2. SIRS S EPSIS S EVERE S EPSIS S EPTIC S HOCK D EATH Early recognition Early antibiotics Source control

3. SIRS S EPSIS S EVERE S EPSIS S EPTIC S HOCK D EATH Temperature: >38.3 or < 36 o C Heart Rate: >90bpm Respiratory Rate: >20 WCC: >12 or <4

4. SIRS

5. newsing [new  sing] verb 1.a NEWS aggregate score of 5 or more (or red in one parameter), sufficient to prompt clinician referral she is newsing at 8

6. Kaukonen et al. NEJM 2015. 23;372(17):1629-38

7. Patients With Severe Sepsis SIRS -ve SIRS +ve SIRS miss 1 in 8

9. T IME F OR C HANGE ?

10. Organ dysfunction should prompt consideration of infection

11. R ESPIRATORY : Pa02/FiO2 ratio N EUROLOGICAL : GCS C ARDIOVASCULAR : MAP or drugs C OAGULATION : Platelets L IVER : Bilirubin R ENAL : Creatinine and urine output SOFA Score February 2016 qSOFA

12. Krebs cycle Pyruvate Glucose Glycolysis Anaerobic Aerobic Lactate Anaerobic

14. Lactate Time Poor prognosis Better prognosis Resuscitation

15. Time is Cytokine 8% per hour Antibiotic delays increase mortality

16. Kumar et al. Crit Care Med 2006. 34(6):1589-1596

17. Statistical significance only reached after 3 hours Ferrer R et al. Crit Care Med 2014. 42(8):1749-55 Empiric Antibiotic Treatment in Severe Sepsis and Septic Shock Time to Antibiotic hr -1

18. A NTIBIOTIC S TEWARDSHIP D ELAYED T HERAPY

19. 45% mortality 30% mortality Rivers et al. NEJM 2001. 345:1368-1377 Early Goal Directed Therapy

21. International Multicentre Prevalence Study on Sepsis (IMPRESS Study) 30% (14%) 26% 44% 26% 36% 35% Hospital mortality 20% v 31% if compliant with 3 hour sepsis bundle

22. S OURCE C ONTROL

23. F LUID Resuscitation

24. Meant is not said, said is not heard, heard is not understood, understood is not done. “ ”