2Learning objectives Recognise that sepsis is a medical emergency Identify the risk factors, signs and symptomsOutline the escalation of the septic patientDefine the initial management actionsDiscuss the requirements for 48 hour sepsis management
3You can make a difference for patients in this hospital Sepsis is amedical emergencyYou can make a difference for patients in this hospitalSepsis is a medical emergency that requires urgent treatment which is as time critical as an AMI, Stroke or traumaEarly treatment with antibiotics and fluid resuscitation are life saving.Need to think of sepsis as a time critical illness ……TIME IS LIFE
4What 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 resuscitationDefine sepsis as a whole of body syndrome so that the audience is aware of the difference between infection and sepsis/severe sepsis and septic shockSepsis is infection plus SIRSSIRS = systemic inflammatory response syndrome which is two or more of the following criteria:Temp < 36°C or > 38°C, RR > 24, HR > 90, WCC < 4 or > 12Severe sepsis is sepsis + organ dysfunction, hypotension and/or hypoperfusionSigns of hypoperfusion include lactic acidosis, oliguria, or an acute alteration in mental statusHypotension: Systolic BP < 90mmHg or a reduction of > 40 mmHg from baselineSeptic shock is severe sepsis with BP unresponsive to fluid bolus
5Systemic Inflammatory Response Syndrome The sepsis continuumSevere SepsisInfectionSystemic Inflammatory Response SyndromeSepsisSeptic ShockIncreasing MortalityThere is an increasing mortality as the patient moves along the sepsis continuumKeep in mind that a patient can present at any stage of the continuum
6Sepsis recognition & management…what is the problem? Sepsis causes more deaths in adults per year than prostate cancer, HIV and breast cancer combined25% mortality associated with septic shockHigh number of sepsis adverse events in NSWApproximately 30% of Rapid Response calls are related to sepsisDelayed recognition and initial appropriate treatment increases mortalityAppropriate recognition and timely management of patients with severe infection and sepsis is a significant problem in NSW hospitals and health care organisations around the world.Incidence:Estimated 18 million cases per year worldwideIncreasing incidence in the elderly and chronically ill (CEC Cost Effectiveness Analysis, 2011)Mortality and morbidity:20-25% mortality in adults and 10% mortality in childrenHigh morbidity - lingering consequences with patients frequently experiencing long term mental and physical deficits and unable to return home (require nursing home admission)Sepsis patients have an extended LOS 11.1 days vs 2.6 days (CEC Cost Effectiveness Analysis 2011)High number of adverse events:CEC Clinical Focus Report on Recognition and Management of Sepsis (2009) showed large number of adverse events for patients with sepsis in NSW.Long delays in recognising and treating patients with sepsis resulting in poor outcomes and deaths.Rapid Response calls:Preliminary NSW sepsis data suggests that 30 per cent of adults who require a Rapid Response are septic.This is replicated in national and international literature, with sepsis being a leading cause for clinical deterioration, accounting for one in three calls for a Rapid Response team (Jones et al. Medical Emergency Team syndromes and an approach to their management.
7Insert summary of your facility/LHD adverse event here
8Difficult diagnosis Not all patients have classic SIRS Clinical diagnosis requiring experience and high index of suspicion for interpretation of history/symptoms/signsSigns often subtleSome 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 2004SIRS: systemic inflammatory response syndromeInfants are at higher risk due to lowered immunity in first few months of life.Elderly patients frequently don’t mount an inflammatory response – will not get raised temperature etc but more likely to be drowsy, confused (delirium), not eating.
9Common signs & symptoms of sepsis Tachypnoea 99%Tachycardia 97%Fever > 38 degrees 70%Hypothermia 13%Metabolic acidosis 38%Acute oliguria 54%Acute encephalopathy 35%Brun-Buisson C et al, JAMA: 274(12), 27 Sept, 1995Accurate and routine measurement of respiratory rate is essentialNote that fever is not always present in the patient with sepsis.Tachypnoea and tachycardia are key triggers.
10The 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 neededBased on three key actions – RECOGNISE, RESUSCITATE and REFERAll are time critical and emphasise that sepsis is a medical emergencyCEC sepsis guidelines are aligned with the Surviving Sepsis Campaign (SSC) International Guidelines (SSC is an international body of work - guidelines were first published in 2004, last updated 2012)
11SEPSISKILLSThe clinician needs to ‘think sepsis’ in day to day care of patients – all patients in hospital are at risk of sepsis.
12When to use the sepsis pathway… The patient has signs or symptoms of infection: suspect sepsisThe patient has observations in the Red or Yellow Zone on the SAGO chart: suspect sepsisThe clinician, patient or relatives are concerned about deterioration: suspect sepsisThe inpatient sepsis pathway should be reviewed and considered for all activations of the Clinical Emergency Response SystemThe sepsis pathway provides clear guidelines for sepsis recognition, notification, escalation and initial management.‘Between the Flags’ criteria are used instead of classic SIRS as the pathway needs to integrate with the Between the Flags system and the Recognition and Management of Patients who are Clinically Deteriorating Policy.Recognition of sepsis risk factors, signs and symptoms may be facilitated via any of the following systems:Observations in the red or yellow zone on a Standard Adult General Observation Chart (SAGO) A patient may be identified as being at risk of or having sepsis during a ward round.REACH (Recognise, Engage, Act, Call, Help is on its way) patient and family activated Rapid Response program. Important note: The sepsis pathway is not intended for patients at risk of febrile neutropenia. Patients with a recent haematological or oncology diagnosis should be managed using relevant local guidelines for febrile neutropenia.
13RECOGNISE: RECOGNISE: Firstly consider – does your patient have a known or suspected infection – challenge the current diagnosis and think ‘could the patient’s deterioration be due to Sepsis’Identify if the patient has any Sepsis risk factors signs or symptoms? – if no look for other causes of deterioration but keep think about sepsisIf yes – does the patient have any Red Zone observation or additional criteria or is there two or more Yellow zone observation of additional criteriaREMEMBER – IF YOU ARE CONCERNED THAT THE PATIENT HAS SEPSIS CONTINUE TREATING FOR SEPSIS UNTIL PROVEN OTHERWISE AND SEEK URGENT SENIOR ADVICESepsis is a difficult clinical diagnosis that requires experience and a high index of suspicion for interpretation of history, signs and symptoms.Sepsis risk factors signs or symptoms?PLUSAny red or yellow zone observations or additional criteria?Consideration should be given to whether sepsis or any other time critical conditions such as a new arrhythmia, hypovolaemia/haemorrhage, PE/DVT, pneumonia/atelectasis, an AMI, stroke or overdose/oversedation could be the cause of the patient’s deterioration.Teachings advocated in the BTF Tier Two education (DETECT training) including A-G assessment apply when assessing patients with suspected sepsis.
14RESPOND & ESCALATE: RESPOND & ESCALATE A Clinical Review or Rapid Response must be activated for the deteriorating patient (if not already done) in accordance with local CERS. Patients who are identified as septic at the time of a ward round or during a routine medical consultation require a CERS call if the patient’s observations are in the Red Zone.Early senior clinician involvement is imperative to ensure that the required skills and knowledge are available to facilitate appropriate diagnosis and management.The ISBAR framework can be used to structure the conversation to ensure completeness of information and standardise communication.
15Time is Critical RESUSCITATE: RESUSCITATE: The sepsis pathways provide clear resuscitation guidelines for patients with severe sepsis or septic shock sepsis using an A-G approach.
16Six key actions within 60 minutes Administer oxygenTake blood cultures and other specimensMeasure serum lactateIV fluid resuscitationIV antibioticsMonitor urine output, vital signs and reassessRESUSCITATE:The guideline is based on a bundle of care which should be delivered within one hour of recognition/diagnosis.The six components are:OxygenBlood culturesSerum lactateIntravenous fluidsAntibioticsMonitoring and reassessment
171. Administer oxygen Improve oxygen delivery to the tissues Maintain SpO %History of COPD maintain SpO %Requires regular reviewESCALATE to Rapid Response if patient is unresponsive to oxygen therapyPatients with sepsis require oxygen until there is clear evidence that there is no hypoperfusion.Patients with chronic lung disease should be managed according to local guidelines.
182. Blood cultures Take blood cultures BEFORE starting antibiotics Take two blood cultures from separate sites if possibleObtain other cultures: urine, CSF, faeces, wound swabs, sputum, other fluids from within cavities,Consult specialty teams early for source controlTwo sets of blood cultures are recommended to enable microbial identification and sensitivity and to guide antibiotic choice. Cultures should be taken from separate sites and should include one from each intravenous device in place for more than 48 hours.Specialist teams should be consulted early for appropriate source control. Treatment of the source of infection (surgical excision/drainage) is imperative to survivalUse the CEC Blood Culture Sampling Guideline or local guidelines.FAQS:Why should I take an anaerobic bottle as part of a set of blood cultures?An anaerobic bottle is now recommended as improvements in broth medium and pathology equipment have increased anaerobic yield and some aerobic organisms will signal faster in an anaerobic bottle.Why 2 sets (4 bottles) of blood cultures?A single set (2 bottles) may miss up to 40% of bacteraemias/fungaemias and if only one set is taken and it is positive it could be the result of a contaminant (false positive result). Two sets showing growth makes it easier to eliminate the risk that a skin contaminant has been cultured. Taking blood from separate sites is a further aid.Do you have to wait between taking the first and second set of blood cultures?No. If 2 sets of blood cultures are taken from different peripheral sites and antibiotics have not been given, there is no reason to delay between taking the blood cultures.
193. Measure serum lactateElevated lactate (lactic acid) level is a sign of global tissue hypoxiaElevated lactate is directly linked to increased mortalityInitial and serial lactate measures are valuable indicators for sepsis managementMeasurement of lactate in all septic patients is a simple strategy that may assist clinicians to more effectively manage the care of septic patients and improve outcomes.Lactate is a normal product of anaerobic cell metabolism and is released into the blood and metabolised by the liver. It is produced in large amounts when there is insufficient oxygen for activity in the cell.Lactate production can be increased in conditions that cause inadequate oxygen delivery, such as trauma, as well as in conditions that have disproportionate oxygen demands such as hyperthermia and seizures. Some medications such as salbutamol, metformin, phenformin and nucleoside can also cause high lactate levels.Normal lactate levels are less than 1.0 mmol/L in both arterial and venous blood. Elevated serum lactate level is strongly associated with morbidity and mortality in critically ill patients. The NSW Between the Flags system mandates that a patient with a lactate of 4.0 mmol/L or more should activate a Rapid Response with immediate intervention by a team of critical care experts.
20NSW sepsis mortality by severity CEC/HIE linked data n=3851 (2012) Elevated lactate can occur before patients have a marked acidosis or low blood pressure. Patients with a blood pressure >90mmHg and a raised lactate have a greatly increased mortality. Whilst they do not appear to be in shock there mortality is equal to or greater than the patient with septic shockCryptic shock is defined as a serum lactate greater than 4 mmol/L with a systolic blood pressure of at least 90mmHg.Serum lactate should be screened in all patients who are suspected of severe infection and sepsis, irrespective of blood pressure and the appearance of being well-perfused..
214. Intravenous fluid resuscitation Fluids will reduce organ dysfunction and multi-organ failureGive a rapid IV bolus of mls 0.9% sodium chlorideReassess for effect after each bolus – HR, BP, RR, capillary refill, urine output
22Aim to achieve systolic BP ≥100mmHg Repeat ml bolus of 0.9% sodium chloride if neededESCALATE to Rapid Response if no improvement in BP after 500mls fluidPatients with renal or cardiac disease:Use smaller volumes of fluidUndertake more frequent assessment for positive and negative affectRefer to ICU for advice and early use of vasopressors
235. 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);Prompt administration of antibiotics is vital for effective management of sepsis. The goal is to commence antibiotic therapy within the first hour of recognition and diagnosis of sepsis. Antibiotic therapy should not be delayed whilst waiting for investigations or results.Delays in administering appropriate antibiotics are associated with increased mortality in patients with septic shock (Kumar 2006). For every hour’s delay after the onset of hypotension there is a 7.6% increase in mortality.Kumar, 2006
24The ‘right’ antibiotic is crucial Take blood cultures before antibiotics but do not delay antibiotics to undertake investigations or await resultsStart antibiotic therapy within 60 minutesUse bolus administration where possibleREMEMBER: one dose is safer than not treating at allPRESCRIBE IT...GET IT...GIVE IT...NOW!!!The CEC Inpatient Sepsis Intravenous Antibiotic Guideline aims to guide the prescription and timely administration of antibiotics for patients that have a diagnosis of sepsis and have been admitted to hospital for 48 hours or more. It is based on the recommendations in Therapeutic Guidelines: Antibiotic version 14, 2010.The guideline is intended to provide an accessible resource which can be adapted to suit individual facility preferences in liaison with the antimicrobial stewardship team, local antimicrobial susceptibility patterns and senior clinicians.A flow chart is provided in the antibiotic guideline to assist the treating doctor in determining (for each case of sepsis) if the Antibiotic Guideline can be used or if escalation to the AMO for further advice is required.Medical and nursing communication is vital to ensure antibiotics are administered immediately.
256. Monitor vital signs and urine output Monitor observations every 30 minutes for 2 hours and then hourly for four hoursRespiratory rateHeart rateBlood pressureCapillary refillLOCUrine outputFrequent monitoring is required to facilitate reassessment.Evidence of improvement in first hour:Systolic BP > 100mmHgImproving capillary refillWarming of extremitiesUrine output > 0.5 ml/kg/hrImproving mental statusDecreasing lactateConsideration should be given to patients who are not responding to treatment and whose priority will now be end-of-life care.The patient and family will need support to understand the severity of the condition and the expected outcome.
26Refer:If no improvement or if you are worried, escalate as per local CERSUpdate the AMOInclude ICU and infectious diseases reviewPoor outcomes for patients with sepsis are often associated with late referral to specialty services and/or delayed retrieval.
27Next steps: sepsis 48 hour management plan Management plan includes:- level of observation- review schedule- escalation planPoor outcomes for patients with sepsis are often associated with late referral to specialty services and/or delayed retrieval.
28Don’t turn your back on the bomb! In summary:Untreated SEPSIS KILLSEarly IV antibiotics and IV fluids saves livesOne dose of antibiotics is less risk than not treating at allSource identification and control are vitalPatients with sepsis are at high risk of deterioration48-72 hour follow up management plan is essentialDon’t turn your back on the bomb!