SEPSIS KILLS program Adult Inpatients Learning objectives • Recognise that sepsis is a medical emergency • Identify the risk factors, signs and symptoms • Outline the escalation of the septic patient • Define the initial management actions • Discuss the requirements for 48 hour sepsis management 2 Sepsis is a medical emergency You can make a difference for patients in this hospital What is sepsis? Sepsis is the body’s systemic response to an infection and can result in multi-organ failure and death SEPSIS = infection + systemic inflammatory response (SIRS) SEVERE SEPSIS = sepsis + organ dysfunction, hypoperfusion or hypotension SEPTIC SHOCK = sepsis + hypotension despite fluid resuscitation The sepsis continuum Infection Systemic Inflammatory Response Syndrome Severe Sepsis Sepsis Increasing Mortality • Septic Shock Sepsis recognition & management…what is the problem? • Sepsis causes more deaths in adults per year than prostate cancer, HIV and breast cancer combined • 25% mortality associated with septic shock • High number of sepsis adverse events in NSW • Approximately 30% of Rapid Response calls are related to sepsis • Delayed recognition and initial appropriate treatment increases mortality Insert summary of your facility/LHD adverse event here 7 Difficult diagnosis • Not all patients have classic SIRS • Clinical diagnosis requiring experience and high index of suspicion for interpretation of history/symptoms/signs • Signs often subtle • Some groups at special risk eg infants, age > 65, neutropenia, haemodialysis, diabetes mellitus, alcoholism, lung disease, patients with invasive devices Laupland et al Crit Care Med 2004 Common signs & symptoms of sepsis • • • • • • • Tachypnoea Tachycardia Fever > 38 degrees Hypothermia Metabolic acidosis Acute oliguria Acute encephalopathy 99% 97% 70% 13% 38% 54% 35% Brun-Buisson C et al, JAMA: 274(12), 27 Sept, 1995 Accurate and routine measurement of respiratory rate is essential The SEPSIS KILLS program RECOGNISE: Risk factors, signs and symptoms of sepsis and inform senior clinician RESUSCITATE: With rapid antibiotics and IV fluids within one hour REFER: To specialist care and initiate retrieval if needed SEPSIS KILLS When to use the sepsis pathway… • The patient has signs or symptoms of infection: suspect sepsis • The patient has observations in the Red or Yellow Zone on the SAGO chart: suspect sepsis • The clinician, patient or relatives are concerned about deterioration: suspect sepsis RECOGNISE: RESPOND & ESCALATE: RESUSCITATE: Six key actions within 60 minutes 1. Administer oxygen 2. Take blood cultures and other specimens 3. Measure serum lactate 4. IV fluid resuscitation 5. IV antibiotics 6. Monitor urine output, vital signs and reassess 1. Administer oxygen • Improve oxygen delivery to the tissues • Maintain SpO2 95 - 98% • History of COPD maintain SpO2 88-92% • Requires regular review • ESCALATE to Rapid Response if patient is unresponsive to oxygen therapy 2. Blood cultures • Take blood cultures BEFORE starting antibiotics • Take two blood cultures from separate sites if possible • Obtain other cultures: urine, CSF, faeces, wound swabs, sputum, other fluids from within cavities, • Consult specialty teams early for source control 3. Measure serum lactate • Elevated lactate (lactic acid) level is a sign of global tissue hypoxia • Elevated lactate is directly linked to increased mortality • Initial and serial lactate measures are valuable indicators for sepsis management NSW sepsis mortality by severity CEC/HIE linked data n=3851 (2012) 30% 26% 27.30% 25% Occult hypoperfusion or cryptic shock 20% 15% 13.40% 9.30% 10% 5% 4.00% 0% BP>90 lac<2 BP<90 lac<2 BP>90 lac>2 BP<90 lac>2 lac >4 4. Intravenous fluid resuscitation • Fluids will reduce organ dysfunction and multi-organ failure • Give a rapid IV bolus of 250500mls 0.9% sodium chloride • Reassess for effect after each bolus – HR, BP, RR, capillary refill, urine output • Aim to achieve systolic BP ≥100mmHg • Repeat 250-500ml bolus of 0.9% sodium chloride if needed • ESCALATE to Rapid Response if no improvement in BP after 500mls fluid • Patients with renal or cardiac disease: Use smaller volumes of fluid Undertake more frequent assessment for positive and negative affect Refer to ICU for advice and early use of vasopressors 5. Intravenous antibiotics • Appropriate early antibiotic therapy reduces mortality in septic shock (Kumar, 2006) • Patients who received antibiotics in the first hour after the onset of hypotension: mortality 20.1% • Each additional hour’s delay: mortality increases by 7.6% • 1. Kumar A et.al. Crit Care Med 2006:34(6);1589-1595. Kumar, 2006 • The ‘right’ antibiotic is crucial • Take blood cultures before antibiotics but do not delay antibiotics to undertake investigations or await results • Start antibiotic therapy within 60 minutes • Use bolus administration where possible • REMEMBER: one dose is safer than not treating at all PRESCRIBE IT... GET IT... GIVE IT... NOW!!! 6. Monitor vital signs and urine output Monitor observations every 30 minutes for 2 hours and then hourly for four hours • • • • • • Respiratory rate Heart rate Blood pressure Capillary refill LOC Urine output Refer: • If no improvement or if you are worried, escalate as per local CERS • Update the AMO • Include ICU and infectious diseases review Next steps: sepsis 48 hour management plan Management plan includes: - level of observation - review schedule - escalation plan In summary: • Untreated SEPSIS KILLS • Early IV antibiotics and IV fluids saves lives • One dose of antibiotics is less risk than not treating at all • Source identification and control are vital • Patients with sepsis are at high risk of deterioration • 48-72 hour follow up management plan is essential • Don’t turn your back on the bomb!