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Identifying Sepsis. Global Sepsis Alliance Jim O’Brien, MD, MSc Professor 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 ? - PowerPoint PPT Presentation

Text of Identifying Sepsis

Sepsis erkennen und erste Schritte der Therapie

Identifying Sepsis...Global Sepsis AllianceJim OBrien, MD, MScProfessor Assistant Director, Medical Intensive Care Unit The Ohio State University Medical Center Sepsis Alliance, Board of Directors1Identifying sepsisWhat is sepsis?

What do we look for in sepsis?

Which patients get sepsis?

2Identifying sepsisWhat is sepsis?

What do we look for in sepsis?

Which patients get sepsis?

3What is sepsis?Lots of terms!!Sepsis Septic Shock,SIRSSSI (signs and symptoms of infection),Septicaemia, Bacteraemia, Toxic Shock Syndrome, Bloodstream infection etc, etc .

Definitions

InfectionInflammatory response to microorganisms, orInvasion of normally sterile tissuesSystemic Inflammatory Response Syndrome (SIRS)Systemic response to a variety of processesSepsisInfection plus2 SIRS criteriaSevere SepsisSepsisOrgan dysfunctionSeptic shockSepsisHypotension despite fluid resuscitationBone RC et al. Chest. 1992;101:1644-55.BacteriaVirusFungiParasiteInfectionSIRSSepsisPancreatitisTraumaInfectionOtherSevere SepsisIdentifying sepsisWhat is sepsis?

What do we look for in sepsis?

Which patients get sepsis?

Considered one of the fathers of critical care medicine, Dr. Max Harry Weil has helped save the lives and ease the suffering of critically ill patients worldwide. By bringing the science of the physiology lab to the patient's bedside, he introduced practices that have become the standard for critical care. Founding president of the Society of Critical Care Medicine, Dr. Weil, since 1975, has been president of the Institute of Critical Care Medicine in Palm Springs, California, an international center, for clinical education and research. He served as Chairman of Medicine and Physician-in-Chief at the University of Health Sciences in Chicago, Illinois from 1981-1992. He currently holds academic appointments at the University of Southern California and Northwestern University. The concept that dangerously ill patients have a better chance at recovery under the care of specially trained physicians and nurses in emergency and intensive care units did not emerge until the early 1960s. Dr. Weil is credited with pioneering the development of the first modern intensive care unit. Within 10 years, almost every hospital in the United States had such facilities. Dr. Weil also has helped train many of the top physicians in critical care medicine. Recognized as a leader in cardiopulmonary resuscitation, Dr. Weil and his collaborators performed much of the original research on sepsis and septic shock and pioneered the concept of fluid challenge to resuscitate patients suffering from circulatory shock He and his team of loyal co-workers developed the clinical use of metabolic markers for states of shock and was one of the first to apply computer technology to data analysis and decision making in the clinical care of shock patients. A State University of New York Downstate graduate, Class of 1952, Dr. Weil continued his graduate training at the University of Minnesota, where he received his Ph.D. After completing research fellowships at the University of Minnesota, National Heart Institute, and The Mayo Clinic, he was named chief of cardiology at the City of Hope Medical Center in California. He joined the faculty of the University of Southern California (USC) School of Medicine, where he was director of the Shock Research Clinic and later served as chairman of the Division of Critical Care Medicine. As professor of physiology and biophysics at the University of Health Sciences, Chicago Medical School, he served as chair of medicine, chief of cardiology, and chief of critical care medicine. In 2004 he received an Sc.D. (Hon) from the State University of News York, Downstate Medical Center, Brooklyn, NY. A frequent speaker at international symposia, Dr. Weil is the coauthor of several medical texts and more than 1,100 other publications. His many honors include recognition for lifetime achievement by the American Heart Association and the Society of Critical Care, as well as an award for contributions to emergency medicine from the American Red Cross for Israel.

7Step 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 0CHeart rate> 90 min-1Respiratory rate> 20 min-1AVPUV, P or UWhite cells< 4 or > 12If 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 rateRespiratory rateAVPUWhite cells Need a FBCIf not diabetic, blood sugar Need to check it!!!

MEWSStep 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 infectionMeningitisEndocarditisDevice relatedCentral lineCannulaAbdominal 25%PainDiarrhoeaDistensionUrgent laparotomy

Soft tissue/ musculoskeletalCellulitisSeptic arthritisFasciitisWound infectionStep 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 177 mol/lor UO 34 mol/l Bone marrow:Platelets 2 mmol/l Coagulopathy:INR>1.5 or aPTT >60secsSeptic shockDefinition of shock:Tissue perfusion is not adequate for the tissues metabolic requirements

What it looks likeLow blood pressureSystolic< 90Mean< 65Drop from normal of> 40 mmHgHigh 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 histaminebradykinininterleukinsnitric oxideCauses of organ failureReduced delivery of oxygen to the tissuesIn sepsis, caused by any or all of:HypoxiaHypotensionLow cardiac outputRedistribution of blood flowOedema- further for oxygen to travel to cellsSmall blood clots (microthrombi)Mitochondria dont work effectively

We need to correct these with interventions... And FAST

Putting this togetherTheSevere Sepsis ScreeningTool

Severe Sepsis Screening ToolAre 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 painDysuria

Abdo pain/ diarrhoea/ distensionHeadache with neck stiffness

Line infectionCellulitis/wound infection/septic arthritis/ Endocarditis

If yes, patient has SEPSISStart SEPSIS SIXSenior staff: check for SEVERE SEPSISSevere 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 mol/lO2 Needed to keep SpO2 > 90%Platelets < 100 x 109/lCreatinine > 177 mol/l or UO < 0.5 ml/kg/hr

When to use the Screening ToolWhen 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 countCase StudyA 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!AirwayPatent, 15 l/min O2 via NRB

BreathingResp Rate 40 min-1SpO2 90%

CirculationHR 130BP 70/40

DisabilityAgitated but GCS 15/15

ExposureTemp 38.5oC

Is this sepsis??ABCDE!AirwayPatent, 15 l/min O2 via NRB

BreathingResp Rate 40 min-1SpO2 90%

CirculationHR 130BP 70/40

DisabilityAgitated but GCS 15/15

ExposureTemp 38.5oC

What would you do next?Case Study 2An 85 year lady, discharged 3 days ago Readmitted to EAU from her nursing home

PMH:dementiahypertensionmalnourished

She has not been taking her medicationIncontinent 2/7, catheterised by district nurses

Increasingly confused over the last two days

What are the issues?Risk factors:ElderlyMalnourishedDementia- may present lateRecent hospital stayNot compliant with medication

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