Sepsis

1. Sepsis A CHANTHAMAVONG M.D

2. Outline • Global health crisis • Source of Sepsis • What’s new in Sepsis-3: SOFA and qSOFA • Sepsis management and Sepsis protocol A CHANTHAMAVONG M.D

3. Global health crisis • 27 000 000 – 30 000 000 people/year develop sepsis • 7 000 000 – 9 000 000 people/year die, 1 death every 3.5 second • Survivors may face lifelong consequences A CHANTHAMAVONG M.D

4. Sources of sepsis The most common sources of sepsis: • Pneumonia • Bloodstream infection • Abdominal infection e.g: appendicitis, infectious diarrhea, gallbladder infection etc. • Meningitis • Skin and soft tissue infection • Catheter-related infection • Urinary tract infection A CHANTHAMAVONG M.D

5. Systemic inflammatory response syndrome (SIRS) to infection 2 or more of: • Temperature >38°C or <36°C • Heart rate >90/min • Respiratory rate >20/min or PaCO2 <32 mm Hg (4.3kPa) • White blood cell count >12 000/mm3 or <4000/mm3 or >10% immature bands A CHANTHAMAVONG M.D

6. Society of Critical Care Medicine And the European Society of Intensive Care Medicine A CHANTHAMAVONG M.D

7. Definition of Sepsis (Sepsis-3) Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection A CHANTHAMAVONG M.D

8. Sepsis Clinical Criteria (Sepsis-3) Infection Change in: Sepsis-related Organ Failure Assessment ≥ 2 Hypotension or Vasopressors PaO2/Fio2 Platelets GCS Creatinine Oliguria Bilirubin A CHANTHAMAVONG M.D

9. A CHANTHAMAVONG M.D † SOFA: Sepsis-Related Organ Failure Assessment

10. Quick Sepsis-Related Organ Failure Assessment (quickSOFA) or (qSOFA) • In out-of-hospital, ED, general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of Sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA) A CHANTHAMAVONG M.D

11. Quick Sepsis-Related Organ Failure Assessment (quickSOFA) or (qSOFA) Note:qSOFA does not define sepsis (but presence of 2 qSOFA criteria is predictor of both increased mortality and ICU stays of > 3 days, in non-ICU patients). A CHANTHAMAVONG M.D

12. Conclusions: SOFA and qSOFA • In ICU, SOFA has greater predictive validity than qSOFA or SIRS • Outside ICU, qSOFA has similar predictive validity to more complex scores A CHANTHAMAVONG M.D

13. Conclusions: SOFA and qSOFA Clinical criteria for sepsis • Infection plus ≥ 2 SOFA points (above baseline) • SOFA score ≥ 2 reflects overall mortality risk ~10% in general hospital pop. with suspected infection Prompt outside the ICU to consider Sepsis • Infection + ≥ 2 qSOFA points A CHANTHAMAVONG M.D

14. Treat sepsis as an emergency Urgent measures (within 15 min.) • Venous access & blood culture (2-3 sets) • i.v. broad-spectrum antibiotics • Measure lactate • Fluid challenge ≥ 30 ml/kg* if MAP < 65 mmHg or elevated lactate • Give oxygen, intubation maybe necessary (SaO2 > 90) A CHANTHAMAVONG M.D

15. Goals of therapy: • Continue fluid resuscitation until _CVP > 8 mmHg** _MAP > 65 mmHg (consider noradrenalin) _ScvO2 > 70% (HCT > 30%, and if ScvO2 < 70% consider dobutamine)*** _Urine output > 0.5 ml/kg/h _Normalization of lactate • Source identification and control * MAP = mean arterial pressure * * CVP >12 mmHg if patient is ventilated * * * HCT = hematocrite; ScvO2 = central venous oxygen saturation A CHANTHAMAVONG M.D

16. Sepsis protocol 0 ຊົ່ວໂມງ A CHANTHAMAVONG M.D

17. Supplement O2 / ET-tube ເປີດເສັ້ນ 2 ເສັ້ນ ≥18 peripheral line • H/C x 2 spp • Lactate (Initial lactate • > 2mmol/L ກວດຄືນທຸກ 2 – 4 ຊມ • ຈົນກວ່າ lactate ຢູ່ໃນຄ່າປົກກະຕິ • ≤2mmol/L) • Antibiotic • Crystalloid 30ml/kg • ຫຼື 1500 ml <65 mmHg MAP ≥65 mmHg Norepinephrine (0.02-2ug/kg/min 1 ຊົ່ວໂມງ ≥65 mmHg Positive and no sign fluid overload Fluid responsive IV load crystalloid 500 ml • Urine 0,5ml/kg/h (6hr) • Lactate clearance ≥10% (6hr) ຫຼືLactate ຢູ່ໃນຄ່າປົກກະຕິ ≤2mmol/L • Source control (ຊອກຄົ້ນ ແລະ ພິຈາລະນາກໍາຈັດແຫຼ່ງຊຶມເຊື້ອ) 6 ຊົ່ວໂມງ

18. 2016 Septic Shock Definition Subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone A CHANTHAMAVONG M.D

19. 2016 Septic Shock criteria Despite adequate fluid resuscitation • vasopressors needed to maintain MAP ≥65 mmHg AND • lactate >2 mmol/l (18 mg/dL) A CHANTHAMAVONG M.D

20. Clinical Criteria Identifying Patients With Sepsis and Septic Shock Patient + suspected infection Monitor clinical condition; reevaluation for possible sepsis if clinically indicated No No Sepsis still suspected? qSOFA≥2 ? (See A) Yes Yes Assess for evidence of organ dysfunction (A) qSOFA variables: Respiratory rate Mental status Systolic blood pressure Monitor clinical condition; reevaluation for possible sepsis if clinically indicated No SOFA≥2 ? (See B) (B) SOFA variables: PaO2/FiO2 ratio Glascow Coma Scale score MAP Administration vasopressors with type and dose rate infusion Crea or urine output Bilirubin Platelet count Yes Sepsis Despite adequate fluid resuscitation, 1. vasopressors required to maintain MAP ≥ 65 mmHg AND 2. Serum lactate level >2 mmol/L No Yes A CHANTHAMAVONG M.D Septic shock

21. Why hypotension AND hyperlactatemia for septic shock? Venous plasma  0.5 - 2.2  mmol/L Cerebrospinal fluid :  1.1 - 2.4  mmol/L (adult) A CHANTHAMAVONG M.D

22. Stop sepsis save lives Thanks for your attention A CHANTHAMAVONG M.D