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by malek ahmad
SEPSIS: DIAGNOSIS
AND MANAGEMENT
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which patient has the highest
mortality?
• 59yr old male - large inferior STEMI
• 27yr old male - multi trauma ISS
• 65yr old female - bleeding gastric ulcer and BP
90/60
• 74yr female P 65 BP 105/60 RR 24 Temp 35 C
mildly confused**
• 32yr female DKA pH 6.90 BSL 45 HCO3 9
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Outline
•Definition of sepsis
•Importance of sepsis
•Sepsis kills programme
•surviving sepsis
campaign
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What is Sepsis?
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Definition
• Sepsis is the presence of infection that induces a
systemic response
• Expect the patient to have signs and symptoms of a
systemic response
• May not always have symptoms and signs at the site
of infection
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• SIRS criteria: 2 of the following + suspected or
confirmed infection = Sepsis
Temp < 36°C or > 38°C
RR > 24
WCC < 4 or > 12
HR > 90
•Severe Sepsis: Sepsis plus organ dysfunction
•Septic Shock: Sepsis with BP <90mmHg for 1
hour despite adequate fluid resuscitation or the
need for inotropes to maintain BP >90mmHg
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• tachypnea
• tachycardia
• fever > 38°C
• acute oliguria
• metabolic acidosis
• acute encephalopathy
• hypothermia < 36°C
Which signs and symptoms are most
common in patients with severe sepsis?
Brun-Buisson C, Doyon F, Carlet J et al Incidence, Risk Factors and Outcome of Severe Sepsis and Septic Shock in Adults: A
Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995
99%
97%
70%
54%
38%
35%
13%
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Problems with SIRS criteria
•Derived from retrospective data
•Aim was to standardise definitions NOT aid early recognition
•Only HR, RR, temperature will be available initially
•A large study found temperature is normal in 17% of patients
with sepsis1
•HR often affected by β-blockers
•Not diagnostic or prognostic
1.Brun-Buisson C, Doyon F, Carlet J et al Incidence, Risk Factors and Outcome of Severe Sepsis and Septic Shock in Adults:
A Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995; 968-974
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common sources of sepsis
•Respiratory 35%
•Urinary tract 35%
•Intra Abdominal 10%
•Unknown 10%
•Meningitis/septic
arthritis/ skin/vascular
access devices 10%
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Why need to worry about
sepsis?
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Importance of sepsis
•Increasing incidence
1997 to 2005 severe sepsis/septic shock increased
from 7.7% of ICU admissions to 14.0 % in Australia
(4 fold increase in total patients)1
More common in the elderly —> incidence
increases as the population ages
•Cost
The cost of care is huge (US$16.7 billion in 2001)2
1. Peake S, for the ARISE Investigators: The outcome of sepsis and septic shock presenting to the Emergency Department
in Australia and New Zealand. Critical Care 2007, 11(Suppl 2):P73
2. Angus DC et al: Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated
costs of care. Crit Care Med 29:1303, 2001
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which patient has the highest
mortality?
• 59yr old male - large inferior STEMI
• 27yr old male - multi trauma ISS
• 65yr old female - bleeding gastric ulcer and BP
90/60
• 74yr female P 65 BP 105/60 RR 24 Temp 35 C
mildly confused**
• 32yr female DKA pH 6.90 BSL 45 HCO3 9
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1) Armstrong PW et al., JAMA, 2007;297:43–51. 2) Clemet N, SJTREM 28:18 2010 3) Rockall TA BMJ. 311(6999):
222- 6, 1995 July 22 4) Mitchell M et al Crit Care Med 2010 Vol. 38, No. 2 5) Hamdy O, Sep 2009
Mortality
1. Inferior AMI 5%
2. Trauma ISS 16-24 7%
3. GIH + low BP 11%
4. Septic Shock 25%
5. Severe DKA <1%
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The Clinical Excellence Commission (CEC) is responsible for leading safety and quality improvement in the NSW public health system. It was established in 2004 to
promote and support improved clinical care, safety and quality across NSW.
The SEPSIS KILLS program aims to reduce preventable harm to patients through improved recognition and management of severe infection and sepsis in emergency
departments and inpatient wards throughout NSW. The Clinical Excellence Commission (CEC) Clinical Focus Report on Recognition and Management of Sepsis found
deficits in a range of clinical settings in NSW health care facilities in 2009. The lack of timely recognition and appropriate management was further demonstrated in the
findings from the CEC Quality Systems Assessment.
The focus of the program is:
RECOGNISE risk factors, signs and symptoms of sepsis
RESUSCITATE with rapid intravenous fluids and antibiotics within the first hour of recognition of sepsis
REFER to senior clinicians and specialty teams, including retrieval as required
The SEPSIS KILLS program is a quality improvement initiative that has been developed from international evidence-based practice. The goal is to reduce preventable
harm to patients with sepsis through early recognition and prompt management.
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Fail to see Sepsis as time critical
• TRAUMA Golden Hour (Dr. R Adam Cowley, surgeon)
• AMI Time is muscle (Dr. Eugene Braunwald, cardiologist)
• STROKE Time is Brain (Dr. Morgan Campbell, neurologist)
• SEPSIS KILLS TIME IS LIFE
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The Surviving Sepsis Campaign is a joint collaboration of the Society of Critical Care Medicine and the
European Society of Intensive Care Medicine committed to reducing mortality from severe sepsis and septic
shock worldwide.
Initiated in 2002, the Campaign progressed in phases that have expanded the scope and reach of the
Campaign via publication of 3 editions of evidence-based guidelines, implementation of a performance
improvement program, and analysis and publication of data from more than 30,000 patient charts collected
around the world.
Now recommitted to increasing the number of hospitals contributing data to 10,000 worldwide; to applying the
guidelines to 100% of patients in whom the diagnosis is suspected; and to developing a strategy to improve the
care of septic patients in underresourced areas.
The potential to save lives is enormous. Assuming that the reduction in mortality seen to date can be sustained
and 10,000 hospitals comply with the Campaign recommendations, we could save 400,000 lives if we treat only
half of the eligible patients with the Surviving Sepsis Campaign Bundles.
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within 3 hours of time of
presentation
• 1. Measure lactate level
• 2. Obtain blood cultures prior to administration
of antibiotics
• 3. Administer broad spectrum antibiotics
• 4. Administer 30ml/kg crystalloid for
hypotension or lactate ≥4mmol/L
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Within 6 hours of time of
presentation
• 5. Apply vasopressors (for hypotension that does not
respond to initial fluid resuscitation) to maintain a
mean arterial pressure (MAP) ≥65mmHg
• 6. In the event of persistent hypotension after initial
fluid administration (MAP < 65 mm Hg) or if initial
lactate was ≥4 mmol/L, re-assess volume status and
tissue perfusion and document findings according to
Table 1.
• 7. Re-measure lactate if initial lactate elevated.
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reassessment of volume status and
tissue perfusion with:
• EITHER
Repeat focused exam (after initial fluid resuscitation) by
licensed independent
practitioner including vital signs, cardiopulmonary, capillary
refill, pulse, and skin findings.
• OR TWO OF THE FOLLOWING:
Measure CVP
Measure ScvO2
Bedside cardiovascular ultrasound
Dynamic assessment of fluid responsiveness with passive leg
raise or fluid challenge
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References
•Brun-Buisson C, Doyon F, Carlet J et al Incidence,
Risk Factors and Outcome of Severe Sepsis and Septic
Shock in Adults: A Multicentre Prospective Study in
Intensive Care Units JAMA: 274(12), 27 Sept, 1995
•Peake S, for the ARISE Investigators: The outcome of
sepsis and septic shock presenting to the Emergency
Department in Australia and New Zealand. Critical
Care 2007, 11(Suppl 2):P73
•Angus DC et al: Epidemiology of severe sepsis in the
United States: Analysis of incidence, outcome, and
associated costs of care. Crit Care Med 29:1303, 2001
•Armstrong PW et al., JAMA, 2007;297:43–51
•Clemet N, SJTREM 28:18 2010
• Rockall TA BMJ. 311(6999):222- 6, 1995 July 22
•Mitchell M et al Crit Care Med 2010 Vol. 38, No. 2
•Hamdy O, Sep 2009
•Dellinger RP, Levy MM, Rhodes A, et al: Surviving
Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock: 2012.
Crit Care Med. 2013; 41:580-637
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