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SEPTIC SHOCK

SEPTIC SHOCK. CVS Monitoring and Shock. Case 3. A young woman arrives in the medical admissions unit with diarrhoea, which she has had for several days. She is drowsy and has mottled skin; She also has a high fever 38.9 C She has a systolic BP - 70 mmHg, pulse 130 b/min.

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SEPTIC SHOCK

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  1. SEPTIC SHOCK CVS Monitoring and Shock

  2. Case 3 A young woman arrives in the medical admissions unit with diarrhoea, which she has had for several days. • She is drowsy and has mottled skin; • She also has a high fever 38.9 C • She has a systolic BP - 70 mmHg, pulse 130 b/min. • Her blood tests show WBC – 3.45, an elevated urea and creatinine with low platelets. Q1: could she have a life-threatening condition? Q2: what immediate steps would you take? Q3: how would you decide which way to proceed?

  3. Initiation of Antibiotic Therapy in Severe Sepsis

  4. Management of shock • A-B-C: OXYGEN THERAPY • VENTILATORY SUPPORT • HAEMODYNAMIC SUPPORT • MONITOR AND CLOSE OBSERVATION: • - BP, HR, SpO2, resp. rate every ½-1 hr depending on situation • - Fluid balance - input/output hourly • - Temperature, GCS/Neuro score when indicated • - Consider invasive monitoring early in A&E • TIME-SENSITIVE CARE: • Correct the underlying cause: • surgical intervention to stop haemorrhage, • treat infection and sepsis • identify fluid losses, • treat ileus or diarrhoea

  5. Case 3 • Picture of young person with severe infection. • A search for the focus of infection should take place but this should not take priority over A, B, C, and "blind" antibiotic therapy ASAP. • A-B-C approach: After you have initiated high concentration oxygen therapy, two large bore cannulae should be inserted and fluid challenges given. Q1: How would you define severity of Infection/Sepsis? Q2: What is your fluid management plan?

  6. Clinical Progression Infection SSI Sepsis Severe Sepsis MOF Death (SIRS) In 2007 in context of Sepsis itself the new term was adopted instead of SIRS - Signs and symptoms of infection (SSI) MOF: multi-organ failure

  7. Systemic inflammatory response syndrome,Sepsis and Ifection

  8. Signs and symptoms of infection (SSI), 2007 Must have 2 or more of the following: • Tachycardia> 90 bpm • Core temperature > 38.3°C < 36°C • Tachypnoea> 20 bpm • WCC >12,000 or <4,000 or >10% immature neutrophils • Hyperglycaemia in the absence of Diabetis Mellitus

  9. Clinical Progression – Sepsis Infection SSI Sepsis Severe Sepsis MOF Death Sepsis : 1) - two or more of SSI, plus 2) - documented or suspected infection (presence of commonly recognised signs of infection without an identifiable pathogen being isolated)

  10. Pathogens involved in sepsisAn overview Gram negative • Only 60% of severe sepsis/septic shock cases are associated with confirmed infection • The most common infection sites are: the lung, abdomen or urinary tract. Gram positive Fungal infection 22% Mixed bacterial 40% 19% Other mixed 13% 3% 3% Unconfirmed

  11. Patient history suggestive of an existing infection may include : Pneumonia, Empyema, Urinary tract infection, Acute abdominal infection, Meningitis, Skin/soft tissue inflammation, Born/joint infection, Catheter or device infection, Endocarditis,Wound infection,

  12. What is VitalPAC?

  13. Modified Early Warning Score (MEWS) –useful tool in recognition of patients with presumed infection Score 3 2 1 0 1 2 3 BP SYS< 80 80-89 90-109 110-160 161-180 181-200 >200 PULSE <40 - 40-50 51-100 101-110 111-129 >130 RESP.< 8 - - 8-20 21-25 26-30 >30 TEMP.-<35 - 35.1-37.9 38.0-38.4 >38.5 - AVPUAlert Voice Pain Unrespon sive ----------------------------------------------------------------------------- Think infection if Score 3 in one category or total Score 4 New Weakness New Confusion

  14. Clinical Progression – Severe Sepsis Infection SSI Sepsis Severe Sepsis MOF Death Severe sepsis: sepsis + one organ dysfunction • Circulatory failure • Respiratory failure • Haematological failure • Renal failure • Hepatic failure • “Brain failure” …

  15. Severe sepsis – examples of organ dysfunction Systolic BP < 90mmHg or MAP < 65 mmHg (or a reduction in SBP 40 mmHg from baseline) O2 saturation (SpO2)<90% on air or on Oxygen, PaO2:FiO2 < 40 kPa Platelets< 100.103 or INR > 1.5 or APTT > 60s Bilirubin > 34 µmol/L Urine output < 0.5 ml/kg/hr for > 2 hrs Creatinine > 176 µmol/L Acute alteretion in mental status

  16. Clinical Progression – Septic Shock Infection SSI Sepsis Severe Sepsis MOF Death Septic Shock Septic shock:Acute circulatory failure that is refractory to adequate volume resuscitation and unexplained by other causes Circulatory failureisdefined as persistent arterial hypotension (SBP < 90 mmHg, MAP< 65, or a reduction in SBP 40 mmHg from baseline) despite adequate volume resuscitation.

  17. Septic Shock Initially is suggested by evidence of end organ hypoperfusion: • Hemodynamic instability • mottled skin, • decreased urine output, • altered level of consciousness, • Lactic and metabolic acidosis… Later - circulatory failure leading to multi-organ failure: • Slightly increased and than decreased Cardiac Output • Significantly reduced SVR, Leaking capilaries • Coagulopathy with throbmocytopenia. • ARDS, ARF, Liver failure, Hypoglycaemia, Although most patients in shock will be hypotensive, some patients will have preserved systolic pressure early in shock as a result of excessive catecholamine release.

  18. Goal directed therapy in Sepsis Surviving Sepsis Campaign Guidelines2004 – 2007Guidelines on Intravenous Fluid Therapy for Adult Surgical PatientsGIFTASUP 2008

  19. Trail results • 263 p-ts presented to A & E with Sepsis (Rivers et al.,) • Randomised, two groups: I - Early Goal Directed Therapy Group (EGDT) II - Control Group (similar, excluding Scv O2 data); • Initial Resuscitation was performed in A&E over the first 6 hour period then transferred to in-patient bed or ICU; • Evaluated for a further 72 hours. Rivers et al., New Eng J Med 2001, 345

  20. EGDT Group - What are the goals and why? • To ensure the Presumptive Diagnosis is made within 2 hours of admission; • Fluid resuscitation 20-40 mls/kg within the recommended target of 6 hours from presentation • Cultures drawn before antibiotics given • Antibiotics within 3 hours of a presumptive diagnosis of a severe sepsis or 1 hour if patient already in hospital • Early CVP monitoring and Central venous O2 Saturation measurement (Scv O2) • Vasopressors given much earlier after initial fluid resuscitation based on end points review

  21. What are the end points and why? • Aims to restore impaired perfusion and Oxygen delivery (D-O2) and prevent from vital organ failure ASAP: • Indicators for adequate perfusion: • CVP 8-12 mmHg • MAP > 65 mmHg • UO > 0.5 ml/kg/hr • Indicators for D-O2 insufficiency: • Scv O2 < 70 % • Lactate > 2.0 mmol/L • Regular reassessment and continuous appropriate monitoring

  22. Trail results • EGDT group Received significantly more iv fluids ( + 3L ), blood and inotropic support at the end of 6 hrs period; • After 6 hrs EGDT group had: - Higher BP - Higher Scv O2 - Lower Base Deficit (BE) • By the end of 72 hrs both group had received the same volume of fluid and amount of inotropic support; • In-hospital mortality 30 vs 46 % • 60 day mortality 50 vs 70 %

  23. Surviving Sepsis Campaign 6 hour bundle (resuscitation bundles) 24 hour bundle (management bundles)

  24. 6 Hour Septic Shock Bundle • Immediate fluid resuscitation using crystalloids or colloids • Obtain blood cultures and Lactate ASAP after diagnosis of sepsis • Antibiotics administered within 1 hour of presumptive diagnosis • Obtain CVP if BP is not responsive to fluids or if serum lactate is elevated • Repeated boluses of crystalloid/colloid 250-500 ml every 30 min until CVP 8-12 mmHg • Vasopressors via central line if MAP < 65 mm Hg during and after adequate fluid resuscitation - Noradrenaline (4 mg in 50 ml of 5% Dextrose - start at 0.05 mcg/kg/min) or Dopamine • If Scv O2 < 70 % after fluid replacement and Noradrenaline - start Inotropes(Dobutamine at 2.5 mcg/kg/min or Adrenaline infusion via central line) and/or give RBC’s (to keep Ht above 30)

  25. GIFTASUP 2008

  26. Fluid requirements in illness Table: Contents of common crystalloids in mmol/L Na K Ca Cl HCO3 Osmolality pH Plasma 140 4.3 2.3 100 26 285-300 7.4 Na Cl 0.9% 154 0 0 154 0 3085.0 Dextrose 5% 0 0 0 0 0 278 4.0 Dextrose Saline (4%/0.18%) 30 0 0 300 283 4.0 Hartmann’s solution 131 5.0 2.0 111 0 275 6.5 Lactate 29 Lactated Ringer’s sol’n 130 4.0 2.2 109 0 273 6.9 Lactate 28 Na Bicarbonate 1.2% 150 0 0 0 150 300 8.0 Na Bicarbonate 8.4% 1000 0 0 0 1000 2000 8.0

  27. GIFTASUP recommendations

  28. Fluid requirements in illness Crystalloids: Pro: cheap, convenient to use, free of side effects Con: volume expansion transient (half-life 20-30 min) fluid accumulates in interstitial space pulmonary oedema may result (initial resuscitation: 20 ml/kg bolus over 30 min) Colloids:(starch - Volulyte, gelatin - Isoplex) Pro: greater increase in plasma volume more sustained (half-life 3-6 hrs) Con: cost allergic reactions clotting abnormalities (initial resuscitation: 0.2-0.3g/kg bolus over 30 min)

  29. Fluid requirements in illness Blood and blood products: Pro: clearly indicated in haemorrhagic shock maintain Hb concentration at an acceptable level* Con: cost rare infection risk (small, but significant consequences) (keep Hb>7g/dl unless patient has ischaemic heart disease, then 10g/dl) Albumin Pro: similar to colloid in terms of long half-life possibly some benefit from transport function of albumin Con: cost (should be used only in special circumstances - for example: burns, cirrhotic liver disease and children with septic shock)

  30. Fluid Therapy - General principles • The appropriate rate of fluid administration should be guided by clinical reassessment and sensible limits • Where a fluid deficit is present (e.g. haemorrhage, diarrhoea, vomiting, insensible or renal losses), the nature (content) of this deficit should be identified • Choose the type of fluid which will best treat the existing deficit and/or maintain euvolaemia • Use “Goal Directed Therapy” - implementation of the proposed clinical endpoints and monitoring of fluid status

  31. Case 3 A young woman arrives in the medical admissions unit with diarrhoea, which she has had for several days. • She is drowsy and has mottled skin; • She also has a high fever 38.9 C • She has a systolic BP - 70 mmHg, pulse 130 b/min. • Her blood tests show WBC – 3.45, an elevated urea and creatinine with low platelets. • The picture is of a young person with severe sepsis/septic shock. Q: What is your management plan?

  32. Case 3 This patient has severe sepsis/septic Shock according to definitions of SSC. Immediate management in this case includes A-B-C-D… • A - assessment of the airway, giving a high concentration O2 (for example, 15 L/min via a reservoir bag mask), • B - examining the chest and respiratory rate, • C - assessment of the circulation (pulse, blood pressure, skin temperature, etc.) and attempt IV cannulation • ABG and Blood Culture should be taken before Antibiotics given • D – GCS (she is alert) Temperature, etc.

  33. Case 3 • There is a history of diarrhoea for several days, which implies severe volume depletion – stat fluid boluses up to 20 ml/kg may require; • Choose the type of fluid which will best treat the existing deficit and/or maintain euvolaemia – Hartmann’s solution (not 0.9% NaCl) +/- Potassium supplements • But in the context of severe sepsis, an abnormally low systemic vascular resistance means that the hypotension may not respond to fluid alone,single shots of vasopressors - metaraminol or ephedrine • An invasive monitoring and vasopressor infusion may be required early.

  34. Summary • Immediate tests and management in acutely ill patients with severe sepsis always consists of: • Arterial blood gases and a bedside glucose measurement. • When intravenous access is obtained - haematology, and biochemistry can be taken at the same time as well as blood cultures, before antibiotics given (ASAP), in many cases the urine should be cultured as well. • Successive fluid challenges are required to restore organ perfusion and the attending doctor should stay with the patient and reassess her until satisfied…, • If this fails, invasive monitoring is indicated and the patient should be referred to ITU for treatment with vasoactive drugs.

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