Identifying Sepsis...

Global Sepsis AllianceJim O’Brien, MD, MScProfessor 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?

•Which patients get sepsis?

Identifying sepsis

•What is sepsis?

•What do we look for in sepsis?

•Which patients get 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 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.

Bacteria

Virus

Fungi

Parasite

Infection SIRSSepsis

Pancreatitis

Trauma

Infection

Other

Severe Sepsis

Identifying sepsis

•What is sepsis?

•What do we look for in sepsis?

•Which patients get sepsis?

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 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 present?Why do we see SIRS??

Temperature: ‘Pyrogens’ raise body temperature. Later, temperature dropsas we lose excess heat

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

RR: The body needs more oxygen in sepsis, and tissues producemore acid. RR increases to help with both.

AVPU: As B.P and cardiac output fall later in sepsis, blood flowto the brain reduces

White cells: Rise to combat infection. As they are used up, if bonemarrow is exhausted WCC falls

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

Step 2: What counts as an infection? Pneumonia 50% Urinary Tract infection Meningitis Endocarditis Device related

Central line Cannula

• Abdominal 25%• Pain• Diarrhoea• Distension• Urgent laparotomy

• Soft tissue/ musculoskeletal• Cellulitis• Septic arthritis• Fasciitis• Wound infection

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 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?

SIRS which is due to an infection

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

or UO <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 shockDefinition of shock:‘Tissue perfusion is not adequate for the tissues’ metabolic requirements’

What it looks like

Low blood pressure Systolic < 90Mean < 65Drop 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 shock1) 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

histamine

bradykinin

interleukins

nitric oxide

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

TheSevere Sepsis Screening

Tool

Severe Sepsis Screening Tool

Are any 2 of the following SIRS criteria 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

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 SEPSISStart SEPSIS SIX

Senior staff: check for SEVERE SEPSIS

Severe Sepsis: Ensure Outreach and Senior Doctor attend NOW!

BP Syst < 90 / Mean < 65 (after initial fluid challenge)

Lactate > 2 mmol/l

Urine output < 0.5 ml/kg/hr for 2 hrsINR > 1.5

aPTT > 60 s

Bilirubin > 34 μmol/lO2 Needed to keep SpO2 > 90%Platelets < 100 x 109/lCreatinine > 177 μmol/l or UO < 0.5 ml/kg/hr

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

•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!

Airway Patent, 15 l/min O2 via NRBBreathing Resp Rate 40 min-1

SpO2 90%Circulation HR 130

BP 70/40Disability Agitated but GCS 15/15Exposure Temp 38.5oC

Is this sepsis??

ABCDE!

Airway Patent, 15 l/min O2 via NRBBreathing Resp Rate 40 min-1

SpO2 90%Circulation HR 130

BP 70/40Disability Agitated but GCS 15/15Exposure Temp 38.5oC

What would you do next?

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?

•Risk factors:• Elderly• Malnourished• Dementia- may present late• Recent hospital stay• Not compliant with medication

•Likely urinary tract infection

•What would you do now?

ABCDE

A Self-maintainedB RR 18/minC HR 110/min, BP120/60

Urine output 30ml in last 5 hoursD Confused, responds to voiceE Catheter in situ. Temp 35.4OC

What concerns you the most?Is this sepsis?

ABCDE

A Self-maintainedB RR 18/minC HR 110/min, BP120/60

Urine output 30ml in last 5 hoursD Confused, responds to voiceE Catheter in situ. Temp 35.4OC

What would you do now?What should we be doing now?

Identifying sepsis

•What is sepsis?

•What do we look for in sepsis?

•Which patients get sepsis?

At risk groups?OldYoungIllInfectionsMalignancy

How many of your patients are included?

Compromised organs Immunocompromised Post chemotherapy Malnutrition Invasive lines

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