1. Identifying Sepsis... Global Sepsis Alliance Jim O’Brien, MD, MSc Professor Assistant Director, Medical Intensive Care Unit The Ohio State University Medical Center Sepsis Alliance, Board of Directors

2. Identifying sepsis What is sepsis? What do we look for in sepsis? Which patients get sepsis?

3. Identifying sepsis What is sepsis? What do we look for in sepsis? Which patients get sepsis?

4. What is sepsis? Lots of terms!! Sepsis Septic Shock, SIRS SSI (signs and symptoms of infection), Septicaemia, Bacteraemia, Toxic Shock Syndrome, Bloodstream infection etc, etc ….

5. Definitions  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  Severe Sepsis  Sepsis  Organ dysfunction  Septic shock  Sepsis  Hypotension despite fluid resuscitation Bone RC et al. Chest. 1992;101:1644-55.

6. Bacteria Virus Fungi Parasite InfectionSIRS Sepsis Pancreatitis Trauma Infection Other Severe Sepsis

7. Identifying sepsis What is sepsis? What do we look for in sepsis? Which patients get sepsis?

8. Step 1: Is SIRS present? A systemic response to a nonspecific insult Infection, trauma, surgery, massive transfusion, etc Defined as  2 of the following: Temperature > 38.3 or < 36 0 C Heart rate> 90 min -1 Respiratory rate> 20 min -1 AVPUV, P or U White cells 12 If not diabetic, blood sugar>7.7 mmol/l

9. Step 1: Is SIRS present? A systemic response to a nonspecific insult Infection, trauma, surgery, massive transfusion, etc Defined as  2 of the following: Temperature Heart rate Respiratory rate AVPU White cells Need a FBC If not diabetic, blood sugar Need to check it!!! MEWS

10. Step 1: Is SIRS present? Why do we see SIRS?? Temperature:‘Pyrogens’ raise body temperature. Later, temperature drops as we lose excess heat HR:To stop B.P falling, heart rate rises RR:The body needs more oxygen in sepsis, and tissues produce more acid. RR increases to help with both. AVPU:As B.P and cardiac output fall later in sepsis, blood flow to the brain reduces White cells: Rise to combat infection. As they are used up, if bone marrow is exhausted WCC falls Blood sugar:Rises as part of our ‘stress response’

11. Step 2: What counts as an infection?  Pneumonia 50%  Urinary Tract infection  Meningitis  Endocarditis  Device related  Central line  Cannula Abdominal 25% Pain Diarrhoea Distension Urgent laparotomy Soft tissue/ musculoskeletal Cellulitis Septic arthritis Fasciitis Wound infection

12. Step 2: What counts as an infection? i.e, if it sounds like an infection (history), or if it looks like an infection (examination, observations), then it probably is an infection!!

13. Step 2: What counts as an infection? Look for inflammation and for pus! Pus - may be obvious or be deep - remember, infected sputum is pus! Inflammation - Develops as the body fights infection - HOT, RED, SWOLLEN and PAINFUL - May be internal (e.g, UTI)

14. Step 3: what is Sepsis? SIRS which is due to an infection

15. Step 4: what is Severe Sepsis? Sepsis with organ dysfunction, including shock: CNS:Acutely altered mental status CVS:Syst <90 or mean <65 mmHg Resp:SpO 2 >90% only with new/ more O 2 Renal:Creatinine >177 μmol/l or UO <0.5 ml/kg/hr for 2 hrs Hepatic:Bilirubin >34 μmol/l Bone marrow:Platelets <100 Hypoperfusion:Lactate >2 mmol/l Coagulopathy:INR>1.5 or aPTT >60secs

16. Septic shock Definition of shock: ‘Tissue perfusion is not adequate for the tissues’ metabolic requirements’ What it looks like Low blood pressureSystolic< 90 Mean< 65 Drop from normal of> 40 mmHg High lactate (beware anyone with lactate >2!) > 4 mmol/l These patients do even worse! Mortality upwards of 50%

17. Causes of septic shock 1) Blood vessels dilate Same volume of blood in a smaller space 2) Capillaries ‘leak’ Water and solutes leave the circulation (seen as oedema) Blood reduces in volume Blood thickens (less water, same number of cells) 3) Cardiac function is impaired histamine bradykinin interleukins nitric oxide

18. Causes of organ failure Reduced delivery of oxygen to the tissues In sepsis, caused by any or all of: Hypoxia Hypotension Low cardiac output Redistribution of blood flow Oedema- further for oxygen to travel to cells Small blood clots (microthrombi) Mitochondria don’t work effectively We need to correct these with interventions... And FAST

19. Putting this together The Severe Sepsis Screening Tool

20. Severe Sepsis Screening Tool Are any 2 of the following SIRS criteria present and new to your patient? Obs: Temperature > 38.3 or 20 min -1 Heart rate > 90 bpm Acutely altered mental state Bloods: White cells 12x10 9 /l Glucose > 7.7 mmol/l (if patient is not diabetic) If yes, patient has SIRS

21. Is this likely to be due to an infection? For example Cough/ sputum/ chest painDysuria Abdo pain/ diarrhoea/ distensionHeadache with neck stiffness Line infectionCellulitis/wound infection/septic arthritis/ Endocarditis If yes, patient has SEPSIS Start SEPSIS SIX

22. Senior staff: check for SEVERE SEPSIS Severe Sepsis: Ensure Outreach and Senior Doctor attend NOW! BP Syst < 90 / Mean < 65 (after initial fluid challenge) Lactate > 2 mmol/l Urine output < 0.5 ml/kg/hr for 2 hrs INR > 1.5 aPTT > 60 s Bilirubin > 34 μmol/l O 2 Needed to keep SpO 2 > 90% Platelets < 100 x 10 9 /l Creatinine > 177 μmol/l or UO < 0.5 ml/kg/hr

23. When to use the Screening Tool  When your scoring system (e.g, MEWS) triggers  On admission if you suspect infection  Unexpected deterioration/ failure to recover  Something is ‘just not right’  High white cell count

24. Case Study A 55 year old man is admitted to the resuscitation room with SOB. He has been unwell for the past 48hrs with a productive cough, lethargy and fever. What will you do first?

25. ABCDE! AirwayPatent, 15 l/min O 2 via NRB BreathingResp Rate 40 min -1 SpO 2 90% CirculationHR 130 BP 70/40 DisabilityAgitated but GCS 15/15 ExposureTemp 38.5 o C Is this sepsis??

26. ABCDE! AirwayPatent, 15 l/min O 2 via NRB BreathingResp Rate 40 min -1 SpO 2 90% CirculationHR 130 BP 70/40 DisabilityAgitated but GCS 15/15 ExposureTemp 38.5 o C

27. What would you do next?

28. Case Study 2 An 85 year lady, discharged 3 days ago Readmitted to EAU from her nursing home PMH: dementia hypertension malnourished She has not been taking her medication Incontinent 2/7, catheterised by district nurses Increasingly confused over the last two days

29. What are the issues? Risk factors: Elderly Malnourished Dementia- may present late Recent hospital stay Not compliant with medication Likely urinary tract infection What would you do now?

30. ABCDE ASelf-maintained BRR 18/min CHR 110/min, BP120/60 Urine output 30ml in last 5 hours DConfused, responds to voice ECatheter in situ. Temp 35.4 O C What concerns you the most? Is this sepsis?

31. ABCDE ASelf-maintained BRR 18/min CHR 110/min,BP120/60 Urine output 30ml in last 5 hours DConfused, responds to voice ECatheter in situ. Temp 35.4 O C What would you do now? What should we be doing now?

32. Identifying sepsis What is sepsis? What do we look for in sepsis? Which patients get sepsis?

33. At risk groups?  Old  Young  Ill  Infections  Malignancy How many of your patients are included?  Compromised organs  Immunocompromised  Post chemotherapy  Malnutrition  Invasive lines

34. Summary Everyone has the potential to get sepsis Patients by definition have a high risk of sepsis Easy to identify – we know what we’re looking for Tools – observations scoring, clinical acumen, experience Sepsis Screening Tool