Sepsis
Management
National
Clinical
Guideline No. 6
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Sepsis Management
National Clinical Guideline
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The aim of the guideline is to facilitate the early recognition and
appropriate treatment of sepsis in Ireland in order to maximise
survival and minimise the burden of chronic sequelae.
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All information regarding the guideline is available on Q-Pulse
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The summary document is available at:
www.health.gov.ie/patient-safety/ncec
www.hse.ie/sepsis
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The guideline adapts the Surviving Sepsis Campaign guidelines 2013
and Sepsis Six to the Irish context.
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Sepsis Management
National Clinical Guideline
“Sepsis is a life threatening condition that arises when the body’s
response to an infection injures its own tissues and organs. Sepsis leads
to shock, multiple organ failure and death especially if not recognised
early and treated promptly. Sepsis remains the primary cause of death
from infection despite advances in modern medicine, including vaccines,
antibiotics and acute care. Millions of people die of sepsis every year
worldwide.”
Merinoff Symposium 2010: Sepsis
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International context
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Approximately 300 cases per 100,000 population per annum. As comparators,
myocardial infarction affects 208 and stroke 223 patients per 100,000 per year.
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Mortality from sepsis is currently as high as mortality from acute myocardial infarction
was in the 1960s.
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In the U.K. sepsis is estimated to claim 37,000 lives annually and cost the NHS
approximately £2.5 billion.
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Sepsis incidence is predicted to grow at a rate of 1.5% annually due to:
- aging population
- increased numbers of invasive procedures
- increasing number of people living with co-morbidities
- increasing number of people long-term immunosuppressive therapies.
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Irish Context
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Up to 60% of all hospital deaths have a sepsis or infection diagnosis
(HIPE data)
Irish Intensive Care Units
Mortality rates of patients with a diagnosis of sepsis is 28.8%
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Mortality rates reduced by 17.7% and average length of stay is
decreasing every year with increased awareness.
(National Clinical Effectiveness Committee, 2014; Dellinger et al 2013)
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Each hour of delay in antimicrobial administration associated with an
average decrease in survival of 7.6%
(Kumar et al, 2006)
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UK report from the Health Service Ombudsman
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Lack of timely history and examination on presentation
Lack of necessary investigations
Failure to recognise the severity of the illness
Inadequate first-line treatment with fluids and antibiotics
Delay in administering first-line treatment
Inadequate physiological monitoring of vital signs
Delay in source control of infection
Delay in senior medical input
Lack of timely referral to critical care
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Sepsis Management
Program is aimed at early identification and treatment
of patients with sepsis
 lead to reduced mortality
 timely ICU admission
 decrease ICU length of stay
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DEFINITIONS
IMPORTANT TO KNOW
Infection is defined as a pathological process caused by invasion of normally sterile
tissue or fluid or body cavity by pathogenic or potentially pathogenic microorganisms.
Sepsis is the clinical syndrome defined by the presence of both infection and the
systemic inflammatory response syndrome (SIRS).
Severe sepsis refers to sepsis complicated by organ dysfunction.
Septic shock is defined as severe sepsis with circulatory shock with signs of organ
dysfunction or hypoperfusion.
Australian Modification of ICD-10 incorporating the Australian Classification of Health Interventions and the Australian Coding
PATHOPHYSIOLOGY OF SEPSIS
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Pathogenic features of the microorganism
Patient’s immune response to these features
Failure of the immune system to control an initially localised infection
Exaggerated immune and inflammatory response
Cellular dysfunction
Vasodilation and leaky capillaries
PATHOPHYSIOLOGY OF SEPSIS
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Distributive shock
Myocardial depression
Bone marrow suppression
Activation of clotting cascade DIC (Disseminatedd Intrtavascular Caogulation)
Organ dysfunction
MODS (Multiple Organ Dysfunction Syndrome)
Death
Infection
Vasodilation
Hypotension
Inflammatory
Mediators
Microvascular Plugging
Vasoconstriction
Maldistribution of Microvascular Blood Flow
Ischemia
Cell Death
Organ Dysfunction
DEATH
Endothelial
Dysfunction
Odema
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Sepsis Screening tool
Infection Suspected
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Any 2 or more
modified Systemic Inflammatory Response Syndrome (SIRS)
criteria present
□ Respiratory rate
>20 (bpm)/Hypoxia
□ WCC <4
or >12 x 10 x9/L
□ Acutely altered
mental status
□ Heart rate >90bpm
□ Temperature
<36 or >38.3 (°C)
□ Bedside glucose
>7.7mmol/L
(in absence of diabetes)
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Presenting complaints to consider
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Cough / flu-like symptoms
UTI / flank pain
Fever
Pleuritic chest pain / SOB
Abdominal pain
Generally unwell with co-morbidities /caution with elderly patients
Confusion
Headache (signs of meningism)
Abcess / local infections
Limb problems (intra-articular infections / septic arthritis)
Wounds
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Pathway of care for patients presenting
with sepsis
DECTECTION
COMMUNICATION
RECOGNITION
Early Warning score
Triage
RSVP
Clinical evaluation
Sepsis screening tool
RESUSCITATE +
REFER
Sepsis 6 within 1hr
Referral to senior
clinicians and ICU if
appropriate
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Adult in-patient trigger
New NEWS score of 4 (5 if on O2) or higher = medical review
Sepsis screening:
Infection suspected + two SIRS criteria = Sepsis
+ organ dysfunction and/or shock = Severe sepsis/septic shock
SIRS
Clinical response
arising from a non
specific insult
Infections and noninfectious causes
Sepsis
SIRS + a presumed
or confirmed
infection
Severe Sepsis
Sepsis + sepsisinduced organ
dysfunction or
tissue
hypoperfusion
Septic Shock
Sepsis induced
hypoperfusion or
hypoperfusion
persisting despite
30ml/kg Fluid
Resuscitation.
Caution:
Some groups of patients, such a older people, may not meet the modified SIRS criteria, even though
infection is suspected. Where this occurs check for signs of organ dysfunction and raised biomarkers such
as CRP.
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Sepsis Management National Clinical Guideline
What is Sepsis 6?
TAKE 3
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CULTURES: Take blood cultures before giving
antimicrobials (if no significant delay i.e.
>45minutes) and consider source control.
2. BLOODS: Check lactate and full blood
count.
3. URINE OUTPUT: Assess urine output and
consider urinary catheterisation for
accurate measurement in patients with
severe sepsis/septic shock.
GIVE 3
. OXYGEN: Titrate O2 supplementation to
saturations of 94 -98% or 88-92% in
chronic lung disease.
2. FLUIDS: Start IV fluid resuscitation if
evidence of hypovolaemia and/or shock.
500ml–1000mls bolus of isotonic
crystalloid over 15–30 minutes and give up
to 30ml/kg, reassessing after each bolus
for signs of hypovolaemia, euvolaemia, or
fluid overload.
3. ANTIMICROBIALS: Give IV antimicrobials
according to local antimicrobial guidelines.
Why within 1 hour?
Each hour of delay in antimicrobial administration decrease in survival of 7.6%.
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SEPSIS BOX
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Prevalence of sources of sepsis
IMPRESS trial (2014) check
Respiratory
35%
Urinary
21%
Intra abdominal
16.5%
Catheter related blood stream
infection
2.3%
Device related
1.3%
CNS
0.8%
Others e.g cellulitis, intra-articular
11.3%
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Diagnostic criteria for sepsis
General variables
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Fever (> 38.3°C)
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Hypothermia (core temperature < 36°C)
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Heart rate > 90/min–1 or more than two SD
above the normal value for age
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Tachypnoea
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Altered mental status
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Significant oedema or positive fluid balance (> 20
mL/kg over 24 hr)
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Hyperglycemia (plasma glucose > 7.7 mmol/L) in
the absence of diabetes
Inflammatory variables
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Leucocytosis (WBC count > 12,000 μL–1)
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Leucopenia (WBC count < 4000 μL–1)
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Normal WBC count with greater than 10%
immature forms Plasma C-reactive protein more
than two SD above the normal value
Haemodynamic variables
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Arterial hypotension (SBP < 90mm Hg, MAP < 70
mmHg, or an SBP decrease > 40 mmHg in adults
or less than two SD below normal for age)
Organ dysfunction variables
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Arterial hypoxaemia (PaO2/FiO2 < 300)
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Acute oliguria (urine output < 0.5 mL/kg/hr for at
least 2 hrs despite adequate fluid resuscitation)
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Creatinine increase > 0.5mg/dL or 44.2 μmol/L
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Coagulation abnormalities (INR > 1.5 or aPTT > 60s)
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Ileus (absent bowel sounds)
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Thrombocytopenia (platelet count < 100,000 μL–1)
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Hyperbilirubinaemia (plasma total bilirubin > 4mg/dL
or 70 μmol/L)
Tissue perfusion variables
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Hyperlactatemia (> 1 mmol/L)
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Decreased capillary refill or mottling
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WCC
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Severe sepsis
Severe sepsis is defined as sepsis-induced tissue hypoperfusion or organ dysfunction
(any of the following thought to be due to the infection)
– Lactate above upper limits laboratory normal
– Urine output < 0.5 ml/kg/hr for more than 2 hrs despite adequate fluid resuscitation
– Acute lung injury with PaO2/FiO2 < 250 in the absence of pneumonia as infection source
– Acute lung injury with PaO2/FiO2 < 300 in the presence of pneumonia as infection source
– Creatinine > 176.8 micromol/l
– Bilirubin > 34.2 micromol/l
– Platelet count < 100,000 μL–1
– Coagulopathy (INR > 1.5)
– Sepsis induced hypotension.
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Septic shock
Septic shock is defined as sepsis-induced tissue hypoperfusion persisting
after resuscitation with 30mls/kg intravenous isotonic crystalloid fluid as
evidenced by:
– Systolic blood pressure < 90 mmHg or MAP < 65 mmHg
– Decrease in systolic blood pressure by 40mmHg from baseline and/or
– Lactate > 4 mmol/l.
Recommendations
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Fluid resuscitation with crystalloid
Only consider albumin in patients who continue to require substantial amounts of
crystalloid to maintain adequate MAP.
Avoid hetastarch i.e. gelofusine
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Avoid IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation
and vasopressor therapy restore haemodynamic stability
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First choice vasopressor – norepinephrine + additional epinephrine/vasopressin if
required. Vasopressin should not be used as initial vasopressor, use for salvage only.
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Dopamine not recommended
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Protocol for glucose management commencing insulin dosing when 2 consecutive
BGL levels >10mmol. Keep BGL < 10. Check BGL 1- 2 hrly until stable and then 4
hrly.
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Early imaging to diagnose source of infection. (Dellinger et al 2013)
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References
Dellinger R.P. et al. (2013) Surviving Sepsis Campaign: International
Guidelines for Management of Severe Sepsis and Septic Shock: 2012.
Critical Care Medicine 41 (2), 580-621.
Kumar A. et al (2006) Duration of hypotension before initiation of effective
antimicrobial therapy is the critical determinant of survival in human septic
shock. Critical Care Medicine 34, 1589-1596.
National Clinical Effectiveness Committee, Health Service Executive (2014) Sepsis
Management: National Clinical Guideline No. 6
www.hse.ie/eng/about/Who/clinical.natclinprog/sepsis/sepsis%20management.pdf
Australian Modification of ICD-10 incorporating the Australian Classification of Health Interventions
and the Australian Coding
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Thank you
Any Questions?
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SEPSIS
DECTECTION
COMMUNICATION
RECOGNITION
Early Warning score
Triage
RSVP
Clinical evaluation
Sepsis screening tool
RESUSCITATE +
REFER
Sepsis 6 within 1hr
Referral to senior
clinicians and ICU if
appropriate