Recognition & Management

of Sepsis

Objectives
What is Sepsis?

Why worry about Sepsis?

Pitfalls

The ACI/CEC Sepsis Project

How to recognise Sepsis

How to treat Sepsis

How to get help

WHAT IS SEPSIS?
Definitions
Pathophysiology

Definitions
Sepsis is the presence of infection that induces
a systemic response
Expect the patient to have signs and
symptoms of a systemic response
May not always have symptoms and signs at
the site of infection

Definitions
SIRS criteria: 2 of the following + suspected or
confirmed infection = Sepsis
Temp < 36C or > 38C
WCC < 4 or > 12

RR > 24
HR > 90

Severe Sepsis: Sepsis plus organ dysfunction

Septic Shock: Sepsis with BP <90mmHg for 1
hour despite adequate fluid resuscitation or
the need for inotropes to maintain BP
>90mmHg

Excuse me SIRS!
The problems with SIRS criteria
Derived from retrospective data
Aim was to standardise definitions NOT aid early
recognition
Only HR, RR, temperature will be available initially
A large study found temperature is normal in 17% of
patients with sepsis1
HR often affected by -blockers
Not diagnostic or prognostic
1.Brun-Buisson C, Doyon F, Carlet J et al Incidence, Risk Factors and Outcome of Severe Sepsis and Septic Shock in
Adults: A Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995; 968-974

Pathophysiology
Pathogenic features of the microorganism
Patients 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

Pathophysiology
Distributive shock
Myocardial depression
Bone marrow suppression

Activation of clotting cascade DIC

Organ dysfunction

MODS
Death

Common sources of sepsis

Respiratory

35%

Urinary tract

35%

Intra Abdominal

10%

Unknown

10%

Meningitis/septic arthritis/
skin/vascular access devices

10%

COST

WHY WORRY ABOUT SEPSIS?

MORTALITY
TIME CRITICAL

Why worry about sepsis?

Increasing incidence
1997 to 2005 severe sepsis/septic shock increased from 7.7%
of ICU admissions to 14.0 % in Australia (4 fold increase in
total patients)1
More common in the elderly incidence increases as the
population ages

Cost
The cost of care is huge (US$16.7 billion in 2001)2

1. Peake S, for the ARISE Investigators: The outcome of sepsis and septic shock presenting to the Emergency
Department in Australia and New Zealand. Critical Care 2007, 11(Suppl 2):P73
2. Angus DC et al: Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated
costs of care. Crit Care Med 29:1303, 2001

US National Centre Health Statistics June 2011

Which patient has the highest mortality?

1. 59yr old male - large inferior STEMI
2. 27yr old male - multi trauma ISS
3. 65yr old female - bleeding gastric ulcer and BP 90/60
4. 74yr female P 65 BP 105/60 RR 24 Temp 35 C mildly
confused**
5. 32yr female DKA pH 6.90 BSL 45 HCO3 9

Mortality
1. Inferior AMI

5%

2. Trauma ISS 16-24

7%

3. GIH + low BP

11%

4. Septic Shock

25%

5. Severe DKA

<1%

1) Armstrong PW et al., JAMA, 2007;297:4351. 2) Clemet N, SJTREM 28:18 2010 3) Rockall TA BMJ. 311(6999):2226, 1995 July 22 4) Mitchell M et al Crit Care Med 2010 Vol. 38, No. 2 5) Hamdy O, Sep 2009

Mortality
25% mortality for severe sepsis and septic shock in
Australia and NZ1
Studies suggest that mortality may be decreasing
with time but is still unacceptably high
215 000 deaths annually in the USA
Delayed recognition and delayed appropriate initial
treatment increase mortality

1. Peake S, for the ARISE Investigators: The outcome of sepsis and septic shock presenting to
the Emergency Department in Australia and New Zealand. Critical Care 2007, 11(Suppl 2):P73

US National Centre Health Statistics June 2011

Mortality vs. Time to Antibiotics

Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
Kumar A; Roberts D; Wood KE; Light B; Parrillo JE; Sharma S; Suppes R; Feinstein D; Zanotti S; Taiberg L; Gurka D; Kumar A; Cheang M
Critical Care Medicine. 34(6):1589-96, 2006 Jun.

Hypotension, Lactate & Mortality

Howell et al: Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care Med 2007

Pit falls
Fail to recognise sepsis
Under-appreciate the mortality

Do not see sepsis as a time critical illness

Later tonight..
After a few drinks
Fall down 10 stairs at a hotel

Friends find you semi-conscious at the bottom

of the stairs
What next?

Trauma Call
Two Intensive Care paramedics for transfer
Trauma Call Team response at major facility

Staff Specialist, 2-3 registrars, 3 senior nursing staff

and various others
Seen immediately in a resuscitation bay
Within one hour your emergency care will be
complete cast for your broken wrist!

At the same time.

72 year old lady
Epigastric pain and nausea
Pulse 60

Blood pressure 115/65

Temp 37.2 C

Respiratory rate 25/minute, SpO2 99% on RA

Alert and Orientated

.....a very different experience

Seen 2 hours post arrival by an intern
Seen 5 hours post arrival by a junior surgical registrar
Cared for by an RN-Year 2 in a non acute bed

Provisional diagnosis of bilary colic

Stay NBM for an ultrasound in the morning

The next morning

An experienced nurse asks MO to review the patient

Steadily increasing RR overnight (now 36)
Confused and slightly agitated
Pulse 65, BP 105/60, SpO2 98% RA
ABG pH 7.20 Lactate 5
IDC no urine out
Hypertension on numerous medications including a
blocker

Fail to see Sepsis as time critical

TRAUMA

Golden Hour

AMI

Time is muscle

STROKE

Time is Brain

SEPSIS KILLS

TIME IS LIFE

The Sepsis Project

In 2009 the Clinical Excellence Commission published a
Clinical Focus Report after a review of IIMS NSW data showed
167 incidents in 18 months
Incident reports detailed delays in diagnosis or inadequate
treatment of sepsis
In response the Sepsis project has been established as a joint
initiative between the Agency for Clinical Innovation, Clinical
Excellence Commission and the Emergency Care Institute

Sepsis Project Goals

Reduce preventable harm to patients with sepsis:
Recognise
Flagging of sepsis risk factors, signs and symptoms at Triage
Early involvement of senior clinicians in diagnosis and
management

Resuscitate
Appropriate fluid resuscitation
Prompt administration of antibiotics - first intravenous
antibiotic administered within one hour of recognition

Refer
To the appropriate in-hospital clinical teams or retrieval

Sepsis adverse event/RCA in this hospital

ACI/CEC Sepsis Project

Phase 1 - Emergency Departments
Phase 2 - Extend project to improve processes
for recognition and management of
sepsis on wards

Sepsis pathway
Developed with wide clinical consultation
Key message that SEPSIS KILLS
3 Rs of sepsis linked to project goals

Recognise Resuscitate Refer

Sepsis Pilot Study time to first intravenous

antibiotic administration

Project resources
Sepsis Toolkit available on the ACI/CEC website including
sepsis pathway, Adult First Dose Empirical IV antibiotic
guideline, implementation guide and planning tool, data
collection guidelines, education resources

ACI/CEC Sepsis Project team telephone support

Monthly teleconferences
Site visits on request
www.cec.health.nsw.gov.au/programs/sepsis

HOW TO RECOGNISE SEPSIS

The key to success

Recognition - the hardest part

Challenging diagnosis to make
Wide range of presentations - non specific signs
Results from the variation in host responses and
the diversity in behaviour of micro-organisms
Signs can be subtle especially in some groups
- elderly
- immunocompromised
- chronically ill
If any doubt - ask for senior medical review
- measure serum lactate

Which signs and symptoms are most

common in patients with severe sepsis?
tachypnea

99%

tachycardia

97%

fever > 38C

70%

hypothermia < 36C

13%

metabolic acidosis

38%

acute oliguria

54%

acute encephalopathy

35%.

Brun-Buisson C, Doyon F, Carlet J et al Incidence, Risk Factors and Outcome of Severe Sepsis and Septic
Shock in Adults: A Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995

SEPSIS PATHWAY
Does your patient have risk factors, signs or symptoms of infection?
Immunocompromised

Skin: cellulitis, wound

Indwelling medical device

Urine: dysuria, frequency, odour

Recent surgery/invasive procedure

Abdomen: pain, peritonism

History of fever or rigors

Chest: cough, shortness of breath

Red Flags in ambulance handover

Neuro: decreased mental alertness,

neck stiffness, headache

AND

RECOGNISE

Does your patient have 2 or more yellow criteria?

Respirations 10 or 25 per minute

Sp02 < 95%

Systolic blood pressure 100 mmHg

Pulse 50 OR 120 per minute

Altered LOC or change in cognitive status

Temp 35.5 or 38.5OC

Re-assess
Treat and re-assess
simultaneously:

NO

Sepsis may still

be a concern

YES

Perform venous blood gas if available

Does your patient have any red criteria?

SBP 90mmHg

Lactate 4 mmol/L

Age > 65 years

Immunocompromised

Base Excess < - 5.0

Respond and Escalate

Does your patient have any red criteria?
SBP 90mmHg

Lactate 4 mmol/L

Age > 65 years

Immunocompromised

YES

NO

YES

NO

Respond and Escalate

This patient may have SEPSIS:

Inform the doctor-in-charge

Monitor vital signs & fluid balance

Obtain blood cultures x 2 sets

Investigate source of infection: e.g.
urinalysis, urine M/C/S, chest x-ray

Obtain IV access and start IV fluids

Administer empiric antibiotics within

one hour unless another diagnosis is
more likely Refer to Therapeutic Guidelines:
Antibiotic, version 14
http://proxy9.use.hcn.com.au/

Refer / communicate with admitting team

Base Excess < - 5.0

This patient has SEVERE SEPSIS

or SEPTIC SHOCK until proven
otherwise:

Inform the doctor-in-charge

Expedite transfer to a resuscitation

area or equivalent

Turn over page for Resuscitation

Guideline

CONSIDER ELIGIBILITY for ARISE

Treatment
Simple, early treatment saves lives

ANTIBIOTICS WITHIN 1 HOUR

IMMEDIATE and appropriate FLUID RESUSCITATION
Do you know the average time it takes to
commence antibiotic treatment in your ED?

Antibiotics
Make giving antibiotics a clinical priority same as
an ECG on someone with chest pain or giving thrombolysis to an AMI

Give antibiotics within one hour

Take 2 sets of blood cultures first
Do not delay awaiting other investigations
Antibiotic cover for suspected cause
If cause unknown, cover with broad spectrum
antibiotics
Refer to Therapeutic Guidelines or
the ACI/CEC Sepsis Adult 1st Dose Empirical IV Antibiotic
Guideline

Antibiotic Guideline
ACI/CEC guideline for the prescription and
administration of the FIRST DOSE of IV antibiotics
Based on the Therapeutic Guidelines: Antibiotic
version 14, 2010
Easy to use resource that incorporates the best
available evidence and the principles of appropriate
use of antibiotics

Antibiotics special situations

Febrile Neutopenia
piperacillin/Tazobactam or cefipime plus gentamicin

Suspected MRSA
Add vancomycin

Line Sepsis
vancomycin + gentamicin

Toxic Shock
lincomycin or clindamycin

Fluid resuscitation
Give 20 mL/kg of 0.9% sodium chloride as a bolus
Repeat if no response

Can continue to give fluid boluses if no signs of

pulmonary oedema
However, if the patient remains in shock after the 2nd
bolus seriously consider starting a vasopressor
Aim MAP > 65 mmHg

Monitoring and Re-assessment

Ongoing frequent clinical review.
ECG, BP, SpO2 monitoring
Aim for MAP > 65mmHg
Measure urine output: aim > 0.5mL/kg/hr

MONITOR LACTATE - Each 10% decrease in lactate

correlates with an 11% decrease in mortality1

1. Shapiro NI. Ann Emerg Med 2005;45:524-528

Refer
Referral to a surgeon to drain any pus
Seek advice from Infectious Diseases
Consult admitting team
HDU/ICU seek advice early

Do you need the patient retrieved?

You can never call too early for help

Improving sepsis care

Think Sepsis - use the sepsis pathway, be vigilant
Identify local medical and nursing champions to lead
the change in the process of care

Provide education for nursing and medical staff

Audit time to IV antibiotics and IV fluids to monitor
improvement
Facilitate a culture where staff are encouraged to
alert senior staff if they suspect sepsis

Objectives achieved
What is Sepsis?

Why worry about Sepsis?

Pitfalls

The ACI/CEC Sepsis Project

How to recognise Sepsis

How to treat Sepsis

How to get help

Key messages

SEPSIS KILLS
TIME IS LIFE

Recognise Resuscitate Refer

Dr Chris Jenkins
Staff Specialist Emergency Physician
John Hunter Hospital
ACI/CEC Sepsis Management Group member/lead author
Christopher.Jenkins@hnehealth.nsw.gov.au
Mary Fullick
Sepsis Project Manager
Clinical Excellence Commission
Tel: (02) 9269 5542
Mary.Fullick@cec.health.nsw.gov.au
Dr Tony Burrell
Director Patient Safety
Clinical Excellence Commission
Tel: (02) 9269 5550
Tony.Burrell@cec.health.nsw.gov.au