severe sepsis
TRANSCRIPT
21,000 cases per year
27% of ITU admissions
46% of bed days
Potentially 4-5 cases per month from MAU
More in CDU About 60-70
severe sepsis cases per year
Several interventions are implemented together and result in a better outcome then when implemented individually
Every intervention in the bundle is based on irrefutable evidence and all elements in the bundle must be executed in the same place and time to ensure that clinical improvement occurs
New infection and any two: Fever > 38.3 C Hypothermia < 36 C Chills and rigors Tachycardia > 90 bpm Tachypnoea > 20 bpm Systolic BP < 90 mmHg Headache or stiff neck WBC > 12,000 or < 4,000 Raised CRP
Acutely altered mental status Systolic BP < 90 mmHg SpO2 < 90% on room air Rising creatinine or > 176
μmol/L or urine output < 0.5 ml/kg/hr for > 2 hours
Rising bilirubin or > 34 μmol/L INR > 1.5 or PTT > 60 sec Platelets < 100,000 Lactate > 2 mmol/L
To be accomplished as soon as possible and scored over the next 6 hours:
Measure serum lactate Take blood cultures before administering antibiotics Give broad spectrum antibiotics (<1 hour for ITU
admissions, <3 hours for MAU admissions) If hypotensive and/or lactate > 4 mmol/L: IV
crystalloid at 20ml/kg and if MAP does not increase to >64 mmHg start vasopressors
If hypotension persists and/or lactate > 4 mmol/L: IV fluids to achieve CVP > 7 mmHg and ScvO2 > 70%
Blood cultures IV broad spectrum antibiotics within 1 hour of diagnosis Involve consultant and ITU Start IV fluids Catherterise bladder Insert a central line and monitor CVP Monitor response with lactate and BP Monitor central venous oxygen saturation Monitor glucose control Monitor urine output (>= 0.5 ml/kg/hr) Prophylactic LMWH and H2 antagonists ITU for vasopressors, inotropes and low dose steroids Address source of infection ALL TO BE COMPLETED WITHIN 2 HOURS OF ARRIVAL
To be accomplished as soon as possible and scored over the next 24 hours:
Low dose steroids Drotecogin alfa Maintain glucose control For ventilated patients maintain
inspiratory plateau pressures < 30 mmH2O
Lactate measurement is integral to the Sepsis Bundle
Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance
Lactate is a better prognostic measure than cytokines
16% reduction in mortality: In-hospital mortality was
30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009)