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POLL: What is sepsis? POLL: What is sepsis? A. A bad infection in - - PDF document

Jun 28, 2023 163 likes •250 views

06/08/2020 SEPSIS AND SEPTIC SHOCK: RECOGNITION AND MANAGEMENT Marisa Lanzman & Stephen Hughes WHAT IS SEPSIS? @MarisaJL @StephenJ_Hughes 5 th August 2020 www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org

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SEPSIS AND SEPTIC SHOCK: RECOGNITION AND MANAGEMENT

Marisa Lanzman & Stephen Hughes @MarisaJL @StephenJ_Hughes 5th August 2020

WHAT IS SEPSIS?

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POLL: What is sepsis?

  • A. A bad infection in the blood
  • B. A life-threatening condition when an

infection causes the body to injure it’s own tissues and organs

  • C. An infection that is resistant to standard

antibiotics

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POLL: What is sepsis?

A life-threatening condition when an infection causes the body to injure it’s own tissues and

  • rgans

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WHAT IS SEPSIS?

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  • Sepsis is a life-threatening condition that arises when the

body’s response to an infection injures its own tissues and

  • rgans causing:
  • Vasodilation
  • Capillary leakage
  • Amplification of cytokines
  • It is NOT ‘just a bad infection’ – cannot just be cured with

antibiotics

SEPSIS IS A MEDICAL EMERGENCY

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06/08/2020 2 HOW DO WE RECOGNISE SEPSIS?

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POLL: How do we recognise Sepsis?

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Which of these is NOT a sign of sepsis?

  • A. Respiratory rate > 20/min
  • B. GCS <15
  • C. Systolic BP < 100
  • D. Temperature > 38.3 or < 36.0
  • E. Urine output > 1 ml/kg/min

POLL: How do we recognise Sepsis?

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Which of these is NOT a sign of sepsis? Urine output > 1 ml/kg/min

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SCORING SYSTEMS

2 OR MORE = SEPSIS

qSOFA score (Sepsis-3) Modified SIRS Criteria (SSC)

  • Respiratory rate

≥ 22/min

  • Altered mentation:

GCS <15

  • Systolic BP

100 mmHg – Temperature >38.3 or <36.0oC – New confusion or drowsiness – Pulse >90/min – RR >20/min – WBC >12 or <4.0 x 109/L – Blood glucose >7.7 mmol/L (not if diabetic)

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SCORING SYSTEMS

NICE; 1 or more = At risk of sepsis

  • r

Sepsis Trust; 1 or more = red flag sepsis

– Behaviour: objective evidence

  • f new altered mental state

– Pulse: >130 bpm – RR ≥ 25 breaths per minute OR new need for 40% oxygen or more to maintain saturation more than 92% (or more than 88% in COPD) – SBP: < 90 mmHg OR > 40 mmHg below normal – Not passed urine in previous 18 hours, or for catheterised patients passed <0.5 ml/kg of urine per hour – Mottled/ashen appearance – Cyanosis of skin/lips/tongue – Non-blanching rash

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TRACK AND TRIGGER SYSTEMS

  • NEWS2
  • Endorsed by RCP
  • Rolled out nationally

via CQUIN 2018

  • Sepsis screen when

score of 5 is reached

  • When score of 7

reached; medical emergency

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SLIDE 3

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NEWS2 EXAMPLE

  • 74 years old
  • Admitted via ED with 2/7

history of UTI symptoms:

– Frequent urination – Cloudy urine – Flank pain

  • History includes:

– Surgery one month ago for bowel obstruction – Hypertension – ?Early signs of dementia

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  • RR = 19
  • Oxygen saturations = 94% on 2 L
  • SBP = 118
  • Pulse = 111
  • GCS = 15
  • Temp = 38.2

What is the NEWS2 score?

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  • RR = 19
  • Oxygen saturations = 94% on 2 L
  • SBP = 118
  • Pulse = 111
  • GCS = 15
  • Temp = 38.2

What is the NEWS2 score?

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WHAT IS SEPTIC SHOCK?

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WHAT IS SEPTIC SHOCK? (Sepsis-3)

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  • Septic shock is a subset of sepsis in which underlying

circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality

  • Patients with septic shock can be identified with a

clinical construct of 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%

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06/08/2020 4 RISK FACTORS – WHO ARE WE WORRIED ABOUT?

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POLL: who would be most at risk of developing of sepsis?

  • A. An 83 year old man?
  • B. A pregnant women?
  • C. A liver transplant recipient?
  • D. A patient with a Hickman line in situ?

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POLL: who would be most at risk of developing of sepsis?

All of them are at risk:

  • A. An 83 year old man
  • B. A pregnant women
  • C. A liver transplant recipient
  • D. A patient with a Hickman line in situ

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RISK FACTORS (NICE)

  • < 1 year or > 75 years or people who are very frail
  • Patients who have impaired immune systems

because of illness or drugs

  • Patients who have had surgery in the last 6 weeks
  • People with any breach of skin integrity
  • People who misuse drugs intravenously
  • Patients with indwelling lines or catheters
  • Women who are pregnant, have given birth or had a

termination of pregnancy or miscarriage in the past 6 weeks

HOW DO WE TREAT SEPSIS?

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SEPSIS 6

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ENSURE SENIOR CLINICIAN ATTENDS

  • Dependent on the institution/setting:

– ST3 or above or – a senior nurse review or – ACP

  • Experience is essential to ensure the diagnosis is

correct and treatment appropriate

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GIVE OXYGEN IF REQUIRED

  • Start if saturations less than 92%.
  • Aim for saturations of 94-98%.
  • If at risk of hypercarbia use target range of 88-92%
  • There’s a critical imbalance between oxygen supply

& demand in sepsis.

  • Correcting low saturations helps to reduce tissue

hypoxia

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OBTAIN IV ACCESS & TAKE BLOODS

  • Include

– cultures & … – blood gas: glucose & lactate, – FBC, – U&Es, – CRP, – Clotting – Consider other samples as indicated

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GIVE IV ANTIBIOTICS

  • Maximum dose broad spectrum therapy
  • Consider:

–LIKELY SOURCE –allergies –local policy –antivirals

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TIMING IS EVERYTHING

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GIVE IV FLUIDS

  • Give crystalloid fluid bolus of 500ml over 15

mins

  • Repeat if clinically indicated
  • Use lactate to help guide further fluid therapy

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MONITOR

  • Use NEWS2
  • Measure urine output- may require catheter
  • Repeat lactate at least hourly if initial lactate

elevated or clinical condition changes

WORKED EXAMPLE - ANTIBIOTICS

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BACK TO OUR PATIENT

  • 74 years old
  • Admitted via ED with 2/7 history of UTI

symptoms:

– Frequent urination – Cloudy urine – Flank pain

  • NEWS2 score = 6
  • Creatinine Clearance = 30 ml/min [Cockcroft-

Gault]

  • Admit to ICU for observation +/- intubation

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ADMIT TO ICU/HIGH DEPENDENCY

  • Unit protocol is to start piperacillin-tazobactam

in patient triggering NEWS2 score ≥5

  • Patient has no allergies
  • Doctor prescribes 4.5g TDS
  • What do you do?

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POLL: Antibiotic prescribing

  • A. Screen and sign off as prescribed – drug is

appropriate

  • B. Increase the dose to QDS
  • C. Decrease the dose to BD
  • D. Advise the nurse to administer as an

extended infusion [3 or 4 hours as per protocol]

  • E. Advise the nurse to administer as a 30 min

infusion

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POLL: Antibiotic prescribing

  • A. Increase the dose to QDS – some ITU’s will do

this for the first 24 hours but this is off license

  • B. Advise the nurse to administer as an extended

infusion [3 or 4 hours as per protocol] – check local policy if there are restrictions regarding renal function and extended infusion. Do not use for first dose.

  • C. Advise the nurse to administer as a 30 min

infusion – will depend on the unit policy

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06/08/2020 7 CONTROVERSIES IN SEPSIS

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SEPSIS CQUIN

  • The NHSE Sepsis CQUIN introduced in

2016/17 applied financial penalties to hospitals not meeting the 1 hour door-to- needle time for antibiotics administration in sepsis

  • Some hospitals introduced sepsis bundles to

manage this but has this done more harm than good?

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RFH SEPSIS BUNDLE

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SEPSIS CQUIN

  • There has been an increase in antibiotic use in ED’s

since the Sepsis CQUIN was introduced:

  • Increased risks of AMR and multiple other

antibiotic-related complications

  • An increasing climate of fear with junior doctors

being reported for not prescribing antibiotics

  • undermining of public confidence in the HC system
  • Studies suggest that only a third of sepsis-related

deaths are directly attributable to sepsis, with only 12% considered definitely or possibly preventable

  • Most deaths were related to underlying conditions,

comorbidities and frailty

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SEPSIS CQUIN

  • No clear outcome benefit has been seen despite the large

increase in ED antibiotic use

  • Many patients, even those without new onset organ

dysfunction are being hastily and often inappropriately treated for sepsis

  • The majority of chest infections presenting to EDs are viral in
  • rigin yet invariably treated with antibiotics.
  • Studies from France, the US & the Netherlands show that 20-

40% of ED patients treated for suspected sepsis are subsequently found to have a non-infectious diagnosis

  • RFH data shows only 22% of blood cultures taken result in

growth of pathogen

WHAT WOULD YOU DO?

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UKCPA PIN COMMITTEE

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USEFUL READING

  • NICE guideline [NG51] : Sepsis: recognition, diagnosis and early

management https://www.nice.org.uk/guidance/ng51

  • Sepsis trust: https://sepsistrust.org/wp-content/uploads/2020/01/5th-

Edition-manual-080120.pdf

  • The Third International Consensus Definitions for Sepsis and Septic Shock

(Sepsis-3): https://jamanetwork.com/journals/jama/fullarticle/2492881

  • Surviving sepsis campaign:

https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult- Patients

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