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Sepsis & Medical Hdu


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Sepsis & Medical Hdu

  1. 1. Sepsis & Medical HDU Sara Furness 2009.
  2. 2. Why talk about sepsis? <ul><li>The mortality from sepsis is high – 30-50% </li></ul><ul><li>This rises to 50-60% when signs consistent with severe sepsis are present. </li></ul><ul><li>As treatments become more aggressive we will see more of it. </li></ul><ul><li>Early aggressive management is needed to improve outcomes. </li></ul><ul><li>It is not always well recognised at presentation. </li></ul>
  3. 3. Some definitions: <ul><li>Systemic Inflamatory Response Syndrome (SIRS) is a dysregulated inflammatory response which is not confined to sepsis: </li></ul><ul><li>Temperature >38.5ºC or <35ºC </li></ul><ul><li>Heart rate >90 beats/min </li></ul><ul><li>Respiratory rate >20 breaths/min or PaCO2 <4.2 mmHg </li></ul><ul><li>WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature (band) forms </li></ul>
  4. 4. Sepsis <ul><li>Sepsis is a clinical syndrome which occurs in severe infection and comprises systemic inflammation and widespread tissue damage. </li></ul><ul><li>i.e. SIRS + infection = SEPSIS </li></ul><ul><li>Septic Shock is the presence of sepsis plus one or both of the following: </li></ul><ul><li>SBP <60mmHg (80mmHg is hypertension) despite adequate fluid </li></ul><ul><li>Maintaining SBP >60mmHg requires significant use of inotropes. </li></ul>
  5. 5. How do I know if it is severe sepsis? <ul><li>SIRS + infection + 1 or more of the following: </li></ul><ul><li>Skin mottling, cap refill >3s, blotchy rash </li></ul><ul><li>Urine output <0.5ml/kg for >1 hour </li></ul><ul><li>Confusion, coma </li></ul><ul><li>DIC, Platelets <100 </li></ul><ul><li>Acute lung injury (ARDS) </li></ul><ul><li>Acute cardiac dysfunction (ECHO or cardiac output monitoring) </li></ul>
  6. 6. Sepsis is a very bad thing… <ul><li>But deaths from Sepsis can be prevented if aggressive early management is started </li></ul><ul><li>Institute for Healthcare Improvement: “Surviving Sepsis” campaign suggested a “bundle” </li></ul><ul><li>Some elements very basic and acheivable anywhere </li></ul><ul><li>Some more complex requiring expertise and higher level care </li></ul><ul><li>How do we reliably deliver this? </li></ul><ul><li>Start with the “Sepsis 6”… </li></ul>
  7. 7. The Sepsis Six <ul><li>O2 therapy to maintain target saturation </li></ul><ul><li>Blood Cultures before abx </li></ul><ul><li>IV antibiotics within 1 hour of identifying </li></ul><ul><li>Blood for Haemoglobin and lactate </li></ul><ul><li>IV fluids for fluid resuscitation </li></ul><ul><li>Urinary Catheter and monitor urine output </li></ul>
  8. 8. Sustain Respiration <ul><li>Even when oxygenation is not disordered, patients tend to breathe fast with sepsis and its hard work! </li></ul><ul><li>Patients need excellent oxygenation to recover. </li></ul><ul><li>If conciousness is decreased they may need early airway intervention </li></ul><ul><li>Ensuring central venous O 2 sats are >70% allows best O 2 delivery in severe ongoing sepsis </li></ul>
  9. 9. Find the cause & early treatment <ul><li>Blood cultures should be taken as soon as it’s apparent the patient is septic, and ideally prior to administration of antibiotics. </li></ul><ul><li>Prompt antibiotic administration </li></ul><ul><li>No target on earth should interfere with this!! </li></ul>
  10. 10. Assess End Organ Damage <ul><li>Blood for Hb (and early transfusion if required) & lactate are mandatory. </li></ul><ul><li>Lactate is on the ABG machine in A&E but has to be sent in serum from MHDU </li></ul><ul><li>In combination with ABG & clinical findings allows an assessment of perfusion </li></ul><ul><li>Catheterise to monitor Urine Output. </li></ul>
  11. 11. Iv Fluid resuscitation <ul><li>Give enough! </li></ul><ul><li>Boluses of fluid, rapidly till 30ml/kg given </li></ul><ul><li>Thats 2100ml in a 70 k man or 3 l in the average Salfordian! </li></ul><ul><li>If BP still remains low then needs CVC to monitor pressure & consider central venous O2 sats </li></ul><ul><li>Should certainly be receiving higher level care at this stage </li></ul>
  12. 12. Higher level targets <ul><li>CVP 8-12 mmHg </li></ul><ul><li>MAP >65 mmHg </li></ul><ul><li>UO > 0.5ml/kg/hr </li></ul><ul><li>SVC sats >70% or mixed venous >65% </li></ul><ul><li>If venous sats poor – more fluid, transfuse to haematocrit >30 and dobutamine up to 20mcg/kg/min </li></ul><ul><li>Frankly by that time I’d expect ITU to be around!! </li></ul>
  13. 13. Mr W <ul><li>Admitted in April 08 </li></ul><ul><li>Cellulitis, unwell, T39 0 , P 120, RR 22 </li></ul><ul><li>WCC 7.6, Glucose 6.7, Mildly confused </li></ul><ul><li>Treated as cellulitis. </li></ul><ul><li>7 am the next day – much sicker: </li></ul><ul><li>SBP 70 to palpation, cap refill 7s, p 150 </li></ul><ul><li>Responding only to voice </li></ul><ul><li>1.5l fluid overnight “as cardiac history” </li></ul>
  14. 14. Applying the sepsis 6.... <ul><li>Is this SIRS? </li></ul>Yes – temp 39, Pulse 120 +, RR >20. Is this septic shock? Yes – SBP 70 in a hypertensive. Is this severe? Yes – cap refill, confused, ?UO Initial recognition was poor and fluid input was suboptimal, especially as SBP sliding overnight. With initial fluid boluses he received 2.5l of fluid and SBP improved to 110. However, later that day he deteriorated again & SBP dropped again.
  15. 15. What happened? <ul><li>Went to HDU & continued to deteriorate </li></ul><ul><li>Finished up in ITU </li></ul><ul><li>Full house of not very good markers </li></ul><ul><li>1 x PEA arrest, 1 x VF arrest from acute MI. </li></ul><ul><li>5 week stay and then made it off the unit & home. </li></ul><ul><li>Died a couple of months later of cardiac disease. </li></ul>
  16. 16. The role of MHDU – a discussion. <ul><li>Early goal </li></ul><ul><li>directed </li></ul><ul><li>Therapy?? </li></ul>When to step up care? To line or not to line? Straight to ITU?? Should there be an MHDU policy? Central venous O 2 Sats on HDU?
  17. 17. Resources <ul><li> </li></ul><ul><li> </li></ul><ul><li>Pete Turkington, Pete Murphy </li></ul><ul><li>Bundle cards. </li></ul>Its up to MHDU how much this is taken on, but I think you have a role in spreading knowledge as well as in providing the care!