1. Sepsis (adults)
September 2015

2. Objectives
Know the spectrum of disease from infection to septic shock (and why this is important)
Understand the difficulties in identifying sepsis
Understand the importance of treating sepsis early
Know how to treat sepsis
Understand toxic shock and what treatment this requires

3. What is sepsis?
Immune system’s response to the lipopolisaccharide in Gram Neg organisms or peptidoglycan in Gram Pos organisms’ cell wall
Triggers a cascade of pro- and anti-inflammatory reactions responsible for the clinical syndrome
Purified lipopolisaccharide infusion is often used to simulate the sespsis syndrome in clinical and genomic studies
Gram positive sepsis is less predictable because of multiple bacterial virulence factors

4. Spectrum of disease
SIRS
Sepsis
Severe sepsis
Septic shock

5. Pitfalls in diagnosing sepsis
Early-on in the disease process
Severe sepsis/septic shock causes multiple organ dysfunction
Elderly patients
Medications like beta-blockers
Temp <36C
Source of infection not obvious

6. Why the urgency in treatment?
Mortality in septic shock with optimal treatment 30% (ProMISe trial)
Delay in reversing shock increases mortality (above 30%)
Every hour’s delay in administering antibiotics increases mortality by 7% per hour (above 30%)

7. Treatment: first 10 minutes
In all patients with SIRS, assess for the presence of septic shock
Focused examination in order to identify the source of sepsis
Diagnostic testing

8. Treatment: first hour
Hypotension/hypoperfusion: 20-30ml/kg fluid bolus
Balanced crystalloid solution if potassium normal
Consider albumin in malnourished or cirrhotic patients
Give broad spectrum antibiotics
Choice of a/b based on presumed source
Enough IV access
Plan imaging early if required to ID source

9. Treatment: first 6 hours
Continue fluid resuscitation if this is still indicated (cool peripheries, delayed CRT, responsiveness to fluid boluses)
Start vasopressors: norepinephrine first line
Aim for MAP >65mmHg / urine output >0.5ml/h / ScvO2 >70% (in early sepsis)

10. So what about the lactate…?
Why is lactate elevated in sepsis?
Hypoperfusion/’anaerobic metabolism’
But tissue oxygenation is still adequate even when PaO2 ≈ 6kPa in sepsis
Shock causes increased production through aerobic and anaerobic glycolysis
Decrease clearance of lactate in shocked state
Why should we measure it?
Reduction in lactate by 20% per 2h improves outcome

11. Sepsis 6 Give O2 Take blood cultures/other microbiology and lactate
Give antibiotics
Fluid bolus
Vasopressors
Measure urine output

12. Toxic shock
Gram positive sepsis (cellulitis, necrotizing fasciitis, myositis, burns)
Patients typically have flushed skin, is profoundly hypotensive with altered mental state
Usual septic shock treatment, but give Clindamycin 1.2g IV as first antibiotic in addition to other antibiotics
Clindamycin ‘switches off’ exotoxin production

13. Summary Think sepsis in any patient with SIRS
Then, with urgency, treat as sepsis
Remember to give Clindamycin in toxic shock