The ‘SEPSIS 6’ <insert date> Faculty: <insert faculty> Surviving Sepsis – ‘Recognise and Act’ <insert date> Faculty: <insert faculty>

Why is high-flow oxygen beneficial? What are the dangers of high-flow oxygen? What are the barriers to giving immediate high-flow oxygen? Who can administer high flow oxygen? And how? © SaIL Centre 2015

Sepsis 6 High Flow oxygen: But… Guidelines suggest that high-flow oxygen should be applied initially, using 15L/min via a non-rebreathe mask. Saturations are not a helpful guide to tissue oxygen delivery, but may be useful to guide therapy in patients with risk of oxygen toxicity An arterial blood gas (ABG) taken as soon as possible. But… There is some conflicting evidence about the role of high-flow oxygen in severe sepsis with shock There is special concern about the administration of high flow oxygen to patients with chronic lung diseases with risk of CO2 retention. © SaIL Centre 2015

Sepsis 6 High Flow oxygen: So… Start High-flow oxygen. Target Saturations 88 – 92% if you KNOW that they are at risk of oxygen toxicity. Reduce oxygen if required. Get an ABG as soon as possible. Closely monitor the patient. Consider reducing the target saturations if suspicion or evidence of CO2 retention Contact Critical Care immediately, unless ceiling of care prohibits this. © SaIL Centre 2015

Who can take blood cultures? Why are they beneficial? What are the problems with taking blood cultures? What are the barriers to taking blood cultures? What other types of culture might you take? Why?

Sepsis 6 Blood cultures: Certainly do if it will not delay the delivery of anti-biotics 45 minutes is suggested maximum acceptable delay Culture other sites as well where possible and necessary Sputum – almost instant sterilisation following antibiotic administration, so do immediately Consider non-bacterial infections: fungal cultures, sputum for AFB, cytology (PCP), viral swabs Culture lines! If >48hrs in situ. Volume of blood in culture bottle should be……..? © SaIL Centre 2015

Why are they beneficial? When do you give antibiotics? What information do you need before giving antibiotics? Which antibiotics do you choose? What are the barriers to giving antibiotics? © SaIL Centre 2015

Sepsis 6 Antibiotics: Check allergies if serious/complex allergies – discuss with micro Broad spectrum unless source clear Review previous microbiology: Previous infections; Previous sensitivities Consult the guideline Use the Infections App – developed within KHP Available free to download. Use the password ‘infection’ in the settings menu to access more information If unsure then discuss with Microbiology – available 24/7 © SaIL Centre 2015

Sepsis 6 Antibiotics: 8% increased mortality with every hour delayed Give first dose intravenously Minimise delays 8% increased mortality with every hour delayed If any doubt, discuss with Micro and GIVE SOMETHING © SaIL Centre 2015

Why are they beneficial? What type of fluids do you use? Intravenous fluids Why are they beneficial? What type of fluids do you use? How much do you give? How fast do you give it? Are there any risks? Who can give IV fluids? What are the barriers to giving IV fluids? © SaIL Centre 2015

Sepsis 6 IV fluids: Appropriate fluid resuscitation is the bedrock of sepsis management Aim is to prevent or reverse tissue hypoperfusion Failure to respond is the clinical marker of Septic Shock Initial resuscitation: Crystalloid Not colloid (Albumin may be used later) Initial fluid challenge upto 30mls/kg i.e 2100 – 3000mls fluid for 70-100kg man. May use aliquots if concerns about fluid overload © SaIL Centre 2015

Sepsis 6 IV fluids: Once persistent hypoperfusion is recognised following initial fluid challenge, patient needs: Critical Care for goal-directed therapy OR… Ward based care with appropriate escalation decision / DNAR © SaIL Centre 2015

How do we get these measurements? Why is this beneficial? Lactate & Hb How do we get these measurements? Why is this beneficial? What is lactate? Why is it important? Why is it helpful to know the Hb? What are the barriers to getting these measurements? © SaIL Centre 2015

Sepsis 6 Lactate and haemoglobin: Blood lactate ≥4.0 associated with increased mortality 30% if lactate alone raised vs 46.1% if lactate raised AND hypotensive Can be used as a measure of success in resuscitation 9.6% reduction in mortality if you can reduce the lactate by ≥20% every 2 hours for the first 8 hours Haemoglobin: Significant anaemia may impair tissue oxygen delivery further and is an important initial consideration. Transfusion is rarely an acute priority and should be guided by senior input © SaIL Centre 2015

What are the risks of measuring it? Hourly urine output Why is this beneficial? How do we do it? Who can do it? What are the risks of measuring it? What are the barriers to achieving this? © SaIL Centre 2015

Sepsis 6 Hourly urine output: Aiming for an output of ≥0.5ml/kg/hr For a 70kg man, satisfactory urine output would be 35mls/hr Surrogate marker of tissue perfusion and degree of shock Allows maintenance of fluid balance and sensible control of fluid input If normal renal function at presentation & NOT Severe Sepsis or Septic Shock Can be monitored without a catheter This may require discussion of risks and benefits within team and with patient If AKI at presentation or Severe Sepsis or Septic Shock Or any other significant co-morbidity or clinical deterioration Urinary catheter definitely required & AKI EPR order set required © SaIL Centre 2015

Sepsis 6 End of the first hour, or upon completion of Sepsis 6. Patient responding to therapy.. Review infection source Review bloods Continue antibiotics – ensure regular antibiotics prescribed Consider imaging to identify source if required Source control Patient not responding to therapy, deteriorating Refer urgently to critical care if not already done Source Control Unless….. Not for escalation Ensure appropriate steps taken for compassionate ward-based / end of life care. © SaIL Centre 2015