Sepsis and Septic Shock Module 4 Recognising and Responding to the Deteriorating Patient This Photo by Unknow Author is licensed under CC BY-SA Learning outcomes At the end of this session students will be able to: • • • • Recognise the burden of sepsis Examine the pathophysiology of sepsis Examine the pathophysiology of shock Differentiate between different types of shock, with special focus on septic shock • Discuss the treatment guidelines relating to the management of septic shock Session structure Pre-session work Presentation Post-session work Pre-session work (10’) Watch Video 1 on Canvas Sepsis is real Sepsis mortality over the years 250,000 admission 2015 in UK NCEPOD (2015) reported mortality was 28.9% Sepsis Trust (2018) sepsis claims more live than lung cancer, bowel, breast and prostate cancer combined. Criteria and definitions over time • Sepsis continuum 1991, 2004, 2008, 2012 • Red flags (Sepsis Trust 2015) • Sepsis 3 consensuses (February 2016) Singer et al (2016) • NICE mild, moderate and high risk criteria (August 2016) • Surviving sepsis campaign (2016) • Royal College of Physician (2017) NEWS 2 • Sepsis Trust (2018) Sepsis Manual RCP 2017 and Sepsis Trust 2018 Definition of sepsis “Sepsis is characterized by a dysregulated host response to infection mediated by the immune system and resulting in organ dysfunction, potentially multi-organ failure, shock and death”. Sepsis identification criteria 1. Adult patient with suspect infection 2. Aggregate NEWS score of 5 and above Let’s break it down • Dysregulated host response to infection • Mediated by the immune system • Results in organ dysfunction • Potentially multi-organ failure • Potentially shock • Potentially death Let’s break it down • Dysregulated host response to infection • Mediated by the immune system • Results in organ dysfunction • Potentially multi-organ failure • Potentially shock • Potentially death SEPSIS: Dysregulated host response to infection Dysfunction Immune system Risk factors Excessive Systemic activation of inflammation Overcompensation Body response Risk Factors for sepsis • • • • • • • • • • Underlying malignancy Age <65 years Haemodialysis Alcoholism Diabetes mellitus Recent surgery or other invasive procedure Breach of skin integrity Indwelling lines or catheters Intravenous drug use Pregnancy or recent pregnancy This Photo by Un under CC BY Most “popular” causes of sepsis Sepsis Trust Manual 2018 Let’s break it down • Dysregulated host response to infection • Mediated by the immune system • Results in organ dysfunction • Potentially multi-organ failure • Potentially shock • Potentially death Intensive Care Sepsis criteria 2016- Sepsis 3 qSOFA calculator Let’s break it down • Dysregulated host response to infection • Mediated by the immune system • Results in organ dysfunction • Potentially multi-organ failure • Potentially shock • Potentially death Need a break? good vessel capacity How does our body maintain blood pressure? Healthy cardiac function appropriate blood volume Normal response to hypotension (Woodrow, 2019) • Baroreceptors in major arteries identify hypotension – hypothalamus/ pituitary/ adrenal axis is stimulated, causing a fight or flight response • ACTH (Adrenocorticothrophic hormone) released from Pituitary gland, stimulating adrenal production of adrenaline and noradrenaline, causing vasoconstriction and increased heart rate, increasing BP. • Increased glucocorticoid secretion • Intrarenal hypotension initiates the renin-angiotensin- aldosterone system (RAAS) • Renin (Kidney) activates Angiotensin (Liver) 1 – A1 causes mild vasoconstriction and turns into A2 in the lungs • A2 is a powerful vasoconstrictor and increases adrenal production of Aldosterone • Aldosterone (adrenal glands) increases renal sodium reabsorbtion • Intrarenal hypotension initiates the renin-angiotensin- aldosterone system (RAAS) • Pituitary gland releases antidiuretic hormone (vasopressin), increasing water reabsorption. Vasoconstriction – reducing blood vessel capacity Body adjusts to hypotension! Increased heart rate – increase blood volume Increased sodium reabsorption + antidiuretic hormone – increase blood volume Stages of shock: Initial (hypodynamic – poor cardiac output causes systemic hypoperfusion and kickstarts anaerobic metabolism) Compensation (sympathetic nervous system – fight of flight: tachycardia, tachypnoea, oliguria, agitation, hyperglycaemia) Progression (Hypotensive – parasympathetic nervous system) Refractory (multiorgan failure, no response to treatments) Perfusion and system failures due to shock Perfusion failure (causes depend on type of shock) System failure • Insufficient circulation volume • Inadequate cardiac output • Excessive peripheral vasodilatation • Perfusion issues cause anaerobic metabolism, metabolic acidosis and increased lactate, which in turn lead to • Multi-organ failure Septic Shock A subset of sepsis • Characterised with profound circulatory, cellular and metabolic abnormalities Clinically can be identified by: 1. the need for vasopressors to keep MABP>65mmHg 2. Lactate> 2 mmol/l • The presence of 1 and 2 in the absence of hypovolaemia (or despite adequate fluid resuscitation) • Associated with hospital mortality is greater than 40% Septic Shock A severe and potentially fatal condition that occurs when sepsis progresses to life threatening low blood pressure. This in turn can lead to respiratory or heart failure, stroke, failure of other organs such as Kidneys, Bowel and liver and can lead ultimately to death. Signs • Low blood pressure • Decreased urine output • Acute confusion • Dizziness • Issues with breathing in the regulation and the rate • Cyanosis of the lips, fingers, toes etc. How does the body react to Septic shock Early intervention is key The red flags of the Sepsis 6 • Objective evidence of new or altered mental state Systolic BP ≤ 90 mmHg (or drop of >40 from normal) • Heart rate ≥ 130 per minute • Respiratory rate ≥ 25 per minute Needs O2 to keep SpO2 ≥ 92% (88% in COPD) • Non-blanching rash / mottled / ashen / cyanotic • Lactate ≥ 2 mmol/l • Recent chemotherapy • Not passed urine in 18 hours (0.5mls?kg/hr if catheterised) The Amber Flags for the Sepsis 6 (send blood, senior review within 1 hour) • Relatives concerned about mental status • Acute deterioration in functional ability • Immunosuppressed • Trauma / surgery / procedure in last 8 weeks • Respiratory rate 21-24 • Systolic BP 91-100 mmHg • Heart rate 91-130 or new dysrhythmia • Temperature • Clinical signs of wound infection Treatment of sepsis and septic shock (nursing perspective) prevention • When possible, prevent infection infection management initial resuscitation hemodynamic supporting supportive nursing care • control of the infection source and transmissionbased precautions. • Early recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. • improving both tissue oxygenation and circulation • nutrition, mouth and eye care, and pressure ulcer prevention and management. Post-session activities • Complete Activity 1 and 2 on Canvas • Read the NICE guidelines on sepsis • Read the Sepsis Manual • Read the Nursing Considerations for the SSC