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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 ?

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identifying sepsis

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 sepsis1
Identifying sepsis
  • What is sepsis?
  • What do we look for in sepsis?
  • Which patients get sepsis?
identifying sepsis2
Identifying sepsis
  • What is sepsis?
  • What do we look for in sepsis?
  • Which patients get sepsis?
what is 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
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.

slide6

Bacteria

Pancreatitis

Virus

Sepsis

Trauma

Infection

SIRS

Severe Sepsis

Fungi

Infection

Parasite

Other

identifying sepsis3
Identifying sepsis
  • What is sepsis?
  • What do we look for in sepsis?
  • Which patients get sepsis?
step 1 is sirs present
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 present1
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 present2
Step 1: Is SIRS present?

Why do we see SIRS??

Temperature: ‘Pyrogens’ raise body temperature. Later, temperature drops

as we lose excess heat

HR: To stop B.P falling, heart rate rises

RR: The body needs more oxygen in sepsis, and tissues produce

more acid. RR increases to help with both.

AVPU: As B.P and cardiac output fall later in sepsis, blood flow

to the brain reduces

White cells: Rise to combat infection. As they are used up, if bone

marrow is exhausted WCC falls

Blood sugar: Rises as part of our ‘stress response’

step 2 what counts as an infection
Step 2: What counts as an infection?
  • Abdominal 25%
    • Pain
    • Diarrhoea
    • Distension
    • Urgent laparotomy
  • Soft tissue/ musculoskeletal
    • Cellulitis
    • Septic arthritis
    • Fasciitis
    • Wound infection
  • Pneumonia 50%
  • Urinary Tract infection
  • Meningitis
  • Endocarditis
  • Device related
    • Central line
    • Cannula
step 2 what counts as an infection1
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 infection2
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
Step 3: what is Sepsis?

SIRS which is due to

an infection

step 4 what is severe sepsis
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

orUO <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 shock
Septic shock

Definition of shock:

‘Tissue perfusion is not adequate for the tissues’ metabolic requirements’

What it looks like

Low blood pressure Systolic < 90

Mean < 65

Drop 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 shock
Causes of septic shock

1) 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

bradykinin

interleukins

nitric oxide

histamine

causes of organ failure
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
Putting this together

The

Severe Sepsis Screening

Tool

severe sepsis screening tool
Severe Sepsis Screening Tool

Are any 2 of the following SIRScriteria 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

slide21

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 SEPSIS

Start SEPSIS SIX

slide22

Senior staff: check for SEVERE SEPSIS

BPSyst< 90 / Mean < 65

(after initial fluid challenge)

Lactate > 2 mmol/l

Urine output < 0.5 ml/kg/hr for 2 hrs

INR > 1.5

aPTT > 60 s

Bilirubin > 34 μmol/l

O2 Needed to keep SpO2 > 90%

Platelets < 100 x 109/l

Creatinine > 177 μmol/l or UO < 0.5

ml/kg/hr

Severe Sepsis: Ensure Outreach and Senior Doctor attend NOW!

when to use the screening tool
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
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
ABCDE!

Airway Patent, 15 l/min O2 via NRB

Breathing Resp Rate 40 min-1

SpO2 90%

Circulation HR 130

BP 70/40

Disability Agitated but GCS 15/15

Exposure Temp 38.5oC

Is this sepsis??

abcde1
ABCDE!

Airway Patent, 15 l/min O2 via NRB

Breathing Resp Rate 40 min-1

SpO290%

Circulation HR 130

BP 70/40

Disability Agitated but GCS 15/15

Exposure Temp 38.5oC

case study 2
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
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?
abcde2
ABCDE

A Self-maintained

B RR 18/min

C HR 110/min, BP120/60

Urine output 30ml in last 5 hours

D Confused, responds to voice

E Catheter in situ. Temp 35.4OC

What concerns you the most?

Is this sepsis?

abcde3
ABCDE

A Self-maintained

B RR 18/min

C HR 110/min, BP120/60

Urine output 30ml in last 5 hours

D Confused, responds to voice

E Catheter in situ. Temp 35.4OC

What would you do now?

What should we be doing now?

identifying sepsis4
Identifying sepsis
  • What is sepsis?
  • What do we look for in sepsis?
  • Which patients get sepsis?
at risk groups
At risk groups?
  • Compromised organs
  • Immunocompromised
  • Post chemotherapy
  • Malnutrition
  • Invasive lines
  • Old
  • Young
  • Ill
  • Infections
  • Malignancy

How many of your patients are included?

summary
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