SEPSIS KILLS program Adult Inpatients

1. SEPSIS KILLS programAdult Inpatients

2. Learning objectives • Recognise that sepsis is a medical emergency • Identify the risk factors, signs and symptoms • Outline the escalation of the septic patient • Define the initial management actions • Discuss the requirements for 48 hour sepsis management

3. Sepsis is a medical emergency You can make a difference for patients in this hospital

4. What is sepsis? Sepsis is the body’s systemic response to an infection and can result in multi-organ failure and death SEPSIS = infection + systemic inflammatory response (SIRS) SEVERE SEPSIS = sepsis + organ dysfunction, hypoperfusion or hypotension SEPTIC SHOCK = sepsis + hypotension despite fluid resuscitation

5. The sepsis continuum Severe Sepsis Infection Systemic Inflammatory Response Syndrome Sepsis Septic Shock Increasing Mortality

6. Sepsis recognition & management…what is the problem? • Sepsis causes more deaths in adults per year than prostate cancer, HIV and breast cancer combined • 25% mortality associated with septic shock • High number of sepsis adverse events in NSW • Approximately 30% of Rapid Response calls are related to sepsis • Delayed recognition and initial appropriate treatment increases mortality

7. Insert summary of your facility/LHD adverse event here

8. Difficult diagnosis • Not all patients have classic SIRS • Clinical diagnosis requiring experience and high index of suspicion for interpretation of history/symptoms/signs • Signs often subtle • Some groups at special risk eg infants, age > 65, neutropenia, haemodialysis, diabetes mellitus, alcoholism, lung disease, patients with invasive devicesLauplandet al Crit Care Med 2004

9. Common signs & symptoms of sepsis • Tachypnoea 99% • Tachycardia 97% • Fever> 38 degrees 70% • Hypothermia 13% • Metabolic acidosis 38% • Acute oliguria 54% • Acute encephalopathy 35% Brun-Buisson C et al, JAMA: 274(12), 27 Sept, 1995 Accurate and routine measurement of respiratory rate is essential

10. The SEPSIS KILLS program RECOGNISE: Risk factors, signs and symptoms of sepsis and inform senior clinician RESUSCITATE: With rapid antibiotics and IV fluids within one hour REFER: To specialist care and initiate retrieval if needed

11. SEPSIS KILLS

12. When to use the sepsis pathway… • The patient has signs or symptoms of infection: suspect sepsis • The patient has observations in the Red or Yellow Zone on the SAGO chart: suspect sepsis • The clinician, patient or relatives are concerned about deterioration: suspect sepsis

13. RECOGNISE:

14. RESPOND & ESCALATE:

15. RESUSCITATE: Time is Critical

16. Six key actions within 60 minutes • Administer oxygen • Take blood cultures and other specimens • Measure serum lactate • IV fluid resuscitation • IV antibiotics • Monitor urine output, vital signs and reassess

17. 1. Administer oxygen • Improve oxygen delivery to the tissues • Maintain SpO2 95 - 98% • History of COPD maintain SpO2 88-92% • Requires regular review • ESCALATE to Rapid Response if patient is unresponsive to oxygen therapy

18. 2. Blood cultures • Take blood cultures BEFORE starting antibiotics • Take two blood cultures from separate sites if possible • Obtain other cultures: urine, CSF, faeces, wound swabs, sputum, other fluids from within cavities, • Consult specialty teams early for source control

19. 3. Measure serum lactate • Elevated lactate (lactic acid) level is a sign of global tissue hypoxia • Elevated lactate is directly linked to increased mortality • Initialand serial lactate measures are valuable indicators for sepsis management

20. NSW sepsis mortality by severity CEC/HIE linked data n=3851 (2012)

21. 4. Intravenous fluid resuscitation • Fluidswill reduce organ dysfunction and multi-organ failure • Give a rapid IV bolus of 250-500mls 0.9% sodium chloride • Reassess for effect after each bolus – HR, BP, RR, capillary refill, urine output

22. Aim to achieve systolic BP ≥100mmHg • Repeat 250-500ml bolus of 0.9% sodium chloride if needed • ESCALATE to Rapid Response if no improvement in BP after 500mls fluid • Patients with renal or cardiac disease: Use smaller volumes of fluid Undertake more frequent assessment for positive and negative affect Refer to ICU for advice and early use of vasopressors

23. 5. Intravenous antibiotics • Appropriate early antibiotic therapy reduces mortality in septic shock (Kumar, 2006) • Patients who received antibiotics in the first hour after the onset of hypotension: mortality 20.1% • Each additional hour’s delay: mortality increases by 7.6% • 1. Kumar A et.al. Crit Care Med 2006:34(6);1589-1595. Kumar, 2006

24. The ‘right’ antibiotic is crucial • Take blood cultures before antibiotics but do not delay antibiotics to undertake investigations or await results • Start antibiotic therapy within 60 minutes • Use bolus administration where possible • REMEMBER: one dose is safer than not treating at all PRESCRIBE IT... GET IT... GIVE IT... NOW!!!

25. 6. Monitor vital signs and urine output Monitor observations every 30 minutes for 2 hours and then hourly for four hours • Respiratory rate • Heart rate • Blood pressure • Capillary refill • LOC • Urine output

26. Refer: • If no improvement or if you are worried, escalate as per local CERS • Update the AMO • Include ICU and infectious diseases review

27. Next steps: sepsis 48 hour management plan Management plan includes: - level of observation - review schedule - escalation plan

28. In summary: • Untreated SEPSISKILLS • Early IV antibiotics and IV fluids saves lives • One dose of antibiotics is less risk than not treating at all • Source identification and control are vital • Patients with sepsis are at high risk of deterioration • 48-72 hour follow up management plan is essential • Don’t turn your back on the bomb!