The Septic Patient

Dr Arunraj Navaratnarajah

Renal SpR, Hammersmith

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

• 11th leading cause of death overall

• It’s common and increasing in frequency as the population ages

• It’s expensive

SEVERE SEPSIS IS DEADLY

34%

50%

28%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Sands,et al Zeni, et al. Angus,et al

Mortality

Severe sepsis is common

0

50

100

150

200

250

300

Severe

Sepsis

CVA Breast

CA

Lung

CA

Incidence

Mortality

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 hypo-perfusion or dysfunction

Areas of mottled skin

Disseminated intravascular coagulation

Capillary refill > 3 sec AKI

UOP < 0.5cc/kg /hr

ARDS or acute lung injury

Lactate > 2mmol /L

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 38.30c, 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 (SvcO2)* Remeasure lactate if initial lactate was elevated

• *CVP ≥8mmHg, SvcO2 ≥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

Markers of perfusion

• What are they?

Markers of perfusion

• What are they?

• Clinical signs – Warm skin, conscious level, u/o

• Haemodynamic variables – CVP

• Bloods – Serum Lactate

– ScvO2 (central venous saturation)

CVP

• What does it mean?

CVP

• What does it mean?

Starling’s Law

Estimate of LVEDV (i.e. preload)

Not always a good correlation with volume-responsiveness

However if low strongly suggestive of hypovolaemia

Lactate

• What does it mean?

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

ScvO2

• What does it mean?

ScvO2

• What does it mean?

What does it mean?

• Balance between oxygen delivery and consumption (VO2)

• Fick principle

• ScvO2 = SaO2 - VO2

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

• ScvO2

• 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

• ScvO2 >70

• HCt > 30

Further Management

What else can be done?

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?