the official training programme of the Surviving Sepsis Campaign

Objectives Understand the importance of sepsis Be able to recognise the septic patient Appreciate the importance of bundle-driven care Contribute to the delivery of that care

Is sepsis important? High mortality Worldwide 1400 deaths a day Angus D - more? Most common cause of death in ICU

How many of these patients die? 39.8%

A U.K. Perspective Lung1 Colon2 Breast3 Sepsis4 cancers Annual UK mortality (2003), thousands Lung1 Colon2 Breast3 Sepsis4 cancers 1,2,3 www.statistics.gov.uk,, 4Intensive Care National Audit Research Centre (2005)

Identifying the Septic Patient

ACCP/SCCM Consensus Definitions Severe Sepsis Sepsis Organ dysfunction Septic shock Hypotension despite fluid resuscitation Infection Inflammatory response to microorganisms, or Invasion of normally sterile tissues Systemic Inflammatory Response Syndrome (SIRS) Systemic response to a variety of processes Sepsis Infection plus 2 SIRS criteria Identifying sepsis Bone RC et al. Chest. 1992;101:1644-55.

Step 1: What is SIRS? A systemic response to a nonspecific insult Infection, trauma, surgery, massive transfusion, etc Defined as 2 of the following: Temperature >38.3 or <36 0C Heart rate >90 min-1 Respiratory rate >20 min-1 White cells <4 or >12 Acutely altered mental state Hyperglycaemia (BM>6.6) in absence of DM SIRS SEVERE SEPSIS Identifying sepsis

Step 2: What counts as an infection? Pneumonia Urinary Tract infection Meningitis Endocarditis Device related Central line Cannula Abdominal Pain Diarrhoea Distension Urgent laparotomy Soft tissue/ musculoskeletal Cellulitis Septic arthritis Fasciitis Wound infection Identifying sepsis

SIRS due to an infection Step 3: what is Sepsis? SIRS due to an infection Identifying sepsis

Step 4: what is Severe Sepsis? Sepsis with organ dysfunction, hypoperfusion or hypotension CNS: Acutely altered mental status CVS: Syst <90 or mean <65 mmHg Resp: SpO2 >90% only with new/ more O2 Renal: Creatinine >175 mmol/l or UO <0.5 ml/kg/hr for 2 hrs Hepatic: Bilirubin >34 mmol/l Bone marrow: Platelets <100 Hypoperfusion: Lactate >2 mmol/l Coagulopathy: INR>1.5 or aPTT>60s Identifying sepsis

Shock secondary to systemic inflammatory response to a new infection What is shock? Tissue perfusion is not adequate for the tissues’ metabolic requirements Septic Shock Shock secondary to systemic inflammatory response to a new infection Types of Shock Cardiogenic Neurogenic Hypovolaemic Anaphylactic and… Identifying sepsis

Severe Sepsis Screening Tool Putting this together The Severe Sepsis Screening Tool

Severe Sepsis Screening Tool Are any 2 of the following present and new to the patient? Temperature >38.3 or <36 0C Heart rate >90 min-1 Respiratory rate >20 min-1 White cells <4 or >12 g/L Acutely altered mental status Hyperglycaemia (glucose>6.6mmol/L) (unless diabetic) If yes, patient has SIRS Screening Tool

If yes, patient has SIRS If yes, patient has SEPSIS Screening Tool Is the history suggestive of a new infection? Pneumonia UTI Abdo pain/ diarrhoea/ distension/ urgent laparotomy Meningitis Cellulitis/ septic arthritis/ fasciitis/ wound infection Endocarditis Catheter (incl central venous) infection If yes, patient has SEPSIS Screening Tool

The patient has SEVERE SEPSIS Start Severe Sepsis Care Pathway If yes, patient has SEPSIS Are any of the following present and new to the patient? Blood pressure systolic <90 or mean <65 mmHg New or increased O2 requirement to maintain SpO2>90% Creatinine >177 mmol/l or UO <0.5 ml/kg/hr for 2 hrs Bilirubin >34 mmol/l Platelets <100 Lactate >2 mmol/l Coagulopathy: INR>1.5 or aPTT>60s The patient has SEVERE SEPSIS Start Severe Sepsis Care Pathway Screening Tool

Septic Shock Defined as Systolic <90 mmHg Mean <65 mmHg Drop of >40 mmHg from patient’s normal systolic Lactate >4 mmol/l

Treating the severely septic patient

The Surviving Sepsis Campaign Resuscitation Bundle Serum lactate measured Blood cultures obtained prior to antibiotic administration. From the time of presentation, broad-spectrum antibiotics administered within 1 hour for all admissions In the event of hypotension and/or lactate >4mmol/L (36mg/dL): Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent) Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/L (36 mg/dl): Achieve central venous pressure (CVP) of >8 mm Hg Achieve central venous oxygen saturation (ScvO2) >70% … within 6 hours of onset!

What you can do Sepsis Six within 1 hour • Oxygen Blood Cultures Antibiotics Fluids Lactate & Hb Insert Catheter & monitor urine output within 1 hour Then ensure Critical Care assistance if shocked to complete EGDT

Therapy Across the Sepsis Continuum SIRS Severe Septic Shock * Early Goal Directed Therapy Antibiotics and Source Control Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand Chest 1992;101:1644.

Goal Directed Therapy Administration of fluids, pressors and transfusion based upon targets for CVP, blood pressure, urine output, mixed venous oxygen saturation and hematocrit

Early Goal-Directed Therapy CVP: central venous pressure MAP: mean arterial pressure ScvO2: central venous oxygen saturation BACK-UP SLIDE: This slide shows specifically how the monitored parameters in EGDT were maintained. “The protocol was as follows: A 500-ml bolus of crystalloid was given every 30 minutes to achieve a central venous pressure of 8 to 12 mm Hg. If the mean arterial pressure was less than 65 mm Hg, vasopressors were given to maintain a mean arterial pressure of at least 65 mm Hg. If the mean arterial pressure was greater than 90 mm Hg, vasodilators were given until it was 90 mm Hg or below. If the central venous oxygen saturation was less than 70 percent, red cells were transfused to achieve a hematocrit of at least 30 percent. After the central venous pressure, mean arterial pressure, and hematocrit were thus optimized, if the central venous oxygen saturation was less than 70 percent, dobutamine administration was started at a dose of 2.5 µg per kilogram of body weight per minute, a dose that was increased by 2.5 µg per kilogram per minute every 30 minutes until the central venous oxygen saturation was 70 percent or higher or until a maximal dose of 20 µg per kilogram per minute was given. Dobutamine was decreased in dose or discontinued if the mean arterial pressure was less than 65 mm Hg or if the heart rate was above 120 beats per minute. To decrease oxygen consumption, patients in whom hemodynamic optimization could not be achieved received mechanical ventilation and sedatives.” (p. 1370) NEJM 2001;345:1368-77.

Fluids; Crystalloids and colloids Vazoactive agents; Noradrenaline and adrenaline Inotropics; Dobutamine

Therapy Across the Sepsis Continuum SIRS Severe Septic Shock Early Goal Directed Therapy Antibiotics and Source Control Insulin and glucose control * Chest 1992;101:1644.

Glucose Control: Mechanisms Stress hyperglycemia is common in sepsis Glucose has pro-inflammatory effects Insulin resistance is common in sepsis Insulin has an anti-inflammatory effect, possibly via NOS. Benefit is likely related to both insulin itself and lowering of blood glucose

Therapy Across the Sepsis Continuum SIRS Severe Septic Shock * Steroids Early Goal Directed Therapy Antibiotics and Source Control Insulin and glucose control Chest 1992;101:1644.

Corticosteroids in Sepsis Obtain a baseline cortisol or ACTH stimulation Start stress dose steroids (hydrocortisone 200-300mg +/- fludrocortisone 50 mcg) Discontinue if levels are adequate

SURVIVING SEPSIS Fluid resuscitation, goal-directed Appropriate cultures prior to antibiotic administration Early targeted antibiotics and source control Use of vasopressors/inotropes when fluid resuscitation optimized

SURVIVING SEPSIS Evaluation for adrenal insufficiency Stress dose corticosteroid administration Insulin drip for glucose control Low tidal volumes (6cc/kg) for mechanical ventilation in ARDS

PREVENT COMPLICATIONS Stress ulcer and DVT prophylaxis Narrow antibiotic spectrum Prevent VAP: 45 degree elevation Facilitate early discontinuation of mechanical ventilation: sedation interruption, early SBT

the official training programme of the Surviving Sepsis Campaign Questions the official training programme of the Surviving Sepsis Campaign