Aims

Early recognition Early goal directed therapy Source control

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Less than one half of the patients who have signs and symptoms of sepsis have positive blood culture results.

Fishing in the dark

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50 year old male smoker Right hemicolectomy for colon cancer Day 5 post-op Temperature 37.2°C WCC 15.2 Respiratory rate 30/min HR 110/min

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What is going on?

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Confused Oliguric BP 80/40

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Although the 1991 Consensus Conference laid the framework to define sepsis, it had important limitations.

The “2 out of 4” criteria for SIRS and the thresholds were somewhat arbitrary and not specific to sepsis alone.

The criteria did not include biochemical markers, such as CRP, procalcitonin, IL-6, all of which are elevated in sepsis.

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The criteria for sepsis were revised to include infection and the presence of any of the diagnostic criteria.

These criteria were based on an expansion of the clinical and laboratory parameters.

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There was no single parameter or set of clinical or laboratory parameters that are adequately sensitive or specific to diagnose sepsis.

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Challenge

Early recognition remains a challenge.

Tissue hypoperfusion can occur in the absence of hypotension and could be present for hours before organ dysfunction manifests.

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Spectrum of sepsis continuum

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SIRS

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Sever sepsis, SIRS plus organ dysfunction

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Sepsis is described as an autodestructive process.

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It permits extension of the normal pathophysiologic response to infection to involve otherwise normal tissues and results in MODS.

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Severe sepsis & septic shock Severe sepsis

Sepsis plus organ

dysfunction, hypotension or hypoperfusion

Septic shock Sepsis hypotension despite

adequate fluid resuscitation

plus evidence of abnormal perfusion

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What do you want to do for this patient?

What are your goals?

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Management principles

Early aggressive resuscitation Early treatment

Rapid identification of source of sepsis Early source control Early, appropriate antibiotics

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Initial history& examination

Resuscitate

Further history& examination

Microbiologicalspecimens

Antibiotics

1 h

our

Investigations

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Need to work rapidly to achieve goals: to administer antibiotics within 1

hour. In this time the patient has to be

resuscitated, diagnosis made and

microbiological specimens taken

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Resuscitate

Fluid resuscitate Fluid challenges

300-500 ml colloid 500-1000 ml crystalloid

Titrate against response (BP & tissue perfusion) and adverse effects

Ignore fluid balance in first 24h

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Resuscitate

Vasopressors Indications:

Hypotension not responsive to fluid Life threatening hypotension

Agents: Norepinephrine Dopamine

Dobutamine Tissue hypoperfusion despite adequate fluid

resuscitation and blood pressure

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CVP 10 BP 110/50, MAP 65 Urine output 50 ml/h Central venous saturation 65%

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Resuscitation Goals

Initial target: MAP 65 mmHg CVP 8-12 mmHg (12-15 if ventilated)

Rise of 3-5 mmHg after fluid challenge

Urine output 0.5 ml/kg

If central venous saturation <70% transfusion of packed cells to achieve a

haematocrit 0.3 dobutamine

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Likely sources of sepsis

Chest Intra-abdominal Urinary tract infection

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Source of sepsis

Breathless, bilateral crackles Abdomen soft Urine dipstick:

WBC 0 Protein +

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Investigations

Other radiology depending on history and examination

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Investigations

Microbiology Blood cultures

2 sets Strict asepsis 20 ml blood sample

Urine specimen Other cultures depending on clinical

features

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Treatment

Assess every patient for a source of infection that is amenable to source control measure

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Treatment

Source control Percutaneous or open drainage Excision Debridement Removal of potentially infected devices

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Treatment

Antibiotics Early Initially cover all likely organisms

Local flora and sensitivity patterns After appropriate microbiological

specimens have been taken

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Likely organisms

Source Environment

Community Healthcare facility Intensive Care Local factors

Patient factors Co-existing illness Previous antibiotics Immunosuppression

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Antibiotics

Healthcare associated peritonitis More resistant flora Similar organisms to those seen in other

nosocomial infections

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Antibiotics

Re-assess Clinical response Microbiological results

Aim to use narrower spectrum

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Antibiotics

Penetration Aminoglycosides and glycopeptides have

relatively poor tissue penetration Most agents have poor CNS penetration

unless meninges inflammed Adverse effects

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Antibiotics

Dual therapy Pseudomonas aeruginosa

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Activated protein C

Withdrawn

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Other Support Modalities

Steroids Glucose control Early RRT in those AKI

Other Support Modalities

Early feeding enteral feeding lowers risk of infection

and improves survival compared with delayed feeding in the critically ill.

Other studies demonstrate the superiority of enteral over parenteral feeding in critically ill patients, with respect to costs and complications, including risk of infection

Summary

Early recognition Early resuscitation Early identification of source Early appropriate antibiotics Early source control

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