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!