP for more support
• This fails = mechanical ventilation
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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
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Hypotension is Bad
• Sepsis = vascular depleted!
Results in:• Peripheral hypoperfusion• Myocardial dysfunction
All this = Hypotension
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Fluid Resuscitation
• Start with fluid bolus:• 20-40ml/kg• Fluid choice
– Saline vs CSL
• Hb <70 give blood
• Look for: ↑BP, ↓HR, ↑Urine Output
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When Fluids Fail
Need to improve hearts:• Contractility• Cardiac out
Use Vasopressors/Inotrope• Noradrenaline• Dopamine• Vasopressin/Adrenaline
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Which Pressor is Best?
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Which Presspor is Best?
Noradrenaline seems to be popular ATM!
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Time to be Invasive
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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!
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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
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Kumar Study!
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Before AB’s Check
• Allergies• Clinical condition/likely source
– Renal function• Local policy • Previous antibiotics• Cultures & sensitivities
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Steroids: Fried or Foe?
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Role of Roid’s
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Role of Roid’s
Consider in vasopressor resistant shock
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Source Control
Aim to:• Control focus of infection• Facilitate restoration of optimal A & P
Through:• Drainage, debridement, removal
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Source Control
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Being Supportive
• Pressure area care• Stress ulcer prophylaxis• DVT prophylaxis• Glucose control• Family support
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Family
• High mortality• Often elderly/comorbidities• Discuss advanced care planning
– Patient & Family– Describe likely outcomes– Set realistic expectations
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Complications of Sepsis
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Resuscitation End Points
• ↑Systolic improving• ↓CRT• Warming of extremities• Urine output ↑0.5mls/kg/hr• Improving mental status• Lactate normalisation
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Forget all this….Get the App!
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Forget all this….Get the App!
http://lifeinthefastlane.com/2013/01/techtool-thursday-013/
![Page 59: Best Practice in Sepsis](https://reader031.vdocument.in/reader031/viewer/2022020115/554aee41b4c9059f798b481c/html5/thumbnails/59.jpg)
Forget all this….Get the App!
http://lifeinthefastlane.com/2013/01/techtool-thursday-013/
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Questions
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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!
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Thank you