Resus: Septic Shock and Sepsis

Related Subjects: Atropine | Acute Anaphylaxis | Basic Life Support | Advanced Life Support | Adrenaline/Epinephrine |Acute Hypotension |Cardiogenic shock |Distributive Shock |Hypovolaemic or Haemorrhagic Shock |Obstructive Shock |Septic Shock and Sepsis |Shock (General Assessment) |Toxic Shock Syndrome |Non invasive ventilation (NIV) |Intubation and Mechanical Ventilation |Critical illness neuromuscular weakness |Multiple Organ Dysfunction Syndrome

In sepsis large volumes of fluid may be required to replace fluid lost into tissues and a clinically important anaemia may result from haemodilution and blood transfusion may be necessary.

Algorithm

Initial Management: O2 target 94-98% unless scale 2 COPD.

ABC, Oxygen, IV access (x2), 500 ml Crystalloid over 15 mins Send FBC, U&E, LFT, Lactate, Trop, Dimer, ABG CXR, Blood and urine cultures. CSF when indicated Consider Urinary catheter to measure urine output Is there Fever, Sepsis, Retained Tampon, Wound Appropriate IV Antibiotic within 1 hr of diagnosis Give 500 ml Crystalloid over 15 mins (30 mL/kg crystalloid) for low BP or lactate > 4 mmol/L unless heart failure Inotrope (Norepinephrine) to keep MAP > 65 mmHg Critical care review: can provide inotropes, ventilation, haemofiltration, monitoring, experience

Third International Consensus (2016) Definitions

• Sepsis: "life-threatening organ dysfunction caused by a dysregulated host response to infection." In laymans terms it means that Sepsis is a self inflicted injury due to our reponse to an infection.
• qSOFA (Quick SOFA) Criteria can be used to triage patients with suspected sepsis
  • Respiratory rate >22/min
  • Altered mentation
  • Systolic blood pressure < 100 mm H
• Septic shock: sepsis with persisting hypotension requiring vasopressors to maintain MAP > 65 mm Hg and having a serum lactate level >2 mmol/L (18 mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%

Risk Factors

• Age > 75
• Impaired immunity (e.g. diabetes, steroids, chemotherapy)
• Recent trauma / surgery / invasive procedure
• Indwelling lines / IVDU / broken skin

A metabolic acidosis with base deficit > 5 mmol/L often indicates increased lactic acid production in poorly perfused, hypoxic tissues. Serial lactate measurements may help in monitoring response to treatment

Likely Source

• Respiratory, Brain, Urine, Surgical
• Skin / joint / wound, Indwelling device, Other

Red flag sepsis: Involve Critical Care/Seniors

• Evidence of new or altered mental state
• SBP < 90 mmHg (or drop of >40 from normal)
• Heart rate > 130/minute or new AF
• Respiratory rate > 25/minute
• Needs 40% O2 to keep SpO2 > 92% (88% in COPD)
• Non-blanching rash / mottled / ashen / cyanotic
• Lactate > 2 mmol/l
• Recent chemotherapy or surgery or IV Drug user
• Not passed urine in 18 hours (<0.5ml/kg/hr if catheterised)
• Mottled, ashen, or cyanotic skin. Nonblanching rash

Quick SOFA: Predicts death or a requirement ICU for ward patients

• Patients are deemed positive for qSOFA if they have two of:
• Glasgow Coma Scale score of <15 (see Box 26.28 )
• Respiratory rate of = 22 breaths/min
• Systolic blood pressure of = 100 mmHg.

Sequential Organ Failure Assessment (SOFA) score

A qSOFA score of =2 is suggestive of sepsis and needs urgent review for escalation

QSOFA score

• Respiratory rate > 22/min +1
• Altered mentation GCS reduced +1
• SBP = 100 mmHg +1

Amber Flag Sepsis

• Relatives or Nursing concerns re mental state
• Acute deterioration in functional ability
• Trauma/ surgery/ procedure in last 6 weeks
• Systolic BP 91-100 mmHg (or drop >40 from normal)
• Heart rate 111- 130 per minute or new arrhythmia
• Respiratory rate 21-24 per minute or breathing hard
• Not passed urine in last 12- 18 hours
• Clinical signs of wound, device or skin infection

Microbiology

• 40% Gram positive and 60% Gram negative
• E.Coli, Staph Aureus, Streptococcus Pneumoniae
• Pyogenic streptococci e.g. Group A
• Neisseria meningitis Coagulase negative in immunosuppressed.
• Very small amount are fungal

More Definitions

• Septicaemia: SIRS + positive blood culture
• Bacteraemia: bacteria in bloodstream +/- SIRS
• Severe Sepsis: SIRS + organ dysfunction or Hypotension
• Septic shock: clinical criteria of sepsis and vasopressor therapy needed to elevate mean arterial pressure = 65 mmHg and lactate > 2 mmol/L(18mg/dL)despite adequate fluid resuscitation

Aetiology (nonspecific)

• Ischaemia, inflammation, Trauma, infection
• Several insults combined.

Aetiology

• There is reduced ability of tissues to extract Oxygen - this is a real problem with an inability to utilise oxygen for oxidative phosphorylation at the mitochondrial level
• The result being lactic acidosis and interestingly the AV O₂ gap narrows as O₂ is not extracted.

Severe Sepsis

• Sepsis plus at least one of the following signs of organ hypoperfusion or dysfunction
• Areas of mottled skin, capillary refilling requires three seconds or longer
• Urine output <0.5 mL/kg for at least one hour, or renal replacement therapy
• Lactate >2 mmol/L
• Abrupt change in mental status
• Abnormal electroencephalographic (EEG) findings
• Platelet count <100,000/mL
• Disseminated intravascular coagulation
• Acute lung injury or acute respiratory distress syndrome (ARDS)
• Cardiac dysfunction on echo or direct measurement of the cardiac index

Clinical

• Pyrexia, Delirium, Oliguria, Dyspnoea
• Hypotensive, Mottled skin and poor capillary return

Investigations

• FBC - WCC elevated or low, Low Hb
• U&E - renal function - possible AKI
• ↑ Amylase - pancreatitis
• CXR: consolidation, collapse, pneumothorax, malignancy
• ABG and ↑ Lactate (elevated)
• Clotting ↑ prolonged APPT and PT if DIC
• Blood and Urine cultures
• Echocardiogram - LV function, valves, tamponade, endocarditis
• Abdominal CT - perforations, obstruction, abscess, fluid collections, AAA

Monitoring

• Regular Temp, Pulse, Resp rate and O2 saturation.
• Urinary catheter can help show renal perfusion and fluid balance
• Central venous catheter capable of measuring central venous oxygen saturation

Sepsis 6: To be completed within 1 hour

• 1. High-flow oxygen to maintain oxygen saturation >95%
• 2. Blood cultures and consider source control
• 3. Intravenous antibiotics
• 4. Intravenous fluid resuscitation
• 5. Check haemoglobin and serial lactates
• 6. Hourly urine output measurement

If after delivering the Sepsis Six, patient still has these then Refer to Intensive Care Unit

• Systolic BP <90 mmHg
• Reduced level of consciousness despite resuscitation
• Respiratory rate over 25 breaths per minute
• Lactate not reducing
• or if patient is clearly critically ill at any time

Management

• ABC, Oxygen target 94-98% unless scale 2, Good IV access.
• If in HDU/ITU central venous line and arterial line
• Give 500mL boluses of N-Saline or equivalent over 15mins. Caution in heart failure. Consider repeating if no improvement.
• Intubation and ventilation if resistant hypoxia or severe hypercapnia
• IV Broad spectrum antibiotics for the likely source. Give within 1 hour.
• If CVP < 6 mmHg then repeated bolus 250 ml N-Saline or colloid
• If CVP > 6 mmHg or poor LV suspected then 100 ml boluses
• Aim for Hb 70-90 g/L or 100 g/L if IHD
• Target mean arterial pressure (MAP) = 65 mm Hg and lactate > 2 mmol/L
• Consider Inotropes: Norepinephrine (Noradrenaline) is the Inotrope of choice and preferred to dopamine which increases arrhythmias and mortality
• Monitor haemodynamic, pH, Lactate, urine output, ABG

References

• The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
• Updates and Controversies in the Early Management of Sepsis and Septic Shock