The Septic Patient Dr Arunraj Navaratnarajah Renal SpR Imperial College NHS Healthcare Trust
Objectives of this session Define SIRS / sepsis / severe sepsis / septic shock Early recognition of Sepsis The factors that precipitate and perpetuate the sepsis cascade Surviving sepsis Campaign Early Goal Directed Therapy
At the end of this session you will be able to Define and use important terminology Identify features of organ failure Prioritise urgent interventions in the septic patient Describe an effective fluid challenge Demonstrate how CVP can be used to guide fluid resuscitation
Why sepsis Sepsis is a leading cause of death in non-coronary care intensive care units 11 th leading cause of death overall It s common and increasing in frequency as the population ages It s expensive
SEVERE SEPSIS IS DEADLY 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 50% 34% 28% Sands,et al Zeni, et al. Angus,et al Mortality
Severe sepsis is common 300 250 200 150 100 Incidence Mortality 50 0 Severe Sepsis CVA Breast CA Lung CA
Definitions Systemic Inflammatory Response Syndrome (SIRS) Sepsis Severe Sepsis Septic Shock
A continuum of severity describing the host systemic inflammatory response
SIRS
SIRS 2 or more of the following: Temp >38ºC or <36ºC HR >90 beats/min RR >20 breaths/min or PaCO2 <4.5kPa WBC >12,000 or <4000 cells/mm3, or >10% immature (band) forms SIRS is the body s response to infection, inflammation, stress
Sepsis
Sepsis SIRS in the presence of proven or suspected infection
Severe Sepsis
Severe Sepsis Sepsis + at least one sign of organ hypoperfusion or dysfunction Areas of mottled skin Capillary refill > 3 sec UOP < 0.5cc/kg /hr Lactate > 2mmol /L Disseminated intravascular coagulation AKI ARDS or acute lung injury Cardiac dysfunction on echo Altered mental status Plt <100 Abnormal EEG Troponin leak
Septic Shock
Septic Shock Septic Shock - Severe sepsis plus one of the following conditions: MAP <60 mm Hg (<80 mm Hg if previous hypertension) after adequate fluid resuscitation Need for pressors to maintain BP after fluid resuscitation Adequate fluid resuscitation = 40 to 60 ml/kg saline solution (NS 5L-10L) Lactate > 4mmol /L
Revised Definitions
Organ Failure CVS RS Renal Hepatic CNS Haematological
Prognostic effects of organ dysfunction in severe sepsis
Prevalence of hospital mortality associated with severe sepsis
Case 1 You are called to Resus to review an 78 year old female who presented with confusion, fever and rigors. She is unable to give a history. Her observations on admission are 38.3 0 c, BP 70/35 Pulse 120 RR 30 What are your thoughts? What would you like to do next?
Case 2 A ICU nurse asks you to urgently see an elective cardiac patient who has just arrived from theatre, ventilated but has had no medical handover His obs are T35.5, BP 80/50, P100, CVP 10, SpO2 99 on 40% O2 Why is this patient hypotensive?
Case 3 The A&E SpR calls to discuss the case of a 50 year old overweight, hypertensive, diabetic female with upper abdominal pain and shock. The surgeons have just started an AAA repair in theatre. Obs: T35, BP 90/40, P100, RR36, SpO2 unrecordable What is the differential diagnosis? What would you like to do next?
How do we manage sepsis and septic shock?
How do we manage sepsis and septic shock? 1) Investigate and treat sepsis Try and find and treat source Early blood cultures Start antibiotics asap ideally within 1 hour and after cultures taken 2) Assess extent of end organ hypo-perfusion and improve oxygen delivery (early goal directed therapy)
2012 SSC Guidelines
SURVIVING SEPSIS CAMPAIGN BUNDLE To be completed within 3 hours Measure lactate level Obtain blood cultures prior to administration of antibiotics (at least 2 sets) Administer broad spectrum antibiotics (within 3 hours in ED, within 1 hour on ward/icu) Administer 40-60 mls/kg/h of crystalloid for hypotension (systolic BP<90) or lactate 4 mmol/l
SURVIVING SEPSIS CAMPAIGN BUNDLE To be completed within 6 hours Apply vasopressor (noradrenalin centrally or dopamine peripherally) for hypotension that does not respond to initial fluid resuscitation to maintain MAP 65 mmhg (or >80 mmhg in known hypertensive patient) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate > 4 mmol/l 1. Measure CVP* 2. Measure central venous saturation (ScvO 2 )* Remeasure lactate if initial lactate was elevated *CVP 8mmHg, ScvO 2 70% and normalisation of lactate
Fluid challenge 250 to 500 ml colloid (or blood products) 500 to 1000ml Hartmann s [NOT 5% dextrose] As fast a possible (with pressure bag) You at the bedside
Fluid challenge Aim is to improve SV (and hence CO) by increasing preload Frank-Starling mechanism
What are they? Markers of perfusion
Markers of perfusion What are they? Clinical signs Warm skin, conscious level, u/o Haemodynamic variables CVP Bloods Serum Lactate ScvO 2 (central venous saturation)
What does it mean? CVP
CVP What does it mean? Starling s Law Estimate of LVEDV (i.e. preload) Not always a good correlation with volumeresponsiveness However if low strongly suggestive of hypovolaemia
What does it mean? Lactate
Lactate What does it mean? Increased production (anaerobic glycolysis) Tissue hypoperfusion Tissue dysoxia Reduced metabolism Hepatic Renal <1 is normal, 1-2 is a concern, >2 is bad, >4 is very bad
What does it mean? ScvO 2
ScvO 2 What does it mean? What does it mean? Balance between oxygen delivery and consumption (VO 2 ) Fick principle ScvO 2 = SaO 2 - VO 2 CO Target > 70%
THERAPEUTIC STRATEGIES IN SEPSIS Optimize Organ Perfusion Pressors may be necessary Compensated Septic Shock: Noradrenaline Dopamine Uncompensated Septic Shock: Dobutamine + Noradrenaline
THERAPEUTIC STRATEGIES IN SEPSIS Control Infection Source Drainage Surgical Radiologically -guided Culture-directed antimicrobial therapy Support of reticuloendothelial system Enteral / parenteral nutritional support Minimize immunosuppressive therapies
THERAPEUTIC STRATEGIES IN SEPSIS Support Dysfunctional Organ Systems Renal replacement therapies (CVVHD, HD). Cardiovascular support (pressors, inotropes). Mechanical ventilation. Transfusion for hematologic dysfunction. Minimize exposure to hepatotoxic and nephrotoxic therapies
Surviving Sepsis targets of fluid resuscitation What are they? SBP MAP CVP Urine output Lactate ScvO 2 HCt
Surviving Sepsis targets of fluid resuscitation What are they? SBP > 90 MAP > 65 CVP 8-12 Urine output > 0.5 ml/kg/hr Lactate < 1 ScvO 2 >70 HCt > 30
What else can be done? Further Management
Further Management What else can be done? Low tidal volume ventilation Steroids in septic shock Activated Protein C Glycaemic control Stress ulcer prophylaxis Thromboprophylaxis Sedation scoring / holds etc.
KEY TAKE HOME POINTS Recongnize Sepsis EARLY and determine SEVERITY EARLY Antibiotics are critical to resolution of shock RESUSCITATE severe sepsis and septic shock ASAP EARLY GOAL DIRECTED THERAPY
Any Questions?