the official training programme of the Surviving Sepsis Campaign

1. the official training programme of the Surviving Sepsis Campaign

2. Objectives • Understand the importance of sepsis • Be able to recognise the septic patient • Appreciate the importance of bundle-driven care • Contribute to the delivery of that care

3. Is sepsis important? • High mortality • Worldwide 1400 deaths a day Angus D - more? • Most common cause of death in ICU

4. How many of these patients die? 39.8%

5. A U.K. Perspective Annual UK mortality (2003), thousands Lung1 Colon2 Breast3 Sepsis4 cancers 1,2,3 www.statistics.gov.uk,, 4Intensive Care National Audit Research Centre (2005)

6. Identifying the Septic Patient

7. ACCP/SCCM Consensus Definitions • Severe Sepsis • Sepsis • Organ dysfunction • Septic shock • Sepsis • Hypotension despite fluid resuscitation • 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 Identifying sepsis Bone RC et al. Chest. 1992;101:1644-55.

8. Step 1: What is SIRS? A systemic response to a nonspecific insult Infection, trauma, surgery, massive transfusion, etc Defined as 2 of the following: Temperature >38.3 or <36 0C Heart rate >90 min-1 Respiratory rate >20 min-1 White cells <4 or >12 Acutely altered mental state Hyperglycaemia (BM>6.6) in absence of DM SEVERE SEPSIS SIRS Identifying sepsis

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

10. Step 3: what is Sepsis? SIRS due to an infection Identifying sepsis

11. Step 4: what is Severe Sepsis? Sepsis with organ dysfunction, hypoperfusion or hypotension CNS: Acutely altered mental status CVS: Syst <90 or mean <65 mmHg Resp: SpO2 >90% only with new/ more O2 Renal: Creatinine >175 mmol/l or UO <0.5 ml/kg/hr for 2 hrs Hepatic: Bilirubin >34 mmol/l Bone marrow: Platelets <100 Hypoperfusion: Lactate >2 mmol/l Coagulopathy: INR>1.5 or aPTT>60s Identifying sepsis

12. Septic Shock Shock secondary to systemic inflammatory response to a new infection What is shock? Tissue perfusion is not adequate for the tissues’ metabolic requirements Types of Shock Cardiogenic Neurogenic Hypovolaemic Anaphylactic and… Identifying sepsis

13. Putting this together The Severe Sepsis Screening Tool

14. Severe Sepsis Screening Tool Are any 2 of the following present and new to the patient? Temperature >38.3 or <36 0C Heart rate >90 min-1 Respiratory rate >20 min-1 White cells <4 or >12 g/L Acutely altered mental status Hyperglycaemia (glucose>6.6mmol/L) (unless diabetic) If yes, patient has SIRS Screening Tool

15. If yes, patient has SIRS Is the history suggestive of a new infection? Pneumonia UTI Abdo pain/ diarrhoea/ distension/ urgent laparotomy Meningitis Cellulitis/ septic arthritis/ fasciitis/ wound infection Endocarditis Catheter (incl central venous) infection If yes, patient has SEPSIS Screening Tool

16. If yes, patient has SEPSIS Are any of the following present and new to the patient? Blood pressure systolic <90 or mean <65 mmHg New or increased O2 requirement to maintain SpO2>90% Creatinine >177 mmol/l or UO <0.5 ml/kg/hr for 2 hrs Bilirubin >34 mmol/l Platelets <100 Lactate >2 mmol/l Coagulopathy: INR>1.5 or aPTT>60s The patient has SEVERE SEPSIS Start Severe Sepsis Care Pathway Screening Tool

17. Septic Shock • Defined as • Systolic <90 mmHg • Mean <65 mmHg • Drop of >40 mmHg from patient’s normal systolic • Lactate >4 mmol/l

18. Treating the severely septic patient

19. The Surviving Sepsis Campaign Resuscitation Bundle • Serum lactate measured • Blood cultures obtained prior to antibiotic administration. • From the time of presentation, broad-spectrum antibiotics administered within 1 hour for all admissions • In the event of hypotension and/or lactate >4mmol/L (36mg/dL): • Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent) • Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. • In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/L (36 mg/dl): • Achieve central venous pressure (CVP) of >8 mm Hg • Achieve central venous oxygen saturation (ScvO2) >70% … within 6 hours of onset!

20. Sepsis Six Sepsis Six Oxygen Oxygen • • Blood Cultures Blood Cultures • • Antibiotics Antibiotics • • Fluids Fluids • • Lactate & Lactate & Hb Hb • • Insert Catheter & monitor urine output Insert Catheter & monitor urine output • • What you can do • within 1 hour • Then ensure Critical Care assistance if shocked to complete EGDT

21. Severe Sepsis Septic Shock SIRS Sepsis Therapy Across the Sepsis Continuum * Early Goal Directed Therapy Antibiotics and Source Control Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand Chest 1992;101:1644.

22. Goal Directed Therapy Administration of fluids, pressors and transfusion based upon targets for CVP, blood pressure, urine output, mixed venous oxygen saturation and hematocrit

23. Early Goal-Directed Therapy CVP: central venous pressure MAP: mean arterial pressure ScvO2: central venous oxygen saturation NEJM 2001;345:1368-77.

24. Fluids; Crystalloids and colloids Vazoactive agents; Noradrenaline and adrenaline Inotropics; Dobutamine

25. Severe Sepsis Septic Shock SIRS Sepsis Therapy Across the Sepsis Continuum Early Goal Directed Therapy Antibiotics and Source Control Insulin and glucose control * Chest 1992;101:1644.

26. Glucose Control: Mechanisms • Stress hyperglycemia is common in sepsis • Glucose has pro-inflammatory effects • Insulin resistance is common in sepsis • Insulin has an anti-inflammatory effect, possibly via NOS. • Benefit is likely related to both insulin itself and lowering of blood glucose

27. Severe Sepsis Septic Shock SIRS Sepsis Therapy Across the Sepsis Continuum * Steroids Early Goal Directed Therapy Antibiotics and Source Control Insulin and glucose control Chest 1992;101:1644.

28. Corticosteroids in Sepsis • Obtain a baseline cortisol or ACTH stimulation • Start stress dose steroids (hydrocortisone 200-300mg +/- fludrocortisone 50 mcg) • Discontinue if levels are adequate

29. SURVIVING SEPSIS • Fluid resuscitation, goal-directed • Appropriate cultures prior to antibiotic administration • Early targeted antibiotics and source control • Use of vasopressors/inotropes when fluid resuscitation optimized

30. SURVIVING SEPSIS • Evaluation for adrenal insufficiency • Stress dose corticosteroid administration • Insulin drip for glucose control • Low tidal volumes (6cc/kg) for mechanical ventilation in ARDS

31. PREVENT COMPLICATIONS • Stress ulcer and DVT prophylaxis • Narrow antibiotic spectrum • Prevent VAP: 45 degree elevation • Facilitate early discontinuation of mechanical ventilation: sedation interruption, early SBT

33. Questions the official training programme of the Surviving Sepsis Campaign