Sepsis

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Sepsis
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Sepsis

• A little less conversation, a little more action
  please

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Aims of this session

• To use Surviving Sepsis guidelines as a framework
• To focus on practical interventions that can
  improve outcome in the septic patient
• To encourage you to think like intensive care
  doctors
• To be as interactive as possible

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At the end of this session you will be able to

• Define and use important terminology
• Identify features of organ failure
• Prioritise urgent interventions in the septic
  patient
• Describe an effective fluid challenge
• Demonstrate how CVP can be used to guide fluid
  resuscitation
• Explain ScvO2 and how it can indicate tissue
  dysoxia

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Definitions

• Systemic Inflammatory Response Syndrome (SIRS)
• Sepsis
• Severe Sepsis
• Septic Shock

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SIRS
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SIRS

• 2 or more of the following
• Temp gt38ºC or lt36ºC
• HR gt90 beats/min
• RR gt20 breaths/min or PaCO2 lt4.5kPa
• WBC gt12,000 or lt4000 cells/mm3, or gt10 immature
  (band) forms

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Sepsis
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Sepsis

• SIRS in the presence of proven or suspected
  infection

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Severe Sepsis
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Severe Sepsis

• Sepsis associated with hypotension, hypoperfusion
  and/or organ-dysfunction

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Septic Shock
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Septic Shock

• Sepsis with hypotension despite adequate fluid
  resuscitation
• May be vasodilatory and/or distributive shock
• Include all patients on vasopressors or inotropic
  support

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Organ Failure

• CVS
• RS
• Renal
• Hepatic
• CNS
• Haematological

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Prognostic effects of organ dysfunction in severe
sepsis
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Prevalence of hospital mortality associated with
severe sepsis
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Case 1

• You are called to Resus to review an 78 year old
  female who presented with confusion, fever and
  rigors.
• She is unable to give a history.
• Her observations on admission are 38.30c, BP
  70/35 Pulse 120 RR 30
• What are your thoughts?
• What would you like to do next?

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Case 2

• A ICU nurse asks you to urgently see an elective
  cardiac patient who has just arrived from
  theatre, ventilated but has had no medical
  handover
• His obs are T35.5, BP 80/50, P100, CVP 10, SpO2
  99 on 40 O2
• Why is this patient hypotensive?

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Case 3

• The AE SpR calls to discuss the case of a 50
  year old overweight, hypertensive, diabetic
  female with upper abdominal pain and shock. The
  surgeons have just started an AAA repair in
  theatre.
• Obs T35, BP 90/40, P100, RR36, SpO2 unrecordable
  
• What is the differential diagnosis?
• What would you like to do next?

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How do we manage sepsis and septic shock?

• Investigate and treat sepsis
• Try and find and treat source
• Early blood cultures
• Start antibiotics asap ideally within 1 hour and
  after cultures taken
• 2) Assess extent of end organ hypoperfusion and
  improve oxygen delivery (early goal directed
  therapy)

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Oxygen delivery

• What does it mean?

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Oxygen delivery

• What does it mean?
• Delivery (DO2) O2 content x cardiac output
• (Hb x SpO2 x 1.34) x (HR x SV)
• Oxygen content Hb x SpO2 x 1.34
• Cardiac output HR x SV

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Fluid Challenge

• What is the difference between an infusion and a
  challenge?

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Fluid Challenge

• What is the difference between an infusion and a
  challenge?
• 250 to 500 ml colloid (or blood products)
• 500 to 1000ml Hartmanns
• NOT 5 dextrose
• As fast a possible (with pressure bag)
• You at the bedside

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Fluid Challenge

• Aim is to improve SV (and hence CO) by increasing
  preload
• Frank-Starling mechanism

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Markers of perfusion

• What are they?

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Markers of perfusion

• What are they?
• Clinical signs
• Warm skin, conscious level, u/o
• Haemodynamic variables
• CVP
• Bloods
• Serum Lactate
• ScvO2

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CVP

• What does it mean?

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CVP

• What does it mean?
• Starlings Law
• Estimate of LVEDV (i.e. preload)
• Not always a good correlation with
  volume-responsiveness
• However if low strongly suggestive of
  hypovolaemia

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Lactate

• What does it mean?

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Lactate

• What does it mean?
• Increased production (anaerobic glycolysis)
• Tissue hypoperfusion
• Tissue dysoxia
• Reduced metabolism
• Hepatic
• Renal
• lt1 is normal, 1-2 is a concern, gt2 is bad,
• gt4 is very bad

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ScvO2

• What does it mean?

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ScvO2

• What does it mean?
• Balance between oxygen delivery and consumption
  (VO2)
• Fick principle
• ScvO2 SaO2 - VO2
• CO
• Target gt 70

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ScvO2

• What can I do if its low?

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ScvO2

• What can I do if its low?
• Delivery Hb x SpO2 x 1.34 x HR x SV

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ScvO2

• What can I do if its low?
• Delivery Hb x SpO2 x 1.34 x HR x SV
• Fluid optimise
• Transfuse packet cells
• HCt gt 30
• Inotropes

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Surviving Sepsis targets of fluid resuscitation

• What are they?
• SBP
• MAP
• CVP
• U/o
• Lactate
• ScvO2
• HCt

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Surviving Sepsis targets of fluid resuscitation

• What are they?
• SBP gt 90
• MAP gt 65
• CVP 8 - 12
• U/o gt 0.5 ml/kg/hr
• Lactate lt 1
• ScvO2 gt70
• HCt gt 30

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Further Management

• What else can be done?

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Further Management

• What else can be done?
• Low tidal volume ventilation
• Steroids in septic shock
• Activated Protein C
• Glycaemic control
• Stress ulcer prophylaxis
• Thromboprophylaxis
• Sedation scoring / holds etc.

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Any Questions?
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Take Home Message(s)

• Early intervention saves lives
• Send cultures immediately
• Give antibiotics early (lt1 hour on ICU, lt3 hrs
  AE)
• Aggressive targeted fluid resuscitation on the
  spot (early goal-directed therapy)
• CVC / ScvO2 if shocked / Lactate gt 4
• Involve surgeons/radiologists early (source
  control)

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At the end of this session you are now able to

• Define and use important terminology
• Identify features of organ failure
• Prioritise urgent interventions in the septic
  patient
• Describe an effective fluid challenge
• Demonstrate how CVP can be used to guide fluid
  resuscitation
• Explain ScvO2 and how it can indicate tissue
  dysoxia