identifying sepsis
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Identifying Sepsis. Global Sepsis Alliance Jim O’Brien, MD, MSc Professor Assistant Director, Medical Intensive Care Unit The Ohio State University Medical Center Sepsis Alliance, Board of Directors. Identifying sepsis. What is sepsis? What do we look for in sepsis ? - PowerPoint PPT PresentationTRANSCRIPT
Identifying Sepsis...
Global Sepsis AllianceJim O’Brien, MD, MScProfessor Assistant Director, Medical Intensive Care Unit The Ohio State University Medical Center Sepsis Alliance, Board of Directors
Identifying sepsis
•What is sepsis?
•What do we look for in sepsis?
•Which patients get sepsis?
Identifying sepsis
•What is sepsis?
•What do we look for in sepsis?
•Which patients get sepsis?
What is sepsis?
•Lots of terms!!•Sepsis •Septic Shock,•SIRS•SSI (signs and symptoms of infection),•Septicaemia, Bacteraemia, •Toxic Shock Syndrome, •Bloodstream infection etc, etc ….
Definitions Infection
Inflammatory response to microorganisms, or
Invasion of normally sterile tissues
Systemic Inflammatory Response Syndrome (SIRS) Systemic response to a
variety of processes Sepsis
Infection plus 2 SIRS criteria
Severe Sepsis Sepsis Organ dysfunction
Septic shock Sepsis Hypotension despite fluid
resuscitation
Bone RC et al. Chest. 1992;101:1644-55.
Bacteria
Virus
Fungi
Parasite
Infection SIRSSepsis
Pancreatitis
Trauma
Infection
Other
Severe Sepsis
Identifying sepsis
•What is sepsis?
•What do we look for in sepsis?
•Which patients get sepsis?
Step 1: Is SIRS present?
A systemic response to a nonspecific insult Infection, trauma, surgery, massive transfusion, etc
Defined as 2 of the following:
•Temperature > 38.3 or < 36 0C•Heart rate > 90 min-1
•Respiratory rate > 20 min-1
•AVPU V, P or U•White cells < 4 or > 12• If not diabetic, blood sugar>7.7 mmol/l
Step 1: Is SIRS present?
A systemic response to a nonspecific insult Infection, trauma, surgery, massive transfusion, etc
Defined as 2 of the following:
•Temperature •Heart rate•Respiratory rate•AVPU•White cells Need a FBC
• If not diabetic, blood sugar Need to check it!!!
MEWS
Step 1: Is SIRS present?Why do we see SIRS??
Temperature: ‘Pyrogens’ raise body temperature. Later, temperature dropsas we lose excess heat
HR: To stop B.P falling, heart rate rises
RR: The body needs more oxygen in sepsis, and tissues producemore acid. RR increases to help with both.
AVPU: As B.P and cardiac output fall later in sepsis, blood flowto the brain reduces
White cells: Rise to combat infection. As they are used up, if bonemarrow is exhausted WCC falls
Blood sugar: Rises as part of our ‘stress response’
Step 2: What counts as an infection? Pneumonia 50% Urinary Tract infection Meningitis Endocarditis Device related
Central line Cannula
• Abdominal 25%• Pain• Diarrhoea• Distension• Urgent laparotomy
• Soft tissue/ musculoskeletal• Cellulitis• Septic arthritis• Fasciitis• Wound infection
Step 2: What counts as an infection?
i.e, if it sounds like an infection (history), or if it looks like an infection (examination, observations), then it
probably is an infection!!
Step 2: What counts as an infection?
Look for inflammation and for pus!
Pus- may be obvious or be deep- remember, infected sputum is pus!
Inflammation
- Develops as the body fights infection- HOT, RED, SWOLLEN and PAINFUL- May be internal (e.g, UTI)
Step 3: what is Sepsis?
SIRS which is due to an infection
Step 4: what is Severe Sepsis?
Sepsis with organ dysfunction, including shock:
CNS: Acutely altered mental status CVS: Syst <90 or mean <65 mmHg Resp: SpO2 >90% only with new/ more O2 Renal: Creatinine >177 μmol/l
or UO <0.5 ml/kg/hr for 2 hrs Hepatic: Bilirubin >34 μmol/l Bone marrow: Platelets <100 Hypoperfusion: Lactate >2 mmol/l Coagulopathy:INR>1.5 or aPTT >60secs
Septic shockDefinition of shock:‘Tissue perfusion is not adequate for the tissues’ metabolic requirements’
What it looks like
Low blood pressure Systolic < 90Mean < 65Drop from normal of > 40 mmHg
High lactate (beware anyone with lactate >2!) > 4 mmol/l
These patients do even worse!
Mortality upwards of 50%
Causes of septic shock1) Blood vessels dilate Same volume of blood in a smaller space
2) Capillaries ‘leak’ Water and solutes leave the circulation (seen as oedema) Blood reduces in volume Blood thickens (less water, same number of cells)
3) Cardiac function is impaired
histamine
bradykinin
interleukins
nitric oxide
Causes of organ failure•Reduced delivery of oxygen to the tissues•In sepsis, caused by any or all of:
• Hypoxia• Hypotension• Low cardiac output• Redistribution of blood flow• Oedema- further for oxygen to travel to cells• Small blood clots (microthrombi)• Mitochondria don’t work effectively
We need to correct these with interventions... And FAST
Putting this together
TheSevere Sepsis Screening
Tool
Severe Sepsis Screening Tool
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-1
Heart rate > 90 bpm Acutely altered mental state
Bloods: White cells < 4x109/l or > 12x109/l Glucose > 7.7 mmol/l (if patient is not diabetic)
If yes, patient has SIRS
Is this likely to be due to an infection?
For example
Cough/ sputum/ chest pain Dysuria
Abdo pain/ diarrhoea/ distension Headache with neck stiffness
Line infection Cellulitis/wound infection/septic arthritis/ Endocarditis
If yes, patient has SEPSISStart SEPSIS SIX
Senior staff: check for SEVERE SEPSIS
Severe Sepsis: Ensure Outreach and Senior Doctor attend NOW!
BP Syst < 90 / Mean < 65 (after initial fluid challenge)
Lactate > 2 mmol/l
Urine output < 0.5 ml/kg/hr for 2 hrsINR > 1.5
aPTT > 60 s
Bilirubin > 34 μmol/lO2 Needed to keep SpO2 > 90%Platelets < 100 x 109/lCreatinine > 177 μmol/l or UO < 0.5 ml/kg/hr
When to use the Screening Tool
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
Case Study
•A 55 year old man is admitted to the resuscitation room with SOB.
•He has been unwell for the past 48hrs with a productive cough, lethargy and fever.
•What will you do first?
ABCDE!
Airway Patent, 15 l/min O2 via NRBBreathing Resp Rate 40 min-1
SpO2 90%Circulation HR 130
BP 70/40Disability Agitated but GCS 15/15Exposure Temp 38.5oC
Is this sepsis??
ABCDE!
Airway Patent, 15 l/min O2 via NRBBreathing Resp Rate 40 min-1
SpO2 90%Circulation HR 130
BP 70/40Disability Agitated but GCS 15/15Exposure Temp 38.5oC
What would you do next?
Case Study 2
•An 85 year lady, discharged 3 days ago Readmitted to EAU from her nursing home
•PMH:• dementia• hypertension• malnourished
•She has not been taking her medication•Incontinent 2/7, catheterised by district nurses
•Increasingly confused over the last two days
What are the issues?
•Risk factors:• Elderly• Malnourished• Dementia- may present late• Recent hospital stay• Not compliant with medication
•Likely urinary tract infection
•What would you do now?
ABCDE
A Self-maintainedB RR 18/minC HR 110/min, BP120/60
Urine output 30ml in last 5 hoursD Confused, responds to voiceE Catheter in situ. Temp 35.4OC
What concerns you the most?Is this sepsis?
ABCDE
A Self-maintainedB RR 18/minC HR 110/min, BP120/60
Urine output 30ml in last 5 hoursD Confused, responds to voiceE Catheter in situ. Temp 35.4OC
What would you do now?What should we be doing now?
Identifying sepsis
•What is sepsis?
•What do we look for in sepsis?
•Which patients get sepsis?
At risk groups?OldYoungIllInfectionsMalignancy
How many of your patients are included?
Compromised organs Immunocompromised Post chemotherapy Malnutrition Invasive lines
Summary
•Everyone has the potential to get sepsis
•Patients by definition have a high risk of sepsis
•Easy to identify – we know what we’re looking for
•Tools – observations scoring, clinical acumen, experience
•Sepsis Screening Tool