Sepsis

SepsisA little less conversation, a little more action please

Aims of this sessionTo use Surviving Sepsis guidelines as a frameworkTo focus on practical interventions that can improve outcome in the septic patient To encourage you to think like intensive care doctorsTo be as interactive as possible

At the end of this session you will be able toDefine and use important terminologyIdentify features of organ failurePrioritise urgent interventions in the septic patientDescribe an effective fluid challenge Demonstrate how CVP can be used to guide fluid resuscitation Explain ScvO2 and how it can indicate tissue dysoxia

DefinitionsSystemic Inflammatory Response Syndrome (SIRS)SepsisSevere SepsisSeptic Shock

SIRS

SIRS2 or more of the following:Temp >38C or 90 beats/minRR >20 breaths/min or PaCO2 12,000 or 10% immature (band) forms

Sepsis

SepsisSIRS in the presence of proven or suspected infection

Severe Sepsis

Severe SepsisSepsis associated with hypotension, hypoperfusion and/or organ-dysfunction

Septic Shock

Septic ShockSepsis with hypotension despite adequate fluid resuscitationMay be vasodilatory and/or distributive shockInclude all patients on vasopressors or inotropic support

Organ FailureCVSRSRenal HepaticCNSHaematological

Prognostic effects of organ dysfunction in severe sepsis

Prevalence of hospital mortality associated with severe sepsis

Case 1You 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?

Case 2A ICU nurse asks you to urgently see an elective cardiac patient who has just arrived from theatre, ventilated but has had no medical handoverHis obs are T35.5, BP 80/50, P100, CVP 10, SpO2 99 on 40% O2

Why is this patient hypotensive?

Case 3The A&E 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?

How do we manage sepsis and septic shock?Investigate and treat sepsisTry and find and treat sourceEarly blood culturesStart antibiotics asap ideally within 1 hour and after cultures taken2) Assess extent of end organ hypoperfusion and improve oxygen delivery (early goal directed therapy)

Oxygen deliveryWhat does it mean?

Oxygen deliveryWhat 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 1.34Cardiac output = HR x SV

Fluid ChallengeWhat is the difference between an infusion and a challenge?

Fluid ChallengeWhat 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

Fluid ChallengeAim is to improve SV (and hence CO) by increasing preloadFrank-Starling mechanism

Markers of perfusionWhat are they?

Markers of perfusionWhat are they?Clinical signsWarm skin, conscious level, u/oHaemodynamic variablesCVPBloodsSerum LactateScvO2

CVPWhat does it mean?

CVPWhat does it mean?Starlings LawEstimate of LVEDV (i.e. preload)Not always a good correlation with volume-responsivenessHowever if low strongly suggestive of hypovolaemia

LactateWhat does it mean?

LactateWhat does it mean?Increased production (anaerobic glycolysis)Tissue hypoperfusionTissue dysoxiaReduced metabolismHepaticRenal2 is bad, >4 is very bad

ScvO2What does it mean?

ScvO2What does it mean?Balance between oxygen delivery and consumption (VO2)Fick principleScvO2 = SaO2 - VO2 COTarget > 70%

ScvO2What can I do if its low?

ScvO2What can I do if its low?Delivery = [Hb] x SpO2 x 1.34 x HR x SV

ScvO2What can I do if its low?Delivery = [Hb] x SpO2 x 1.34 x HR x SVFluid optimiseTransfuse packet cellsHCt > 30%Inotropes

Surviving Sepsis targets of fluid resuscitationWhat are they?SBPMAPCVPU/oLactateScvO2HCt

Surviving Sepsis targets of fluid resuscitationWhat are they?SBP > 90MAP > 65CVP 8 - 12U/o > 0.5 ml/kg/hr Lactate < 1ScvO2 >70HCt > 30

Further ManagementWhat else can be done?

Further ManagementWhat else can be done?Low tidal volume ventilationSteroids in septic shockActivated Protein CGlycaemic controlStress ulcer prophylaxisThromboprophylaxisSedation scoring / holds etc.

Any Questions?

Take Home Message(s)Early intervention saves livesSend cultures immediatelyGive antibiotics early (

At the end of this session you are now able toDefine and use important terminologyIdentify features of organ failurePrioritise urgent interventions in the septic patientDescribe 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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