Sepsis

Amar Javaid

Systemic response to infection, characterised by an exaggerated inflammatory response and widespread tissue injury

Sepsis

SSI + Infection

(20% mortality)

Severe Sepsis

SSI + Infecton + Organ dysfunction

(40% Mortality)

Septic Shock

SSI + Infection + Organ dysfunction + Hypotension

(60% Mortality)

Managing Sepsis

Sepsis Six

If hypotensive and/or lactate >4 administer 30ml/kg crystalloid

Broad spectrum Abx within 3 hours of ED admission and within 1 hour of recognition on ward

• Oxygen
• Fluid Resuscitation
• Blood Cultures
• Antibiotics
• Measure Hb and Lactate
• Monitor UO

DO2 = CO x CaO2

DO2 = (SV x HR) x ((Hb x SaO2 x 1.34) + (PaO2 x 0.0225))

• HR 110
• BP 105/76
• Temp 38.5
• RR 18
• Sats 92% on RA
• UO has tailed off
• 'Just doesn't look right'

• JB is now day 2 post op
• Uncomplicated recovery so far
• Had shot of intra-op Abx
• Allowed clear fluids orally
• Being NG fed (just started)

What do you do?

• A - patent - talking, slightly confused
• B - Decreased A/E bibasally, no added sounds, RR 22, Sats 100% on 15L NRB
• C - HR 118, CRT ~ 2-3 secs, BP 100/60
• D - E3, V4, M6 - 13/15
• E - Abdomen tender, wound dressed, some guarding, no rebound tenderness, minimal BS
• BM 6.4

So what next?

• You give some fluid
• ABG on 15L NRB - pH 7.2, pO2 44, pCO2 4.6, Lac 1.9, Bic 17, BE -4.2
• CXR - Bibasal atelectasis, no consolidation

Does the patient have SSI?

• Temp 38.5
• HR 118
• Altered mental state
• RR 22

• You make your SHO aware
• Diligently do the 'Sepsis Six'
• Take cultures and send bloods
• Prescribe Abx
• Tell the nurse you will r/v pt again with bloods

You return slightly bitter after prescribing 20 warfarins, re-writing 8 drug charts and blindly prescribing more 'maintenance fluids' for what seems like all the surgical patients in the hospital, pushing half of them into pulmonary oedema and the other half into hyperchloraemic metabolic acidosis because you still haven't discovered balanced crystalloids; this on top of the 12 elective clerkings (8 of whom were in hospital at 2pm)

• Now he really doesn't look right
• Turns out nurse has been busy on her break, didn't get a chance to administer the Abx you prescribed
• Talking but you can't understand him
• Temp 39.2, HR 126, RR 28, BP 88/64 sats 94% on 15L NRB
• Repeat ABG - pH 7.15, pO2 35, pCO2 3.8, Lac 4.4, Bic 11, BE -8.4
• Bloods - WCC 24, Hb 11.2, Plt 89, CRP 542, Na 144, K 5.9, Ur 14, CR 255

Is this sepsis/severe sepsis/septic shock?

• You give bolus of fluid 30mls/kg
• Little response
• UO has been 10mls/hr for last 3 hours

What now?

(Apart from hiding in the store room and crying whilst resisting the urge to punch the nurse in her face on your way out)

• You give Abx yourself
• Bleep your SHO and Reg who are both scrubbed with a ruptured AAA in theatre with your consultant

Who do you call now?

• Critical Care arrive
• Confirm septic shock
• Punch the nurse and you for not giving Abx earlier
• Move the patient to HDU then ICU
• Insert a CVC and start NA
• Able to maintain MAP>65 but NA climbing
• Start Hydrocortisone 50mg QDS
• CVVHF for acidosis, AKI with hyperkalaemia and sepsis
• Pt develops ARDS --> Intubated and ventilated
• CT confirms anastamotic breakdown -->theatre

• He has his ileostomy refashioned
• Develops full blown ARDS
• Has a tracheostomy inserted at day 7
• Has managed established NG feeds by day 10 with the help of some prokinetics
• IV Abx for 14/7
• Develops some ICU psychosis requiring clonidine
• Takes a further 2 weeks before he can be weaned off the ventilator and put on to Drager CPAP and stepped down to HDU

• He is eventually discharged home 2 months after admission for elective surgery
• However unable to work as labourer at building site because of residual weakness
• In these times of austerity his employer sacks him
• Used to sing but since tracheostomy rubbish voice
• He becomes depressed and turns to heroin
• His girlfriend SG dumps him
• Now he is a long-term financial burden on the economy and the NHS with his thieving, abscesses, endocarditis, valve replacement and mandatory methadone rehabilitation programme

All because YOU didn't give Abx

Any Questions?

• You are the 'front-line' in fighting sepsis
• Fluids and Abx SAVE LIVES
• Please learn to administer Abx youself
• If a patient has SSI --> Sepsis Six
• If Severe Sepsis or Septic Shock --> Early involvement of Critical Care
• Now go out and save lives (Ok from tomorrow when you're back)

Summary

What is Sepsis?

Case Study

SEPSIS

• You're oncall surgical FY1
• Bleeped by ward
• Patient has EWS 4
• What information would you like?

Recognising Sepsis

• 28 yr old male - JB
• Normally fit & well
• Stabbed to abdomen --> Laparotomy --> bowel resection with ileostomy
• Post-op - reversal of ileostomy

Signs & Symptoms of Infection (SSI)

• Temp - <36 or >38
• HR >90
• RR >20 or PaCO2 <4 kPa
• WCC - <4 or >12
• Acutely altered mental state
• Hyperglycaemia in absence of diabetes

Signs of Organ Dysfunction

• SBP <90 or MAP <70
• UO <0.5ml/kg/hr
• Lactate >2
• Unable to maintain SpO2>90% without O2
• INR >1.5
• Plts <100
• Bilirubin >34
• Creatinine >177