Sepsis

1. Sepsis

2. What is sepsis? • Sepsis was defined in a 1992 consensus definitions conference as a systemic response to new infection. This is known as SIRS – systemic inflammatory response syndrome

3. Prevalence and incidence • Worldwide sepsis kills over 1400 people a day • In the UK over 37,000 people die from sepsis annually • Each episode of sepsis costs the NHS £20,000 • More people die from sepsis each year than the following combined: • Lung Cancer • Breast Cancer • Bowel Cancer

4. Types of Sepsis • Sepsis – Systemic inflammatory response syndrome resulting from a presumed or known site of infection • Sever Sepsis – Sepsis with an acute associated organ failure • Septic Shock – A subset of sever sepsis, defined as a persistently low mean arterial blood pressure despite adequate fluid resuscitation • Refractory Shock – Persistently low mean arterial blood pressure despite vasopressor therapy and adequate fluid resuscitation

5. Pathophysiology • Can occur as a result of infection at any body site, the most common pathogen is bacteria but it can be caused by fungi, viruses or parasites as well • Characterized by simultaneous activation of inflammation and coagulation • Cytokines and white blood cells trigger vasodilation to increase capillary permeability, neutrophil activation and adhesion of platelets to the endothelium • Baroreceptors in the carotid arteries and aorta respond to a drop in the patient’s blood pressure and activate the sympathetic nervous system

6. Pathophysiology continued • Vasoconstrictors • Epinephrine • Norepinephrine… are all released to maintain blood flow to vital organs (the heart and brain) • Blood is shunted from the non – vital organs • Eventually affects: • Cardiac output • Circulating volume • Blood Pressure • = Multiple Organ Dysfunction Syndrome (MODS) • = Death

7. Defining Sepsis • Systemic Inflammatory Response Syndrome (SIRS) is defined by the presence of two or more of the following symptons: • Temperature <36°C or >38°C • Heart rate >90 beats per minute • Respiratory rate >20 beats per minute • White blood count <4,000 per ml or >12,000 - Levy et al, 2003

8. Patients at a higher risk of Sepsis • People <1 year and >65 years • Those with a chronic illness • People who are immunosuppressed • Those who are on a broad – spectrum antibiotic use • Exposure to infection associated with surgical and invasive procedures • N.B. >65 years is due to a decline in immune function

9. Severe Sepsis • Sepsis complicated by organ dysfunction • Sepsis – induced hypotension • Most patients who acquire severe sepsis do so on the first day of a hospital stay • Hypoperfusion abnormalities such as: • Lactic acidosis, oliguria, acute alteration of mental state Mortality rate of 35%, 7 times higher than that of Acute Coronary Syndrome

10. Septic Shock • The presence of sepsis and a state of acute circulatory failure, characterized by refractory arterial hypotension(<90mm Hg) – not explainable by other causes • Evidence of hypoperfusion (high lactate) • The patient is dependent on vasopressors at this point • Transition from severe sepsis to septic shock normally happens within 24 hours of hospitalization • Mortality rate approaching 50% • Will be likely to require invasive monitoring such as venous catheters and vaso – active drug infusions

11. Diagnosis • Difficult to do – first six hours are very important as this is the time when tissue hypoxia can be reversed • Early organ dysfunction is normally the first notable find • Other diagnostic criteria: • Hemodynamic instability • Arterial hypoxemia • Oliguria • Coagulopathy • Altered liver function tests • Serum lactate level is a diagnostic marker – lactate is generated by anaerobic cellular metabolism and may reflect the severity of cellular derangements

12. Treatment • Often focused on supporting failing organ systems with interventions: • Fluid replacement – for restoration of tissue perfusion and normalization of oxidative metabolism • Airway management – for patients with progressive hypoxemia, hypercapnia, neurologic deterioration or respiratory muscle failure • Antibiotic Therapy • Vasopressors – when fluid administration fails to restore an adequate arterial pressure and organ perfusion • Need to increase cardiac output • For every hour’s delay in beginning treatment, a patient’s risk of death increases by 7.6% (Kumar et al, 2006)

13. Sepsis Six • An operation pathway which comprises tasks which can be completed immediately in a ward or A & E • When given within 1 hour of Sepsis being recognised, the Sepsis Six pathway is proven to save lives. The steps: • Give high flow oxygen (via non – rebreathe bag) • Take blood cultures • Give IV antibiotics • Start IV fluid resuscitation (Hartmann’s or equivalent) • Check haemoglobin and lactate • Monitor accurate hourly urine output (may require a catheter) - Surviving Sepsis Campaign

14. Surviving Sepsis Campaign • Main aims were to improve the management, diagnosis and treatment of sepsis • How this is being achieved: • Increasing awareness, understanding and knowledge • Changing perceptions and behaviour • Influencing public policy • Defining standards of care Through the campaign it was determined that the greatest achievement was through education and changing the process of care which patients with sepsis received