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 Lung1 Colon2 Breast3 Sepsis4 cancers Annual
UK mortality
(2003),
thousands
Lung1
Colon2
Breast3
Sepsis4
cancers
1,2,3
4Intensive Care National Audit Research Centre (2005)

6. Identifying the Septic Patient

7. ACCP/SCCM Consensus Definitions
Severe Sepsis
Sepsis
Organ dysfunction
Septic shock
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:

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

13. Severe Sepsis Screening Tool
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 If yes, patient has SEPSIS Screening Tool
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. The patient has SEVERE SEPSIS Start Severe Sepsis Care Pathway
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. What you can do Sepsis Six within 1 hour•
Oxygen
Blood Cultures
Antibiotics
Fluids
Lactate & Hb
Insert Catheter & monitor urine output
within 1 hour
Then ensure Critical Care assistance if shocked to complete EGDT

21. Therapy Across the Sepsis Continuum
SIRS
Severe
Septic
Shock *
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
BACK-UP SLIDE: This slide shows specifically how the monitored parameters in EGDT were maintained.
“The protocol was as follows: A 500-ml bolus of crystalloid was given every 30 minutes to achieve a central venous pressure of 8 to 12 mm Hg. If the mean arterial pressure was less than 65 mm Hg, vasopressors were given to maintain a mean arterial pressure of at least 65 mm Hg. If the mean arterial pressure was greater than 90 mm Hg, vasodilators were given until it was 90 mm Hg or below. If the central venous oxygen saturation was less than 70 percent, red cells were transfused to achieve a hematocrit of at least 30 percent. After the central venous pressure, mean arterial pressure, and hematocrit were thus optimized, if the central venous oxygen saturation was less than 70 percent, dobutamine administration was started at a dose of 2.5 µg per kilogram of body weight per minute, a dose that was increased by 2.5 µg per kilogram per minute every 30 minutes until the central venous oxygen saturation was 70 percent or higher or until a maximal dose of 20 µg per kilogram per minute was given. Dobutamine was decreased in dose or discontinued if the mean arterial pressure was less than 65 mm Hg or if the heart rate was above 120 beats per minute. To decrease oxygen consumption, patients in whom hemodynamic optimization could not be achieved received mechanical ventilation and sedatives.” (p. 1370)
NEJM 2001;345:

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

25. Therapy Across the Sepsis Continuum
SIRS
Severe
Septic
Shock
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. Therapy Across the Sepsis Continuum
SIRS
Severe
Septic
Shock *
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 mg +/- 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. the official training programme of the Surviving Sepsis Campaign
Questions
the official training programme of the Surviving Sepsis Campaign