Sepsis! Dr Eric Van Den Bergh Consultant in Emergency Medicine 2015

Transcription

1 Sepsis! Dr Eric Van Den Bergh Consultant in Emergency Medicine 2015

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4 Annual UK Mortality Sepsis Stroke Heart attack COPD Lung cancer COPD Heart attack Stroke Sepsis Lung cancer

5 Severe Sepsis/Septic Shock Audit E. Van Den Bergh C.Smith 01/2015-7/2015

6 Sepsis 6 1. Give high-flow oxygen via non-rebreather bag 2. Take blood cultures and consider source control 3. Give IV antibiotics according to local protocol 4. Start IV fluid resuscitation Hartmann s or equivalent 5. Check lactate 6. Monitor hourly urine output consider catheterisation within one hour plus Critical Care support to complete EGDT

7 Severe Sepsis & Septic Shock Pathway Ref Sepsis Six = PATIENT NAME: DATE OF BIRTH: CC NUMBER: AFFIX LABEL 1. Take Blood Cultures 2. Give IV antibiotics 3. Start IV fluid resuscitation 4. Give high flow oxygen 5. Check haemoglobin and lactate 6. Monitor accurate hourly urine output Inclusion criteria (Severe Sepsis) Suspicion of Severe Infection AND Any TWO of the following: Temperature > 38 o or < 36 o C Respiratory Rate > 20/min Heart Rate > 90/min WCC < 4000 or > AND ONE of the following: Systolic Blood Pressure < 90mm Hg Serum lactate > 4mmols/l Risk factors, Signs or symptoms of infection Red-Flags in ambulance handover Immunocompromised Indwelling medical devices Recent surgery/invasive procedure Recent Rigors/fever Chest: Cough/SOB Urine: dysuria, frequency, odour Skin: cellulitis Abdomen: pain, peritonitis Neuro: Headache, Meningism, confusion FIRST 60 MINUTES Pathway Commenced on _/ / (Date) at : Investigate: INSTITUTE THE SEPSIS SIX * Tick Time Blood culture, FBC, U&Es, Coag. Screen, LFTs, Lactate, ABGs/ VBG Urinanalysis and micro/c&s Chest x-ray Give: IV antibiotics - refer to Hospital Guidelines 20-30ml/Kg Crystalloid or Colloid over 30minutes (Caution: Monitor for fluid overload) Oxygen and consider need for IPPV : : : : : : : Monitor : Urine output hourly [ consider urine catheter ] Oxygen saturation and non-invasive blood pressure every 15 minutes ECG continously MEWS Scores Discuss with Senior Doctor on Duty Refer Critical care outreach (VOIP 2314) and Refer to the appropriate Speciality Team : : : : Initial assessment completed by (PRINT) (Signed) at : _(Time) Severe Sepsis Pathway V2 April 2015 (Page Over)

8 Desired Outcomes Promote early recognition of community acquired sepsis. Ensure sepsis is graded and the sickest patients are identified early. Ensure a basic set of treatments are performed in a timely manner Get antibiotic stewardship right. Improve coding of sepsis, severe sepsis and septic shock

9 Method 30 consecutive patient records coded as having severe sepsis, commencing 01/01/15 Paper notes, PDOC, nursing notes and lab results examined for evidence of meeting audit criteria

10 35 Results 2015 Time from arrival or triage to: High flow O2 initiated Serum lactate measurement Blood cultures First intravenous crystalloid fluid bolus Antibiotics Urine output measured <1 hour <2 hours >2 hours

11 70.0% Results IV antibiotics given 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Within 1 Hour Within 2 Hours > 2 hours Not Recorded Within 1 Hour Within 2 Hours > 2 hours Not Recorded

12 Results IV crystalloid given 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Within 1 Hour Within 2 Hours > 2 hours Not Recorded Within 1 Hour Within 2 Hours > 2 hours Not Recorded

13 What is sepsis?

14 Infection Sepsis Severe Sepsis Septic shock Burns Burns SIRS Organ dysfunction Hypoperfusion

15 <1% 10% 35% 50% 50% 50% Severe Septic Infection Sepsis Sepsis shock SIRS Organ dysfunction Hypoperfusion Burns Burns

16 Where did we start?

17 Early goal-directed therapy in the treatment of severe sepsis and septic shock Rivers et al. New England Journal of Medicine [N Engl J Med 2001;345: ]

18 Getting the basics right

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24 We need Red Flags!

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26 UK Sepsis Trust Clinical Toolkits Produced in association with NHS England Modified from Surviving Sepsis Campaign s Evaluation for Severe Sepsis Screening Tool 2005

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32 Simple Strategy Concentrate on the front end Concentrate on getting the simple stuff right More recent papers tell us this was probably the right approach Suspect Screen Sepsis Six

33 Is any red flag present? Systolic B.P < 90 mmhg or MAP < 65 mmhg Lactate > 2 mmol/l Heart rate > 130 per minute Respiratory rate > 25 per minute Oxygen saturations < 91% Responds only to voice or pain/ unresponsive Purpuric rash

34 Time for Action

35 Achieving reliable sepsis care

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38 Successes Established motivated core team Simple message that is accessible to everyone Linking to other work

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40 Challenges The enormity of the problem patients to treat people to train Keeping everyone involved and enthused

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42 Antibiotics Although a global restriction of antibiotics is an important strategy to reduce the development of antimicrobial resistance and to reduce cost, it is not an appropriate strategy in the initial therapy for this patient population

43 Definitions change SIRS is dead! Definitions to change from sepsis/severe sepsis and septic shock to sepsis/septic shock SIRS no longer to be utilised as access point to screening tool. Likely to be NEWS score of 5 or more, or individual parameter scoring 3. To be used in Red Flag assessment Syst <100mmHG, RR>25, GCS <14. Changes to occur Feb 2016

44 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 EWS, Clinical Acumen and Experience Sepsis Screening Tool

45 Take home messages Sepsis presentation maybe non-specific, hugely variable and multi-system When source unclear review presenting symptoms and signs and use appropriate imaging Procalcitonin is a useful biomarker in sepsis PCR techniques such as Septifast can aid with the rapid detection of known bacterial genome

46 Any questions?