Sepsis. Shock. Peri-arrest. J Albrett Intern teaching Dec 17

Introduction Definitions Best practice Thinking under pressure Escalating care

SIRS Core temp <36 or >38.5 HR >90/min WCC >12 or <4 RR > 20 or Mechanical ventilation. Need two of.

Sepsis SIRS plus documented or highly suspected infection as cause for SIRS

Severe Sepsis ●Sepsis-induced hypotension ●Lactate above upper limits of laboratory normal ●Urine output <0.5 mL/kg/hr for more than two hours despite adequate fluid resuscitation ●Acute lung injury with PaO2/FIO2 <250 in the absence of pneumonia as infection source ●Acute lung injury with PaO2/FIO2 <200 in the presence of pneumonia as infection source ●Creatinine >2 mg/dL (176.8 micromol/L) ●Bilirubin >4 mg/dL (34.2 micromol/L) ●Platelet count <100,000 microL–1 ●Coagulopathy (INR >1.5)

“Bystanders were treated for shock and offered counselling” Shock is best simply described as failure to deliver adequate oxygen. There are many definitions. In severe states of septic shock mitochondrial function is impaired but for our purposes a simple definition works best.

Surviving sepsis Where hypoperfusion is evident targeted aggressive fluid administration should be commenced. Particularly an elevated lactate level should be normalised. Within the first three hours Measure lactate Obtain blood cultures Administer broad spectrum antibiotics 30 mL/kg crystalloid for hypotension or lactate > 4.0

Surviving sepsis Blood cultures should not delay antibiotics by more than 45 minutes. At least two separate peripheral blood cultures plus one set from every line in situ Antibiotics should be broad enough to cover all likely pathogens and account for local resistance pattern Antibiotics must be given within one hour.

Surviving sepsis Source control De-escalation of antibiotics Fluids Should be always within one hour and use minimally invasive techniques where possible in the presence of shock. De-escalation of antibiotics Should be de-escalated within 3-5 days when organism/sensitivities identified. Fluids At least 30 mL/kg NOT HES (Voluven)… Never!!!

New definition for sepsis Sepsis 3. Sepsis is a severe disease (10% mortality) Severe sepsis has been abandoned. Septic shock. Two of three qSOFA points 40% mortality

In practice If the patient has a lactate over 4.0mmol/L or hypotension/shock you should escalate their care. They may need central and arterial lines, inotropes, intubation and ventilation, dialysis or early source control. BUT you can Put lines in. Take blood cultures. Fluid challenge. Establish baseline lactate. Administer early antibiotics.

Scenario one 1900 OCHS Busy shift No dinner/tired/hungry Med reg very stressed in ED with eight referrals Askes you to see….

35 year old male Smoker. Usually fit and well. Increasingly SOB for 3 days with a minimally productive hacking cough. GP started roxithromycin.

Patient looks Normal colour Complaining of being cold/shivering Breathing fast, sitting up Has oxygen mask on and saturations are 94%

Patient observations HR 110/min BP 90/60 mmHg SpO2 94% Temperature 39.8 Not drowsy. Awake and appropriate.

What are you thoughts right now?

Probably need to diagnose on treat concurrently A irway + oxygen B reathing C irculation and treatment D isability E xpose pt with lights on.

How would you describe the patient situation to your registrar?

Your registrar reluctantly agrees to see the patient Observes He is young Saturations are OK and BP is acceptable You point out the lack of improvement in HR or BP despite fluid resuscitation….

Mental model Is it congruent with yours? How do you react when your concerns are dismissed as inexperienced or “scared”?

Graded assertiveness P A C E R

OCHS 2000 ATSP in HDU 75 year old. Male. Had laparotomy for perforated bowel 4 days ago. Two days in ICU, now in HDU for two days.

Complaint Has a new fever 38.3 HR 110 AF. BP 90/60 RR 30 / min Has been drowsy all day but nurse says he is always like that.

ICU nurse Is very angry the surgical registrar sent you. Is saying quite loudly in earshot of patient that you will be of little use and your registrar is not on her Christmas card list.

History and examining the patient

Potential sources of sepsis in this man.

Investigations

Who should you escalate you concerns to? Surgical reg? Medical reg? Anaesthestic registrar? Anaesthetist? Surgeon?

NIBP Vs IAL DINAMAP

Phlebostatic axis.

21 year old female In ED. Fell off horse yesterday. Headache and sore neck ever since. No decrease LOC at any stage. Is in 10/10 pain.

ATSP in OPHRS 93 year old man Agitated delerium. Outline your approach to delerium.