1. Acute Medicine Nurse Study Day: 01/04/15
Sepsis | Tom Heaps 09:30-10:20
Oncological Emergencies | Clare Pollard 10:20-11:10
BREAK 11:10-11:
Diabetic Ketoacidosis | Tom Heaps 11:30-12:20
Close and Feedback 12:20-12:30

2. Tom Heaps Consultant Acute Physician
Surviving Sepsis
Tom Heaps
Consultant Acute Physician

3. Introduction incidence of severe sepsis 90/100,000/year
incidence of sepsis needing ICU 25-38/100,000/year
overall mortality 28-50%
estimated 36,800 deaths per year in UK

4. Clinical Case 78-year-old male presenting to ED
PMHx T2DM, CKD1, IHD, BPH
48h history of dysuria, confusion and malaise
T° 38.3C, HR 112, BP 103/55mmHg, RR 24, SpO2 93% o/a
delirious ++
warm extremities, bounding pulse
R basal crackles
suprapubic tenderness
Hb 11.1, WCC 18, platelets 103, urea 12, creatinine 144 (baseline ~120), LFTs normal, CRP 273, clotting normal

5. Does he meet the criteria for sepsis?
Systemic Inflammatory Response Syndrome (SIRS)
defined by ≥2 of the following;
temperature >38°C or <36°C
HR >90min-1
RR >20min-1 or PaCO2 <4.25kPa
new onset confusion
hyperglycaemia (CBG >7.7mmol/l) in absence of diabetes
WBC >12 x109 or <4 x109 or high CRP (if available)
infection, trauma, surgery, burns, pancreatitis
SEPSIS = SIRS + infection +/- bacteraemia
mortality increases with number of SIRS criteria

6. What is your initial management?
oxygen (if required to achieve target SpO2)
blood cultures
IV antibiotics
IV fluids
VBG or ABG (plus FBC, U&E, LFT, CRP, coagulation)
urinary catheter and commence fluid balance
urine cultures
CXR

7. VBG/ABG in sepsis
lactate on VBG correlates well with arterial lactate except in cases of severe shock
measure ABG if shocked or oxygenation/ventilation a concern
lactate levels correlate highly with mortality
40% if lactate >4mmol/l
15% if lactate <2mmol/l
serial measurements and lactate clearance in response to resuscitation more important than absolute values

8. Fluid resuscitation in sepsis
hypovolaemia in sepsis is absolute (reduced fluid intake, fluid loss, insensible losses) and relative (vasodilatation)
500mL boluses up to 30mL/kg (~2L for 70kg person) over ≤30min
repeated up to 60mL/kg (~4L for 70kg person) after senior review
Which fluid? crystalloid vs colloid
no evidence that albumin superior to saline (SAFE trial)
colloids are more expensive and risks of AKI (HES), anaphylaxis and coagulopathy
Which crystalloid?
balanced solutions e.g. Hartmann’s are more expensive
less risk of hyperchloraemic acidosis than with 0.9% NaCl
in vitro evidence only that hyperchloraemic acidosis is harmful

9. Antibiotics in sepsis time to administration is critical factor
8% increase in mortality for every 1h delay after onset of hypotension
aim to administer IV broad spectrum antibiotics within 1h of presentation with severe sepsis
empirical choice governed by probable source of infection and local guidelines (available on intranet)
separate guideline for suspected/proven febrile neutropenia

10. Clinical Case Continued
ABG on air pH 7.36, pO2 9.2, pCO2 2.8, lactate 4.8, BE -5.6
blood cultures taken
CXR unremarkable
catheterized
urine dipstick leucocytes 3+, nitrite +ve, RBC 2+, protein +
IV co-amoxiclav and gentamicin given for suspected UTI
IV 0.9% NaCl 2L prescribed each over 8h
2h later BP 91/44mmHg and urine output 50ml total

11. Does he have SEVERE sepsis?
SEVERE sepsis = sepsis plus evidence of organ dysfunction (or tissue hypoperfusion);
alteration in mental state (confusion)
hypoxemia (PaO2 <9.6kPa at FiO in absence of pulmonary disease)
elevated plasma lactate (>4mmol/l), increased CRT or skin mottling
oliguria (urine output <30ml or <0.5 ml/kg for 1h)
hypotension (sBP <90mmHg, MAP <65mmHg or reduction in sBP of 40mmHg from baseline)
creatinine >177umol/l
bilirubin >34umol/l
platelets <100, INR >1.5 or disseminated intravascular coagulation (DIC)

12. Does he have SEVERE sepsis?
SEVERE SEPSIS = sepsis plus evidence of sepsis-induced tissue hypoperfusion or organ dysfunction;
alteration in mental state (confusion)
hypoxemia (PaO2 <9.6kPa at FiO in absence of pulmonary disease)
elevated plasma lactate (>4mmol/l), increased CRT or skin mottling
oliguria (urine output <30ml or <0.5 ml/kg for 1h)
sepsis-induced hypotension (sBP <90mmHg, MAP <70mmHg or reduction in sBP of 40mmHg from baseline)
creatinine >177umol/l
bilirubin >34umol/l
platelets <100, INR >1.5 or disseminated intravascular coagulation (DIC)

13. ‘RED FLAG’ Sepsis Tachycardia: HR >125/min
New concept introduced by latest guidelines from UK Sepsis Trust
Early detection (MEWS-based) of patients at risk of deterioration who may benefit from more aggressive treatment as ‘severe’ sepsis
Many markers of severe sepsis may not be evident / available at time of first presentation
Tachycardia: HR >125/min
Hypotension: systolic BP <90mmHg
Tachypnoea: RR >20
Hypoxaemia: SpO2 <90% (or only ≥90% with O2)
Drowsiness: AVPU of V, P or U

14. Clinical Case Continued
given fluid challenge of 2L Hartmann’s over 1h
total fluid input now 3L
repeat VBG shows lactate 6.2
no urine output in last 1h
BP 80/52mmHg
mottling of lower extremities
increasing confusion

15. What is the diagnosis now?
SEPTIC SHOCK =
SEVERE SEPSIS +
hypotension which is refractory to fluid replacement
WHAT NEEDS TO HAPPEN NOW?
senior review
decisions re. CPR/escalation (if not already made!)
transfer to ITU if appropriate
Invasive monitoring, vasopressors, ventilation etc.

16. What is my role as a nurse?
Recognize and screen for sepsis
Suspect Infection?
MEWS ≥ 4
High temperature
Symptoms suggestive of infection
Risk of neutropenia/immunosuppression
Confirm diagnosis using SIRS criteria (≥2 positive)
Any features of ‘red flag’ or severe sepsis?
Obtain medical review (immediate if severe sepsis)
ELDERLY PATIENTS MAY PRESENT ATYPICALLY

17. Use the new AMU sepsis pathway

18. What is my role as a nurse?
Get the ‘SEPSI6’ trolley and initiate the ‘SEPSIS 6’ BUNDLE
3x Investigations
VBG/ABG (and other bloods)
Blood cultures (and other cultures)
Urine output monitoring (insert catheter if severe sepsis)
3x Treatments
Oxygen
IV Fluids
IV antibiotics
ALL WITHIN 1h OF RECOGNIZING ‘RED FLAG’ OR SEVERE SEPSIS
reduced mortality from 44% to 20% at GHH

19. What is my role as a nurse?
Monitoring and Co-ordination of Care
ensure antibiotics given promptly and fluids running to time
hourly observations (for 1st 4h even if MEWS <4) and urine output / fluid balance chart
repeat VBG for lactate
involve CCOT early
prompt doctors to make escalation/CPR decisions
alert senior medical staff if condition deteriorates or fails to improve as expected

20. Take Home Messages SEPSIS = SIRS + infection
SEVERE sepsis = sepsis plus ≥1 marker of organ dysfunction
RED FLAG sepsis should be treated initially as SEVERE sepsis
severe sepsis is a MEDICAL EMERGENCY which kills in 1/3 of cases
early RECOGNITION and RESUSCITATION are key
PROMPT antibiotics and ADEQUATE IV fluids will SAVE MORE LIVES than ITU
GRAB THE ‘SEPSI6’ TROLLEY AND CARRY OUT THE ‘SEPSIS SIX’ WITHIN 1h of recognition of SEVERE / RED FLAG sepsis
escalate to senior and involve CCOT EARLY if patient fails to respond
use the new AMU sepsis pathway and ‘Sepsis 6’ Stickers