1. Sepsis is SIRS which is due to aninfectionSepsis is a major cause of mortality, killingapproximately 1,400 people worldwide everyday,Surviving Sepsis Campaign (2008)

2. Severe Sepsis:A Growing Healthcare ChallengeToday>750,000cases of severesepsis/yearin the US*1,800,0001,600,0001,400,0001,200,0001,000,000800,000600,000400,000*Angus DC. Crit Care Med 2001;29:1303-10Future200,0002001 2025 2050Year600,000500,000400,000300,000200,000100,000Severe Sepsis CasesUS PopulationSepsis CasesTotal US Population/1,000 3. Severe Sepsis: Comparison WithOther Major DiseasesIncidence of Severe Sepsis Mortality of Severe Sepsis300250200150100500AIDS* Colon BreastCancerCHF SevereSepsisCases/100,000250,000200,000150,000100,00050,0000Deaths/YearAIDS* SevereSepsisBreast AMICancerNational Center for Health Statistics, 2001. American Cancer Society, 2001. *American Heart Association.2000. Angus DC et al. Crit Care Med 2001 4. SIRSINFECTIONPANCREATITISBURNSTRAUMAOTHERSEPSISSEVERESEPSISSEPTICSHOCKBacteriaFungusParasitesVirusAdapted from: Bone RC et al. Chest 1992;101:1644-55Opal SM et al. Crit Care Med 2000;28:S81-2 5. Pneumonia 50% Urinary Tractinfection Device related Central line Cannula Meningitis Endocarditis Abdominal 25% Pain Diarrhoea Distension Urgent laparotomy Soft tissue/musculoskeletal Cellulitis Septic arthritis Fasciitis Wound infection 6. Sepsis: Defining a Disease ContinuumInfection SIRS SepsisSevereSepsisSIRS with a presumed orconfirmed infectious processA clinical response arising from a nonspecificinsult, including 2 of the following:Temperature 38oC or 36oCHR 90 beats/minRespirations 20/minWBC count 12,000/mm3 or4,000/mm3 or >10% immature neutrophilsSIRS : Systemic Inflammatory Response SyndromeSEPTICSHOCKThe invasion and multiplication ofmicroorganisms such as bacteria,viruses, and parasites that are notnormally present within the body. 7. Infection/ SIRS SepsisTraumaSevereSepsisSepsis with 1 sign of organfailureCardiovascular ( hypotension)Lungs, ex: ARDSKidneys, ex : AKILiverDigestiveBrain - confusionSEPTICShockHYPOTENSION despiteadequate fluidresuscitation/RequiringVasopressors or Inotropes 8. 35 year old male patient brought to ICU with 3day old perforation, Posted for emergencyLaparatomy Has chills with fever Tachypneic- RR 40/mt, has respiratory distress, Tense abdomen, bilateral crepts, Spo2 Is on he 89% in on septic room air.shock ? Pulse 130/mt well felt, BP 80/60 mm Hg,Restless, Investigations WBC 19,000 T.B 3.5, Enzymes Normal SC-2.0 INR 2.0, Platelets 1.2 lac Lactate 5.0 SCVO2 60%, 9. Shock is defined as a life-threatening,generalized maldistribution of blood flowresulting in failure to deliver and/or utilizeadequate amounts of oxygen, leading to tissuedysoxia. Hypotension [SBP < 90 mmHg, SBP decrease of40 mmHg from baseline, or mean arterialpressure (MAP) < 65 mmHg], while commonlypresent, should not be required to define shock.Shock requires evidence of inadequate tissueperfusion on physical examination. 10. Definition of shock:Tissue perfusion is not adequate for the tissues metabolicrequirementsWhat it looks likeLow blood pressure Systolic < 90Mean < 65Drop from normal of > 40 mmHgHigh lactate (beware anyone with lactate >2!) > 4 mmol/lThese patients do even worse!Mortality upwards of 50%Tissuedysoxia 11. 1) Blood vessels dilateSame volume of blood ina smaller space2) Capillaries leakWater and solutes leave the circulation (seen as oedema)Blood reduces in volumeBlood thickens (less water, same number of cells)3) Cardiac function is impairedhistaminebradykinininterleukinsnitric oxide 12. 35 year old male patient brought to ICU with 3day old perforation, Posted for emergencyLaparatomy Has chills with fever Tachypneic- RR 40/mt, has respiratory distress, Tense abdomen, bilateral crepts, Spo2 on 89% on room air. Pulse 130/mt well felt, BP 80/60 mm Hg,Restless, Investigations WBC 19,000 T.B 3.5, Enzymes Normal SC-2.0 INR 2.0, Platelets 1.2 lac Lactate 5.0 SCVO2 60%,Severe SEPSIS 13. Severe Sepsis : Sepsis + > 1 organ dysfunctionArterial hypotensionTachycardiaAltered skin perfusionDecreased U.OHyperlactatemia Altered WBC countIncreased CRP,PCT concentrationsGeneral signs & symptomsFeverTachypneaPositive fluid balance edemaGeneral inflammatoryreactionHemodynamicalterationsSigns of organ dysfunctionHypoxemiaCoagulation abnormalitiesAltered mental status 14. tachypnea 99% tachycardia 97% fever > 38C 70% hypothermia < 36C 13% metabolic acidosis 38% acute oliguria 54% acute encephalopathy 35%.Brun-Buisson C, Doyon F, Carlet J et al Incidence, Risk Factors and Outcome of Severe Sepsis and SepticShock in Adults: A Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995 15. Acute Organ DysfunctionTachycardiaHypotension CVP PAOPAlteredConsciousnessConfusionPsychosisTachypneaPaO2 90/min1 or morethan two SD above the normalvalue for age Tachypnea Altered mental status Significant edema or positivefluid balance (> 20 mL/kg over24 hr) Hyperglycemia (plasma glucose> 140 mg/dL or 7.7 mmol/L) inthe absence of diabetes Leukocytosis (WBC count >12,000 L1) Leukopenia (WBC count 40 mm Hgin adults or less than two SDbelow normal for age) Arterial hypoxemia (Pao2/FIO2< 300) Acute oliguria (urine output 0.5 mg/dLor 44.2 mol/L Coagulation abnormalities (INR> 1.5 or aPTT > 60 s) Ileus (absent bowel sounds) Thrombocytopenia (plateletcount < 100,000 L1) Hyperbilirubinemia (plasma totalbilirubin > 4 mg dL or 70 mol/L) 20. TISSUE PERFUSIONVARIABLES Hyperlactatemia (>1mmol/L) Decreased capillary refill ormottling 21. SEVERE SEPSIS DEFINITION = SEPSIS-INDUCEDTISSUE HYPOPERFUSION OR ORGAN DYSFUNCTION(ANY OF THE FOLLOWING THOUGHT TO BE DUE TOTHE INFECTION) Sepsis-induced hypotension Lactate above upper limits laboratory normal Urine output < 0.5 mL/kg/hr for more than 2 hrs despiteadequate fluid resuscitation Acute lung injury with PaO2/FIO2 < 250 in the absence ofpneumonia as infection source Acute lung injury with PaO2/FIO2 < 200 in the presence ofpneumonia as infection source Creatinine > 2.0 mg/dL (176.8 mol/L) Bilirubin > 2 mg/dL (34.2 mol/L) Platelet count < 100,000 L Coagulopathy (international normalized ratio > 1.5) 22. TheSevere Sepsis ScreeningTool 23. Are any 2 of the following SIRS criteria present and new to your patient?Obs: Temperature > 38.3 or < 36 0C Respiratory rate > 20 min-1Heart rate > 90 bpm Acutely altered mental stateBloods: White cells < 4x109/l or > 12x109/l Glucose > 7.7 mmol/l(if patient is not diabetic)If yes,patient has SIRS 24. Is this likely to be due to an infection?For exampleCough/ sputum/ chest pain DysuriaAbdo pain/ diarrhoea/ distension Headache with neck stiffnessLine infection Cellulitis/wound infection/septicarthritis/ EndocarditisIf yes,patient has SEPSIS 25. Senior staff: check for SEVERE SEPSISBP Syst < 90 / Mean < 65(after initial fluid challenge)Lactate > 2 mmol/lUrine output < 0.5 ml/kg/hr for 2 hrsINR > 1.5aPTT > 60 sBilirubin > 34 mol/lO2 Needed to keep SpO2 > 90%Platelets < 100 x 109/lCreatinine > 177 mol/l or UO < 0.5ml/kg/hrSevere Sepsis: Ensure Outreach andSenior Doctor attend NOW! 26. When your scoring system (e.g, MEWS) triggers On admission if you suspect infection Unexpected deterioration/ failure to recover Something is just not right High white cell count 27. Everyone has the potential to get sepsis Easy to identify we know what were looking for Tools observations scoring, clinical acumen, experience Sepsis Screening Tool 28. TerimaKasih