generic sepsis presentation 9aug 2011

8/9/2019 Generic Sepsis Presentation 9aug 2011

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Recognition & Managementof Sepsis


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Objectives

What is Sepsis? Why worry about Sepsis?

Pitfalls The ACI/CEC Sepsis Project How to recognise Sepsis How to treat Sepsis How to get help


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WHAT IS SEPSIS?

Definitions

Pathophysiology


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Definitions

Sepsis is the presence of infection that inducesa systemic response

Expect the patient to have signs andsymptoms of a systemic response May not always have symptoms and signs at

the site of infection


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Definitions

SIRS criteria: 2 of the following + suspected orconfirmed infection = SepsisTemp < 36C or > 38C RR > 24WCC < 4 or > 12 HR > 90

Severe Sepsis: Sepsis plus organ dysfunction Septic Shock: Sepsis with BP 90mmHg


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Excuse me SIRS!

The problems with SIRS criteria Derived from retrospective data Aim was to standardise definitions NOT aid early

recognition Only HR, RR, temperature will be available initially A large study found temperature is normal in 17% of

patients with sepsis 1 HR often affected by -blockers Not diagnostic or prognostic

1.Brun-Buisson C, Doyon F, Carlet J et al Incidence, Risk Factors and Outcome of Severe Sepsis and Septic Shock in Adults: A Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995; 968-974


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Pathophysiology

Pathogenic features of the microorganism Patients immune response to these features Failure of the immune system to control an initially

localised infection Exaggerated immune and inflammatory response Cellular dysfunction Vasodilation and leaky capillaries


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Pathophysiology

Distributive shock Myocardial depression Bone marrow suppression Activation of clotting cascade DIC Organ dysfunction

MODS Death


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Common sources of sepsis

Respiratory 35% Urinary tract 35%

Intra Abdominal 10% Unknown 10% Meningitis/septic arthritis/ 10%

skin/vascular access devices


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WHY WORRY ABOUT SEPSIS?

COST

MORTALITY

TIME CRITICAL


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Why worry about sepsis?

Increasing incidence1997 to 2005 severe sepsis/septic shock increased from 7.7%of ICU admissions to 14.0 % in Australia (4 fold increase intotal patients) 1

More common in the elderly incidence increases as thepopulation ages

CostThe cost of care is huge (US$16.7 billion in 2001) 2

1. Peake S, for the ARISE Investigators: The outcome of sepsis and septic shock presenting to the EmergencyDepartment in Australia and New Zealand. Critical Care 2007, 11 (Suppl 2) :P73

2. Angus DC et al: Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associatedcosts of care. Crit Care Med 29:1303, 2001


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US National Centre Health Statistics June 2011


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Which patient has the highest mortality?

1. 59yr old male - large inferior STEMI2. 27yr old male - multi trauma ISS

3. 65yr old female - bleeding gastric ulcer and BP 90/60

4. 74yr female P 65 BP 105/60 RR 24 Temp 35 C mildlyconfused**

5. 32yr female DKA pH 6.90 BSL 45 HCO3 9


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Mortality

1. Inferior AMI 5%

2. Trauma ISS 16-24 7%

3. GIH + low BP 11%

4. Septic Shock 25%

5. Severe DKA


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Mortality

25% mortality for severe sepsis and septic shock inAustralia and NZ 1

Studies suggest that mortality may be decreasingwith time but is still unacceptably high

215 000 deaths annually in the USA Delayed recognition and delayed appropriate initial

treatment increase mortality

1. Peake S, for the ARISE Investigators: The outcome of sepsis and septic shock presenting tothe Emergency Department in Australia and New Zealand. Critical Care 2007, 11 (Suppl 2) :P73


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US National Centre Health Statistics June 2011


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Mortality vs. Time to Antibiotics

Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.Kumar A; Roberts D; Wood KE; Light B; Parrillo JE; Sharma S; Suppes R; Feinstein D; Zanotti S; Taiberg L; Gurka D; Kumar A; Cheang M

Critical Care Medicine. 34(6):1589-96, 2006 Jun.


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Hypotension, Lactate & Mortality

Howell et al: Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care Med 2007


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Pit falls

Fail to recognise sepsis

Under-appreciate the mortality

Do not see sepsis as a time critical illness


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Later tonight..

After a few drinks

Fall down 10 stairs at a hotel

Friends find you semi-conscious at the bottomof the stairs

What next?


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Trauma Call

Two Intensive Care paramedics for transfer Trauma Call Team response at major facility Staff Specialist, 2-3 registrars, 3 senior nursing staff

and various others Seen immediately in a resuscitation bay Within one hour your emergency care will be

complete cast for your broken wrist!


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At the same time.

72 year old lady Epigastric pain and nausea Pulse 60 Blood pressure 115/65 Temp 37.2 C

Respiratory rate 25/minute, SpO 2 99% on RA Alert and Orientated


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.....a very different experience

Seen 2 hours post arrival by an intern Seen 5 hours post arrival by a junior surgical registrar Cared for by an RN-Year 2 in a non acute bed Provisional diagnosis of bilary colic Stay NBM for an ultrasound in the morning


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The next morning

An experienced nurse asks MO to review the patient Steadily increasing RR overnight (now 36) Confused and slightly agitated

Pulse 65, BP 105/60, SpO 2 98% RA ABG pH 7.20 Lactate 5 IDC no urine out

Hypertension on numerous medications including a blocker


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Fail to see Sepsis as time critical

TRAUMA Golden Hour

AMI Time is muscle

STROKE Time is Brain

SEPSIS KILLS TIME IS LIFE


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The Sepsis Project

In 2009 the Clinical Excellence Commission published aClinical Focus Report after a review of IIMS NSW data showed167 incidents in 18 months

Incident reports detailed delays in diagnosis or inadequatetreatment of sepsis

In response the Sepsis project has been established as a jointinitiative between the Agency for Clinical Innovation, ClinicalExcellence Commission and the Emergency Care Institute


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Sepsis Project GoalsReduce preventable harm to patients with sepsis:

Recognise Flagging of sepsis risk factors, signs and symptoms at Triage Early involvement of senior clinicians in diagnosis and

management

Resuscitate Appropriate fluid resuscitation Prompt administration of antibiotics - first intravenous

antibiotic administered within one hour of recognition

Refer To the appropriate in-hospital clinical teams or retrieval


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Sepsis adverse event/RCA in this hospital


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ACI/CEC Sepsis Project

Phase 1 - Emergency Departments

Phase 2 - Extend project to improve processes

for recognition and management ofsepsis on wards


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Sepsis pathway

Developed with wide clinical consultation Key message that SEPSIS KILLS

3 Rs of sepsis linked to project goals

Recognise Resuscitate Refer


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Sepsis Pilot Study time to first intravenousantibiotic administration


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Project resources

Sepsis Toolkit available on the ACI/CEC website includingsepsis pathway, Adult First Dose Empirical IV antibioticguideline, implementation guide and planning tool, datacollection guidelines, education resources

ACI/CEC Sepsis Project team telephone support Monthly teleconferences Site visits on request www.cec.health.nsw.gov.au/programs/sepsis
http://www.cec.health.nsw.gov.au/programs/sepsishttp://www.cec.health.nsw.gov.au/programs/sepsis


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HOW TO RECOGNISE SEPSIS

The key to success


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Recognition - the hardest part

Challenging diagnosis to make Wide range of presentations - non specific signs Results from the variation in host responses and

the diversity in behaviour of micro-organisms Signs can be subtle especially in some groups

- elderly- immunocompromised

- chronically ill If any doubt - ask for senior medical review

- measure serum lactate


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Which signs and symptoms are mostcommon in patients with severe sepsis?

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

SEPSIS PATHWAY


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SBP 90mmHg Lactate 4 mmol/L Base Excess < - 5.0

Age > 65 years Immunocompromised

Does your patient have risk factors, signs or symptoms of infection?

Respirations 10 or 25 per minute

Sp0 2 < 95%Systolic blood pressure 100 mmHg

Pulse 50 OR 120 per minute

Altered LOC or change in cognitive status

Temp 35.5 or 38.5 OC

Immunocompromised

Indwelling medical device

Recent surgery/invasive procedure

History of fever or rigors

Red Flags in ambulance handover

Skin: cellulitis, wound

Urine: dysuria, frequency, odour

Abdomen: pain, peritonism

Chest: cough, shortness of breath

Neuro: decreased mental alertness,neck stiffness, headache

AND

R E C O G N I S E

Does your patient have 2 or more yellow criteria?

Treat and re-assesssimultaneously :

Sepsis may stillbe a concern

Re-assess

Perform venous blood gas if available YES

Does your patient have any red criteria?

NO


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R e s p o n

d a n

d E s c a

l a t e

This patient has SEVERE SEPSISor SEPTIC SHOCK until provenotherwise :

Inform the doctor-in-charge

Expedite transfer to a resuscitationarea or equivalent

Turn over page for ResuscitationGuideline

CONSIDER ELIGIBILITY for ARISE

This patient may have SEPSIS :

Inform the doctor-in-charge

Monitor vital signs & fluid balance Obtain blood cultures x 2 sets Investigate source of infection: e.g.

urinalysis, urine M/C/S, chest x-ray Obtain IV access and start IV fluids Administer empiric antibiotics within

one hour unless another diagnosis ismore likely Refer to Therapeutic Guidelines:

Antibiotic , version 14http://proxy9.use.hcn.com.au/

Refer / communicate with admitting team

NO YES

SBP 90mmHg Lactate 4 mmol/L Base Excess < - 5.0Age > 65 years Immunocompromised

Does your patient have any red criteria?

NO YES

Respond and Escalate
http://proxy9.use.hcn.com.au/http://proxy9.use.hcn.com.au/


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Treatment

Simple, early treatment saves lives

ANTIBIOTICS WITHIN 1 HOUR

IMMEDIATE and appropriate FLUID RESUSCITATION

Do you know the average time it takes tocommence antibiotic treatment in your ED?


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Antibiotics Make giving antibiotics a clinical priority same as

an ECG on someone with chest pain or giving thrombolysis to an AMI Give antibiotics within one hour Take 2 sets of blood cultures first Do not delay awaiting other investigations Antibiotic cover for suspected cause If cause unknown, cover with broad spectrum

antibiotics Refer to Therapeutic Guidelines or

the ACI/CEC Sepsis Adult 1 st Dose Empirical IV AntibioticGuideline


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Antibiotic Guideline

ACI/CEC guideline for the prescription andadministration of the FIRST DOSEof IV antibiotics

Based on the Therapeutic Guidelines: Antibiotic

version 14, 2010 Easy to use resource that incorporates the best

available evidence and the principles of appropriate

use of antibiotics


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Antibiotics special situations

Febrile Neutopeniapiperacillin/Tazobactam or cefipime plus gentamicin

Suspected MRSAAdd vancomycin

Line Sepsisvancomycin + gentamicin

Toxic Shocklincomycin or clindamycin


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Fluid resuscitation

Give 20 mL/kg of 0.9% sodium chloride as a bolus Repeat if no response Can continue to give fluid boluses if no signs of

pulmonary oedema However, if the patient remains in shock after the 2 nd

bolus seriously consider starting a vasopressor

Aim MAP > 65 mmHg


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Monitoring and Re-assessment

Ongoing frequent clinical review. ECG, BP, SpO2 monitoring Aim for MAP > 65mmHg

Measure urine output: aim > 0 .5mL/kg/hr MONITOR LACTATE - Each 10% decrease in lactate

correlates with an 11% decrease in mortality 1

1. Shapiro NI. Ann Emerg Med 2005;45:524-528


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Refer

Referral to a surgeon to drain any pus Seek advice from Infectious Diseases Consult admitting team

HDU/ICU seek advice early Do you need the patient retrieved?

You can never call too early for help


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Improving sepsis care

Think Sepsis - use the sepsis pathway, be vigilant Identify local medical and nursing champions to lead

the change in the process of care

Provide education for nursing and medical staff Audit time to IV antibiotics and IV fluids to monitor

improvement

Facilitate a culture where staff are encouraged toalert senior staff if they suspect sepsis


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Objectives achieved

What is Sepsis? Why worry about Sepsis?

Pitfalls The ACI/CEC Sepsis Project How to recognise Sepsis How to treat Sepsis How to get help


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Key messages

SEPSIS KILLS TIME IS LIFE Recognise Resuscitate Refer


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Dr Chris JenkinsStaff Specialist Emergency PhysicianJohn Hunter Hospital

ACI/CEC Sepsis Management Group member/lead [email protected]

Mary FullickSepsis Project Manager

Clinical Excellence CommissionTel: (02) 9269 [email protected]

Dr Tony BurrellDirector Patient SafetyClinical Excellence CommissionTel: (02) 9269 [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]

generic sepsis presentation 9aug 2011

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