CODE SEPSIS

By Kane Guthrie FCENA

Sepsis

• Why Code Sepsis

• R/V evidence in sepsis care

• Approach to the septic patient

• Resuscitating & managing sepsis

SEPSIS

• Sepsis is a common life-threatening condition that occurs

when a once localised bacterial/fungal infection becomes

systemic & produces an unregulated inflammatory

immune response.

Sepsis the Problem!

• Major public health problem

• High Mortality

• Comprises 12% of ICU admits

• Burden of death 3x that of national road toll

Sepsis Pitfalls

• Fail to recognise/screen for sepsis

• Under appreciate the mortality

• Failure to respect as Time Critical Illness

The Current Code’s

Trauma STEMI Stroke

The Current Code’s

Trauma

7%Mortality

STEMI

5% Mortality

Stroke

8%Mortality

Septic Shock Mortality

?

Septic Shock Mortality

25%

Risk Factors!

Symptoms of Sepsis

Risk Assessment

Where to Look

• Respiratory

• Urinary Tract

• Intra Abdominal

• Unknown

• Meningitis/septic

arthritis/skin/vascular

access devices

• 35%

• 35%

• 10%

• 10%

• 10%

How to Look for Sepsis

• FBC, U&E, CRP,Coags, Lactate• Blood cultures x2 (Indwelling devices)• MSU• CXR• Swabs • Sputum • Consider – US, CT, LP (case specific)

Lactate• Reflects cellular hypoxia

– Hypoperfusion

• Rise’s early in shock development

• Lactate ^4mmol - panic value

• Repeat – assess lactate normalisation

Blood Cultures

• Taken when infection suspected• Best during fever (high rate of capturing

organism)• From IV & Invasive devices• Before antibiotics

– But don’t delay Ab’s !

RESUSCITATION&

MANAGEMENT

The Game Plan

The Goals of Sepsis Tx!

1. Respiratory support2. Maintain circulating blood volume3. Immediate antibiotic administration4. Removal of source

The approach

• Airway• Breathing• Circulation• Disability • Environment• Senior DR to R/V• Ensure IV access

The Sepsis Six

1. Give Oxygen2. Blood Cultures3. IV antibiotics4. Fluid challenge5. Check lactate6. Urine output

Respiratory Support

Hypoperfused tissue = oxygen depleted↓

Respiratory rate increases ↓

Compensatory mechanism↓

Results in metabolic acidosis

Give them O2

• Supplemental O2 – maximise O2 available

• Use High flow– Cautious in COPD

• Aim for SPO2 >95%

When the Lungs Fail

• High risk of ARDS

• May require NIV– CPAP or BiPAP for more support

• This fails = mechanical ventilation

Mechanical Ventilation in Sepsis

• Use low tidal volumes 6-8ml/kg/IBW• Optimise your PEEP• Keep plateau pressure <30• Sit them up to 30°• Check cuff pressure• Avoid hyperoxia

Hypotension is Bad

• Sepsis = vascular depleted!

Results in:• Peripheral hypoperfusion• Myocardial dysfunction

All this = Hypotension

Fluid Resuscitation

• Start with fluid bolus:• 20-40ml/kg• Fluid choice

– Saline vs CSL

• Hb <70 give blood

• Look for: ↑BP, ↓HR, ↑Urine Output

When Fluids Fail

Need to improve hearts:• Contractility• Cardiac out

Use Vasoactives• Noradrenaline• Vasopressin• Dopamine

Which Pressor is Best?

Which Pressor is Best?

Noradrenaline seems to be popular ATM!

Time to be Invasive

Renal Dose Dopamine

Myth that it prevents:• Acute renal failure• Does increase contractility slightly• Limited evidence in low doses

• It works best if ICU don’t want the patient!

Early Appropriate AB’s

• 1st dose within 1 hour• Broad spectrum first• Greatly reduces mortality• Duration 7-10 days• Consider antifungals/viral in special pop

Kumar Study!

Steroids: Friend or Foe?

Role of Roid’s

Role of Roid’s

Consider in vasopressor resistant shock

Source Control

Aim to:• Control focus of infection• Facilitate restoration of optimal A & P

Through:• Drainage, debridement, removal

Source Control

Being Supportive

• Pressure area care• Stress ulcer prophylaxis• DVT prophylaxis• Glucose control• Family support

Complications of Sepsis

Questions

Take Home Points

Sepsis:– Time sensitive disease– Be suspicious & look for it– Requires early intervention

• Antibiotics & fluids within 1 hour!