1. Sepsis Management National Clinical Guideline No. 6

2. Sepsis Management National Clinical Guideline
The aim of the guideline is to facilitate the early recognition and appropriate treatment of sepsis in Ireland in order to maximise survival and minimise the burden of chronic sequelae.
All information regarding the guideline is available on Q-Pulse
The summary document is available at:
The guideline adapts the Surviving Sepsis Campaign guidelines 2013 and Sepsis Six to the Irish context.

3. Sepsis Management National Clinical Guideline
“Sepsis is a life threatening condition that arises when the body’s response to an infection injures its own tissues and organs. Sepsis leads to shock, multiple organ failure and death especially if not recognised early and treated promptly. Sepsis remains the primary cause of death from infection despite advances in modern medicine, including vaccines, antibiotics and acute care. Millions of people die of sepsis every year worldwide.” Merinoff Symposium 2010: Sepsis

4. International context
Approximately 300 cases per 100,000 population per annum. As comparators, myocardial infarction affects 208 and stroke 223 patients per 100,000 per year.
Mortality from sepsis is currently as high as mortality from acute myocardial infarction was in the 1960s.
In the U.K. sepsis is estimated to claim 37,000 lives annually and cost the NHS approximately £2.5 billion.
Sepsis incidence is predicted to grow at a rate of 1.5% annually due to:
- aging population
- increased numbers of invasive procedures
- increasing number of people living with co-morbidities
- increasing number of people long-term immunosuppressive therapies.

5. Irish Context
Up to 60% of all hospital deaths have a sepsis or infection diagnosis
(HIPE data)
Irish Intensive Care Units
Mortality rates of patients with a diagnosis of sepsis is 28.8%
Mortality rates reduced by 17.7% and average length of stay is decreasing every year with increased awareness.
(National Clinical Effectiveness Committee, 2014; Dellinger et al 2013)
Each hour of delay in antimicrobial administration associated with an average decrease in survival of 7.6% (Kumar et al, 2006)

6. UK report from the Health Service Ombudsman
Lack of timely history and examination on presentation
Lack of necessary investigations
Failure to recognise the severity of the illness
Inadequate first-line treatment with fluids and antibiotics
Delay in administering first-line treatment
Inadequate physiological monitoring of vital signs
Delay in source control of infection
Delay in senior medical input
Lack of timely referral to critical care

7. Sepsis Management
Program is aimed at early identification and treatment of patients with sepsis  lead to reduced mortality  timely ICU admission  decrease ICU length of stay

8. DEFINITIONS IMPORTANT TO KNOW
Infection is defined as a pathological process caused by invasion of normally sterile tissue or fluid or body cavity by pathogenic or potentially pathogenic micro-organisms.
Sepsis is the clinical syndrome defined by the presence of both infection and the systemic inflammatory response syndrome (SIRS).
Severe sepsis refers to sepsis complicated by organ dysfunction.
Septic shock is defined as severe sepsis with circulatory shock with signs of organ dysfunction or hypoperfusion.
Australian Modification of ICD-10 incorporating the Australian Classification of Health Interventions and the Australian Coding

9. PATHOPHYSIOLOGY OF SEPSIS
Pathogenic features of the microorganism
Patient’s immune response to these features
Failure of the immune system to control an initially localised infection
Exaggerated immune and inflammatory response
Cellular dysfunction
Vasodilation and leaky capillaries

10. PATHOPHYSIOLOGY OF SEPSIS
Distributive shock
Myocardial depression
Bone marrow suppression
Activation of clotting cascade DIC (Disseminatedd Intrtavascular Caogulation)
Organ dysfunction
MODS (Multiple Organ Dysfunction Syndrome)
Death

11. Microvascular Plugging Maldistribution of Microvascular Blood Flow
Infection
Vasodilation
Inflammatory
Mediators
Endothelial
Dysfunction
Hypotension
Microvascular Plugging
Vasoconstriction
Odema
Maldistribution of Microvascular Blood Flow
Ischemia
Cell Death
Organ Dysfunction
DEATH

12. modified Systemic Inflammatory Response Syndrome (SIRS)
Sepsis Screening tool
Infection Suspected +
Any 2 or more
modified Systemic Inflammatory Response Syndrome (SIRS)
criteria present
□ Respiratory rate
>20 (bpm)/Hypoxia
□ WCC <4
or >12 x 10 x9/L
□ Acutely altered
mental status
□ Heart rate >90bpm
□ Temperature
<36 or >38.3 (°C)
□ Bedside glucose
>7.7mmol/L
(in absence of diabetes)

13. Presenting complaints to consider
Cough / flu-like symptoms
UTI / flank pain
Fever
Pleuritic chest pain / SOB
Abdominal pain
Generally unwell with co-morbidities /caution with elderly patients
Confusion
Headache (signs of meningism)
Abcess / local infections
Limb problems (intra-articular infections / septic arthritis)
Wounds

14. Pathway of care for patients presenting with sepsis
DECTECTION
Early Warning score
Triage
RESUSCITATE + REFER
Sepsis 6 within 1hr
Referral to senior clinicians and ICU if appropriate
COMMUNICATION
RSVP
RECOGNITION
Clinical evaluation
Sepsis screening tool

15. Adult in-patient trigger New NEWS score of 4 (5 if on O2) or higher = medical review Sepsis screening: Infection suspected + two SIRS criteria = Sepsis organ dysfunction and/or shock = Severe sepsis/septic shock
SIRS
Clinical response arising from a non specific insult
Infections and non-infectious causes
Sepsis
SIRS + a presumed or confirmed infection
Severe Sepsis
Sepsis + sepsis-induced organ dysfunction or tissue hypoperfusion
Septic Shock
Sepsis induced hypoperfusion or hypoperfusion persisting despite 30ml/kg Fluid Resuscitation.
Caution:
Some groups of patients, such a older people, may not meet the modified SIRS criteria, even though infection is suspected. Where this occurs check for signs of organ dysfunction and raised biomarkers such as CRP.

16. Sepsis Management National Clinical Guideline
What is Sepsis 6?
Why within 1 hour?
Each hour of delay in antimicrobial administration decrease in survival of 7.6%.
TAKE 3
GIVE 3
CULTURES: Take blood cultures before giving antimicrobials (if no significant delay i.e. >45minutes) and consider source control.
2. BLOODS: Check lactate and full blood
count.
3. URINE OUTPUT: Assess urine output and
consider urinary catheterisation for
accurate measurement in patients with
severe sepsis/septic shock.
. OXYGEN: Titrate O2 supplementation to
saturations of % or 88-92% in
chronic lung disease.
2. FLUIDS: Start IV fluid resuscitation if
evidence of hypovolaemia and/or shock.
500ml–1000mls bolus of isotonic
crystalloid over 15–30 minutes and give up
to 30ml/kg, reassessing after each bolus
for signs of hypovolaemia, euvolaemia, or
fluid overload.
3. ANTIMICROBIALS: Give IV antimicrobials
according to local antimicrobial guidelines.

17. SEPSIS BOX

18. Prevalence of sources of sepsis IMPRESS trial (2014) check
Respiratory
35%
Urinary
21%
Intra abdominal
16.5%
Catheter related blood stream infection
2.3%
Device related
1.3%
CNS
0.8%
Others e.g cellulitis, intra-articular
11.3%

19. Diagnostic criteria for sepsis
General variables
Fever (> 38.3°C)
Hypothermia (core temperature < 36°C)
Heart rate > 90/min–1 or more than two SD above the normal value for age
Tachypnoea
Altered mental status
Significant oedema or positive fluid balance (> 20 mL/kg over 24 hr)
Hyperglycemia (plasma glucose > 7.7 mmol/L) in the absence of diabetes
Inflammatory variables
Leucocytosis (WBC count > 12,000 μL–1)
Leucopenia (WBC count < 4000 μL–1)
Normal WBC count with greater than 10% immature forms Plasma C-reactive protein more than two SD above the normal value
Haemodynamic variables
Arterial hypotension (SBP < 90mm Hg, MAP < 70 mmHg, or an SBP decrease > 40 mmHg in adults or less than two SD below normal for age)
Organ dysfunction variables
Arterial hypoxaemia (PaO2/FiO2 < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
Creatinine increase > 0.5mg/dL or 44.2 μmol/L
Coagulation abnormalities (INR > 1.5 or aPTT > 60s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < 100,000 μL–1)
Hyperbilirubinaemia (plasma total bilirubin > 4mg/dL or 70 μmol/L)
Tissue perfusion variables
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling
WCC

20. Severe sepsis
Severe sepsis is defined as sepsis-induced tissue hypoperfusion or organ dysfunction (any of the following thought to be due to the infection) – Lactate above upper limits laboratory normal – Urine output < 0.5 ml/kg/hr for more than 2 hrs despite adequate fluid resuscitation – Acute lung injury with PaO2/FiO2 < 250 in the absence of pneumonia as infection source – Acute lung injury with PaO2/FiO2 < 300 in the presence of pneumonia as infection source – Creatinine > micromol/l – Bilirubin > 34.2 micromol/l – Platelet count < 100,000 μL–1 – Coagulopathy (INR > 1.5) – Sepsis induced hypotension.

21. Septic shock
Septic shock is defined as sepsis-induced tissue hypoperfusion persisting after resuscitation with 30mls/kg intravenous isotonic crystalloid fluid as evidenced by: – Systolic blood pressure < 90 mmHg or MAP < 65 mmHg – Decrease in systolic blood pressure by 40mmHg from baseline and/or – Lactate > 4 mmol/l.

22. Recommendations Fluid resuscitation with crystalloid
Only consider albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate MAP.
Avoid hetastarch i.e. gelofusine
Avoid IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy restore haemodynamic stability
First choice vasopressor – norepinephrine + additional epinephrine/vasopressin if required. Vasopressin should not be used as initial vasopressor, use for salvage only.
Dopamine not recommended
Protocol for glucose management commencing insulin dosing when 2 consecutive BGL levels >10mmol. Keep BGL < 10. Check BGL hrly until stable and then 4 hrly.
Early imaging to diagnose source of infection. (Dellinger et al 2013)

23. References
Dellinger R.P. et al. (2013) Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: Critical Care Medicine 41 (2), Kumar A. et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine 34, National Clinical Effectiveness Committee, Health Service Executive (2014) Sepsis Management: National Clinical Guideline No. 6 Australian Modification of ICD-10 incorporating the Australian Classification of Health Interventions and the Australian Coding

24. Thank you Any Questions?

25. Referral to senior clinicians and ICU if appropriate
SEPSIS
DECTECTION
Early Warning score
Triage
RESUSCITATE + REFER
Sepsis 6 within 1hr
Referral to senior clinicians and ICU if appropriate
COMMUNICATION
RSVP
RECOGNITION
Clinical evaluation
Sepsis screening tool