Early diagnosis of Sepsis & Management of septic patient
^ outdated stuff
Intended Learner Outcomes
> definition of sepsis, severe sepsis, septic shock, MOD
> Criteria for recognition and diagnosis
> Early management (priot to HDU/ICU transfer)
Why sepsis is a problem?
Many people suffer + thousands die from it each year
Kills more people than breast, bowel, & prostrate cabcer (under-reported? probably more)
Accounted for billion rupees in hospital costs
Why concerned about sepsis?
>Sepsis if not recognized and treated initially, may evolve through septic shock to multi organ failure (MOD)
> Septic shock/ MOD are associated with higher incidence of morbidity & mortality
> Early recognition & management of sepsis is vital in improving outcomes of patients
Why is sepsis difficult to spot?
- Sepsis can have a number of faces
- In some cases it can be very obvious (hypotension/ febrile) & in some not so obvious (frequently underdiagnosed)
- Early recognition: potentially reversible
What is an infection?
Infection is defined as
"an inflammatory response to the invasion of tissues by micro organisms”
What is sepsis?
- Sepsis defined as a Life-threatening organ dysfunction caused by a dysregulated host response to infection
Diagnosis of Sepsis?
Early recognition is the Key
- Severe sepsis is a time sensitive disease
- If you don’t recognize a severely septic patient, all other points in the protocol become null and irrelevant!
- Risk Prediction
0 Criteria ROD < 1%
1 Criteria ROD 2 - 3%
2 Criteria ROD 8%
3 Criteria ROD > 20%
- In the ICU, patients with suspected or presumed infection can be clinically identified by the presence of 2 or more SOFA points
Patients with septic shock can be clinically identified if, despite adequate resuscitation,
- If they require vasopressors to maintain MAP ≥65 mmHg
AND
- Their serum lactate level is > 2 mmol/l
1.Dilate the vasculature Hypotension
2.Leaky capillaries Oedema & aggravate hypovolemia
3.Activates clotting cascade Generate micro-thrombi
- Lungs – ARDS
- CVS –Refractory Hypotension
- Renal – ARF
- Liver – ALF
- CNS – Altered LOC
- Haemat -DIC
Management of Sepsis & Septic Shock
Medical Emergency
Treatment and Resuscitation start
Immediately
SEPSIS KILLS; ACT FAST
Bundle Care
Bundles -
- A group of interventions implemented together
- to achieve predefined goals in a specified time frame
- Better outcome than when implemented individually.
Hour one bundle; Initial resuscitation should begin immediately
1. Obtain blood cultures before administration of antibiotics
2. Administer broad spectrum antibiotics
3. Measure lactate
4. Begin rapid administration of 30ml/ Kg crystalloid for hypotension or lactate >4 mmol/L
5. Apply vasopressor if hypotensive during or after fluid to maintain a mean arterial pressure >65 mm Hg
- Re-measure lactate if initial lactate elevated > 2 mmol/L
Initial resuscitation
- at least 30 mL/kg of IV crystalloid fluid be given within the first 3 hours
- following initial fluid resuscitation, additional fluids be guided by frequent reassessment of hemodynamic status
- A portion of this may be albumin. Also in refractory hypotension albumin can be added
- Avoid HES (hydroxyethyl starches)
Vasoactive agents (call anaesthetists coz central venous access blah blah)
Vasoactive drugs
üNoradrenaline
1st choice
If diastolic BP is low and MAP is < 65
start noradrenaline even if not fully resuscitated
ü Vasopressin
as a second-line agent,
low dose vasopressin (up to 0.03 u/min)
if target mean arterial pressure (MAP) cannot be achieved by norepinephrine alone
- * Titrate vasoactive agents to target a MAP of > 65-70 mmHg
Reassessment of volume status and tissue perfusion
- Repeat focused exam including vital signs-physiological variables
- Heart rate
- Blood pressure
- Arterial oxygen saturation
- Respiratory rate
- Temperature
- Urine output
- Serum lactate levels
Source Control
- specific anatomic diagnosis of infection requiring emergent source control be identified or excluded as rapidly as possible
- source control intervention be implemented as soon as medically and logistically practical after the diagnosis is made
- Drainage of an abscess
- Wound debridement
- Removal of an infected prosthesis
...
>> ABG machine is kept in ICU so contact anaesthethist in iCU and even if capable immediately dispatch to ICU in ice thingy
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