1. Sepsis

2. What is sepsis?
Sepsis was defined in a 1992 consensus definitions conference as a systemic response to new infection. This is known as
SIRS – systemic inflammatory response syndrome

3. Prevalence and incidence
Worldwide sepsis kills over 1400 people a day
In the UK over 37,000 people die from sepsis annually
Each episode of sepsis costs the NHS £20,000
More people die from sepsis each year than the following combined:
Lung Cancer
Breast Cancer
Bowel Cancer

4. Types of Sepsis
Sepsis – Systemic inflammatory response syndrome resulting from a presumed or known site of infection
Sever Sepsis – Sepsis with an acute associated organ failure
Septic Shock – A subset of sever sepsis, defined as a persistently low mean arterial blood pressure despite adequate fluid resuscitation
Refractory Shock – Persistently low mean arterial blood pressure despite vasopressor therapy and adequate fluid resuscitation

5. Pathophysiology
Can occur as a result of infection at any body site, the most common pathogen is bacteria but it can be caused by fungi, viruses or parasites as well
Characterized by simultaneous activation of inflammation and coagulation
Cytokines and white blood cells trigger vasodilation to increase capillary permeability, neutrophil activation and adhesion of platelets to the endothelium
Baroreceptors in the carotid arteries and aorta respond to a drop in the patient’s blood pressure and activate the sympathetic nervous system

6. Pathophysiology continued
Vasoconstrictors
Epinephrine
Norepinephrine… are all released to maintain blood flow to vital organs (the heart and brain)
Blood is shunted from the non – vital organs
Eventually affects:
Cardiac output
Circulating volume
Blood Pressure
= Multiple Organ Dysfunction Syndrome (MODS)
= Death

7. Defining Sepsis
Systemic Inflammatory Response Syndrome (SIRS) is defined by the presence of two or more of the following symptons:
Temperature <36°C or >38°C
Heart rate >90 beats per minute
Respiratory rate >20 beats per minute
White blood count <4,000 per ml or >12,000
- Levy et al, 2003

8. Patients at a higher risk of Sepsis
People <1 year and >65 years
Those with a chronic illness
People who are immunosuppressed
Those who are on a broad – spectrum antibiotic use
Exposure to infection associated with surgical and invasive procedures
N.B. >65 years is due to a decline in immune function

9. Severe Sepsis Sepsis complicated by organ dysfunction
Sepsis – induced hypotension
Most patients who acquire severe sepsis do so on the first day of a hospital stay
Hypoperfusion abnormalities such as:
Lactic acidosis, oliguria, acute alteration of mental state
Mortality rate of 35%, 7 times higher than that of Acute Coronary Syndrome

10. Septic Shock
The presence of sepsis and a state of acute circulatory failure, characterized by refractory arterial hypotension(<90mm Hg) – not explainable by other causes
Evidence of hypoperfusion (high lactate)
The patient is dependent on vasopressors at this point
Transition from severe sepsis to septic shock normally happens within 24 hours of hospitalization
Mortality rate approaching 50%
Will be likely to require invasive monitoring such as venous catheters and vaso – active drug infusions

11. Diagnosis
Difficult to do – first six hours are very important as this is the time when tissue hypoxia can be reversed
Early organ dysfunction is normally the first notable find
Other diagnostic criteria:
Hemodynamic instability
Arterial hypoxemia
Oliguria
Coagulopathy
Altered liver function tests
Serum lactate level is a diagnostic marker – lactate is generated by anaerobic cellular metabolism and may reflect the severity of cellular derangements

12. Treatment
Often focused on supporting failing organ systems with interventions:
Fluid replacement – for restoration of tissue perfusion and normalization of oxidative metabolism
Airway management – for patients with progressive hypoxemia, hypercapnia, neurologic deterioration or respiratory muscle failure
Antibiotic Therapy
Vasopressors – when fluid administration fails to restore an adequate arterial pressure and organ perfusion
Need to increase cardiac output
For every hour’s delay in beginning treatment, a patient’s risk of death increases by 7.6% (Kumar et al, 2006)

13. Sepsis Six
An operation pathway which comprises tasks which can be completed immediately in a ward or A & E
When given within 1 hour of Sepsis being recognised, the Sepsis Six pathway is proven to save lives. The steps:
Give high flow oxygen (via non – rebreathe bag)
Take blood cultures
Give IV antibiotics
Start IV fluid resuscitation (Hartmann’s or equivalent)
Check haemoglobin and lactate
Monitor accurate hourly urine output (may require a catheter)
- Surviving Sepsis Campaign

14. Surviving Sepsis Campaign
Main aims were to improve the management, diagnosis and treatment of sepsis
How this is being achieved:
Increasing awareness, understanding and knowledge
Changing perceptions and behaviour
Influencing public policy
Defining standards of care
Through the campaign it was determined that the greatest achievement was through education and changing the process of care which patients with sepsis received