Sepsis
Sepsis
“A little less conversation, a little
more action please”
Aims of this session
• To use Surviving Sepsis guidelines as a
framework
• To focus on practical interventions that
can improve outcome in the septic
patient
• To encourage you to think like intensive
care doctors
• To be as interactive as possible
At the end of this session you
will be able to
• Define and use important terminology
• Identify features of organ failure
• Prioritise urgent interventions in the
septic patient
• Describe an effective fluid challenge
• Demonstrate how CVP can be used to
guide fluid resuscitation
• Explain ScvO2 and how it can indicate
tissue dysoxia
Definitions
• Systemic Inflammatory Response
Syndrome (SIRS)
• Sepsis
• Severe Sepsis
• Septic Shock
‘SIRS’
‘SIRS’
• 2 or more of the following:
– Temp >38ºC or <36ºC
– HR >90 beats/min
– RR >20 breaths/min or PaCO2 <4.5kPa
– WBC >12,000 or <4000 cells/mm3, or
>10% immature (band) forms
‘Sepsis’
‘Sepsis’
• SIRS in the presence of proven or
suspected infection
‘Severe Sepsis’
‘Severe Sepsis’
• Sepsis associated with hypotension,
hypoperfusion and/or organ-dysfunction
‘Septic Shock’
‘Septic Shock’
• Sepsis with hypotension despite
adequate fluid resuscitation
• May be ‘vasodilatory’ and/or
‘distributive’ shock
• Include all patients on vasopressors or
inotropic support
Organ Failure
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CVS
RS
Renal
Hepatic
CNS
Haematological
Prognostic effects of organ dysfunction in severe sepsis
Prevalence of hospital mortality associated with severe sepsis
Case 1
You are called to Resus to review an 78 year old female
who presented with confusion, fever and rigors.
She is unable to give a history.
Her observations on admission are 38.30c, BP 70/35
Pulse 120 RR 30
What are your thoughts?
What would you like to do next?
Case 2
A ICU nurse asks you to urgently see an elective
cardiac patient who has just arrived from theatre,
ventilated but has had no medical handover
His obs are T35.5, BP 80/50, P100, CVP 10, SpO2 99
on 40% O2
Why is this patient hypotensive?
Case 3
The A&E SpR calls to discuss the case of a 50 year old
overweight, hypertensive, diabetic female with upper
abdominal pain and shock. The surgeons have just
started an AAA repair in theatre.
Obs: T35, BP 90/40, P100, RR36, SpO2 unrecordable
• What is the differential diagnosis?
• What would you like to do next?
How do we manage sepsis
and septic shock?
1) Investigate and treat sepsis
•
•
•
Try and find and treat source
Early blood cultures
Start antibiotics asap ideally within 1 hour
and after cultures taken
2) Assess extent of end organ
hypoperfusion and improve oxygen
delivery (early goal directed therapy)
Oxygen delivery
What does it mean?
Oxygen delivery
What does it mean?
Delivery (DO2) = O2 content x cardiac
output
= ([Hb] x SpO2 x 1.34) x (HR x SV)
Oxygen content = [Hb] x SpO2 x 1.34
Cardiac output = HR x SV
Fluid Challenge
What is the difference between an infusion and a
challenge?
Fluid Challenge
What is the difference between an infusion and a
challenge?
250 to 500 ml colloid (or blood products)
500 to 1000ml Hartmann’s
[NOT 5% dextrose]
As fast a possible (with pressure bag)
You at the bedside
Fluid Challenge
Aim is to improve SV (and hence CO) by increasing
preload
Frank-Starling mechanism
Markers of perfusion
What are they?
Markers of perfusion
What are they?
• Clinical signs
– Warm skin, conscious level, u/o
• Haemodynamic variables
– CVP
• Bloods
– Serum Lactate
– ScvO2
CVP
What does it mean?
CVP
What does it mean?
Starling’s Law
Estimate of LVEDV (i.e. preload)
Not always a good correlation with
volume-responsiveness
However if low strongly suggestive of
hypovolaemia
Lactate
What does it mean?
Lactate
What does it mean?
• Increased production (anaerobic glycolysis)
– Tissue hypoperfusion
– Tissue dysoxia
• Reduced metabolism
– Hepatic
– Renal
• <1 is normal, 1-2 is a concern, >2 is bad,
>4 is very bad
ScvO2
What does it mean?
ScvO2
What does it mean?
• Balance between oxygen delivery and
consumption (VO2)
• Fick principle
• ScvO2 = SaO2 - VO2
CO
• Target > 70%
ScvO2
What can I do if it’s low?
ScvO2
What can I do if it’s low?
Delivery = [Hb] x SpO2 x 1.34 x HR x SV
ScvO2
What can I do if it’s low?
Delivery = [Hb] x SpO2 x 1.34 x HR x SV
Fluid optimise
Transfuse packet cells
HCt > 30%
Inotropes
Surviving Sepsis targets of
fluid resuscitation
What are they?
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SBP
MAP
CVP
U/o
Lactate
ScvO2
HCt
Surviving Sepsis targets of
fluid resuscitation
What are they?
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SBP > 90
MAP > 65
CVP 8 - 12
U/o > 0.5 ml/kg/hr
Lactate < 1
ScvO2 >70
HCt > 30
Further Management
What else can be done?
Further Management
What else can be done?
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Low tidal volume ventilation
Steroids in septic shock
Activated Protein C
Glycaemic control
Stress ulcer prophylaxis
Thromboprophylaxis
Sedation scoring / holds etc.
Any Questions?
Take Home Message(s)
• Early intervention saves lives
• Send cultures immediately
• Give antibiotics early (<1 hour on ICU, <3 hrs
A&E)
• Aggressive targeted fluid resuscitation on the
spot (early goal-directed therapy)
• CVC / ScvO2 if shocked / Lactate > 4
• Involve surgeons/radiologists early (source
control)
At the end of this session you
are now able to
• Define and use important terminology
• Identify features of organ failure
• Prioritise urgent interventions in the septic
patient
• Describe an effective fluid challenge
• Demonstrate how CVP can be used to guide
fluid resuscitation
• Explain ScvO2 and how it can indicate tissue
dysoxia