Acute Medicine Nurse Study Day: 01/04/15

1. Acute Medicine Nurse Study Day: 01/04/15 • Sepsis | Tom Heaps 09:30-10:20 • Oncological Emergencies | Clare Pollard 10:20-11:10 ------------------------ BREAK 11:10-11:30 ------------------------ • Diabetic Ketoacidosis | Tom Heaps 11:30-12:20 • Close and Feedback 12:20-12:30

2. Surviving Sepsis Tom Heaps Consultant Acute Physician

3. Introduction incidence of severe sepsis 90/100,000/year incidence of sepsis needing ICU 25-38/100,000/year overall mortality 28-50% estimated 36,800 deaths per year in UK

4. Clinical Case • 78-year-old male presenting to ED • PMHx T2DM, CKD1, IHD, BPH • 48h history of dysuria, confusion and malaise • T° 38.3C, HR 112, BP 103/55mmHg, RR 24, SpO2 93% o/a • delirious ++ • warm extremities, bounding pulse • R basal crackles • suprapubic tenderness • Hb 11.1, WCC 18, platelets 103, urea 12, creatinine 144 (baseline ~120), LFTs normal, CRP 273, clotting normal

5. Does he meet the criteria for sepsis? Systemic Inflammatory Response Syndrome (SIRS) • defined by ≥2 of the following; • temperature >38°C or <36°C • HR >90min-1 • RR >20min-1 or PaCO2 <4.25kPa • new onset confusion • hyperglycaemia (CBG >7.7mmol/l) in absence of diabetes • WBC >12 x109 or <4 x109 or high CRP (if available) • infection, trauma, surgery, burns, pancreatitis SEPSIS = SIRS + infection +/- bacteraemia • mortality increases with number of SIRS criteria

6. What is your initial management? • oxygen (if required to achieve target SpO2) • blood cultures • IV antibiotics • IV fluids • VBG or ABG (plus FBC, U&E, LFT, CRP, coagulation) • urinary catheter and commence fluid balance • urine cultures • CXR

7. VBG/ABG in sepsis • lactate on VBG correlates well with arterial lactate except in cases of severe shock • measure ABG if shocked or oxygenation/ventilation a concern • lactate levels correlate highly with mortality • 40% if lactate >4mmol/l • 15% if lactate <2mmol/l • serial measurements and lactate clearance in response to resuscitation more important than absolute values

8. Fluid resuscitation in sepsis • hypovolaemia in sepsis is absolute (reduced fluid intake, fluid loss, insensible losses) and relative (vasodilatation) • 500mL boluses up to 30mL/kg (~2L for 70kg person) over ≤30min • repeated up to 60mL/kg (~4L for 70kg person) after senior review • Which fluid? crystalloid vs colloid • no evidence that albumin superior to saline (SAFE trial) • colloids are more expensive and risks of AKI (HES), anaphylaxis and coagulopathy • Which crystalloid? • balanced solutions e.g. Hartmann’s are more expensive • less risk of hyperchloraemic acidosis than with 0.9% NaCl • in vitro evidence only that hyperchloraemic acidosis is harmful

9. time to administration is critical factor 8% increase in mortality for every 1h delay after onset of hypotension aim to administer IV broad spectrum antibiotics within 1h of presentation with severe sepsis empirical choice governed by probable source of infection and local guidelines (available on intranet) separate guideline for suspected/proven febrile neutropenia Antibiotics in sepsis

10. Clinical Case Continued • ABG on air pH 7.36, pO2 9.2, pCO2 2.8, lactate 4.8, BE -5.6 • blood cultures taken • CXR unremarkable • catheterized • urine dipstick leucocytes 3+, nitrite +ve, RBC 2+, protein + • IV co-amoxiclav and gentamicin given for suspected UTI • IV 0.9% NaCl 2L prescribed each over 8h • 2h later BP 91/44mmHg and urine output 50ml total

11. Does he have SEVERE sepsis? SEVERE sepsis = sepsis plus evidence of organ dysfunction (or tissue hypoperfusion); • alteration in mental state (confusion) • hypoxemia (PaO2 <9.6kPa at FiO2 0.21 in absence of pulmonary disease) • elevated plasma lactate (>4mmol/l), increased CRT or skin mottling • oliguria (urine output <30ml or <0.5 ml/kg for 1h) • hypotension (sBP <90mmHg, MAP <65mmHg or reduction in sBP of 40mmHg from baseline) • creatinine >177umol/l • bilirubin >34umol/l • platelets <100, INR >1.5 or disseminated intravascular coagulation (DIC)

12. Does he have SEVERE sepsis? SEVERE SEPSIS = sepsis plus evidence of sepsis-induced tissue hypoperfusion or organ dysfunction; • alteration in mental state (confusion) • hypoxemia (PaO2 <9.6kPa at FiO2 0.21 in absence of pulmonary disease) • elevated plasma lactate (>4mmol/l), increased CRT or skin mottling • oliguria (urine output <30ml or <0.5 ml/kg for 1h) • sepsis-induced hypotension (sBP <90mmHg, MAP <70mmHg or reduction in sBP of 40mmHg from baseline) • creatinine >177umol/l • bilirubin >34umol/l • platelets <100, INR >1.5 or disseminated intravascular coagulation (DIC)

13. ‘RED FLAG’ Sepsis • New concept introduced by latest guidelines from UK Sepsis Trust • Early detection (MEWS-based) of patients at risk of deterioration who may benefit from more aggressive treatment as ‘severe’ sepsis • Many markers of severe sepsis may not be evident / available at time of first presentation Tachycardia: HR >125/min Hypotension: systolic BP <90mmHg Tachypnoea: RR >20 Hypoxaemia: SpO2 <90% (or only ≥90% with O2) Drowsiness: AVPU of V, P or U

14. Clinical Case Continued • given fluid challenge of 2L Hartmann’s over 1h • total fluid input now 3L • repeat VBG shows lactate 6.2 • no urine output in last 1h • BP 80/52mmHg • mottling of lower extremities • increasing confusion

15. What is the diagnosis now? SEPTIC SHOCK = SEVERE SEPSIS + hypotension which is refractory to fluid replacement WHAT NEEDS TO HAPPEN NOW? • senior review • decisions re. CPR/escalation (if not already made!) • transfer to ITU if appropriate • Invasive monitoring, vasopressors, ventilation etc.

16. What is my role as a nurse? Recognize and screen for sepsis • Suspect Infection? • MEWS ≥ 4 • High temperature • Symptoms suggestive of infection • Risk of neutropenia/immunosuppression • Confirm diagnosis using SIRS criteria (≥2 positive) • Any features of ‘red flag’ or severe sepsis? • Obtain medical review (immediate if severe sepsis) ELDERLY PATIENTS MAY PRESENT ATYPICALLY

17. Use the new AMU sepsis pathway

18. What is my role as a nurse? Get the ‘SEPSI6’ trolley and initiate the ‘SEPSIS 6’ BUNDLE 3x Investigations • VBG/ABG (and other bloods) • Blood cultures (and other cultures) • Urine output monitoring (insert catheter if severe sepsis) 3x Treatments • Oxygen • IV Fluids • IV antibiotics ALL WITHIN 1h OF RECOGNIZING ‘RED FLAG’ OR SEVERE SEPSIS • reduced mortality from 44% to 20% at GHH

19. What is my role as a nurse? Monitoring and Co-ordination of Care • ensure antibiotics given promptly and fluids running to time • hourly observations (for 1st 4h even if MEWS <4) and urine output / fluid balance chart • repeat VBG for lactate • involve CCOT early • prompt doctors to make escalation/CPR decisions • alert senior medical staff if condition deteriorates or fails to improve as expected

20. Take Home Messages SEPSIS = SIRS + infection SEVERE sepsis = sepsis plus ≥1 marker of organ dysfunction RED FLAG sepsis should be treated initially as SEVERE sepsis severe sepsis is a MEDICAL EMERGENCY which kills in 1/3 of cases early RECOGNITION and RESUSCITATION are key PROMPT antibiotics and ADEQUATE IV fluids will SAVE MORE LIVES than ITU GRAB THE ‘SEPSI6’ TROLLEY AND CARRY OUT THE ‘SEPSIS SIX’ WITHIN 1h of recognition of SEVERE / RED FLAG sepsis escalate to senior and involve CCOT EARLY if patient fails to respond use the new AMU sepsis pathway and ‘Sepsis 6’ Stickers