SEPTIC SHOCKSEPTIC SHOCK

CVS Monitoring and ShockCVS Monitoring and Shock

Case 3

A young woman arrives in the medical admissions unit with diarrhoea, which she has had for several days.

She is drowsy and has mottled skin; She also has a high fever 38.9 C She has a systolic BP - 70 mmHg, pulse 130 b/min. Her blood tests show WBC – 3.45, an elevated urea and

creatinine with low platelets.

Q1: could she have a life-threatening condition?Q1: could she have a life-threatening condition?

Q2: what immediate steps would you take?Q2: what immediate steps would you take?

Q3: how would you decide which way to proceed?Q3: how would you decide which way to proceed?

Initiation of Antibiotic Therapy in Severe Sepsis

•

Management of shockManagement of shock

• A-B-C: OXYGEN THERAPY • VENTILATORY SUPPORT• HAEMODYNAMIC SUPPORT

• MONITOR AND CLOSE OBSERVATION:- BP, HR, SpO2, resp. rate every ½-1 hr depending on situation- Fluid balance - input/output hourly- Temperature, GCS/Neuro score when indicated - Consider invasive monitoring early in A&E

• TIME-SENSITIVE CARE: • Correct the underlying cause: Correct the underlying cause:

• surgical intervention to stop haemorrhage,surgical intervention to stop haemorrhage,• treat infection and sepsistreat infection and sepsis• identify fluid losses, identify fluid losses, • treat ileus or diarrhoeatreat ileus or diarrhoea

Case 3 Picture of young person with severe infection.

A search for the focus of infection should take place but this should not take priority over A, B, C, and "blind" antibiotic therapy ASAP.

A-B-C approach: After you have initiated high concentration oxygen therapy, two large bore cannulae should be inserted and fluid challenges given.

Q1: How would you define severity of Infection/Sepsis?

Q2: What is your fluid management plan?

Clinical Progression

In 2007 in context of Sepsis itself the new term was adopted instead of SIRS - Signs and symptoms of infection (SSI)

MOF: multi-organ failure

Infection Infection SSISSI Sepsis Severe Sepsis MOF Death Sepsis Severe Sepsis MOF Death (SIRS)

Systemic inflammatory response syndrome,Systemic inflammatory response syndrome, Sepsis and IfectionSepsis and Ifection

Signs and symptoms of infection (SSI), 2007

Must have 2 or more of the following:• Tachycardia > 90 bpm• Core temperature > 38.3°C < 36°C• Tachypnoea > 20 bpm • WCC >12,000 or <4,000 or >10% immature

neutrophils • Hyperglycaemia in the absence of Diabetis

Mellitus

Clinical Progression – Sepsis

Sepsis : 1) - two or more of SSI, plus2) - documented or suspected infection (presence of commonly recognised signs of

infection without an identifiable pathogen being isolated)

Infection SSI Infection SSI SepsisSepsis Severe Sepsis MOF Death Severe Sepsis MOF Death

Pathogens involved in sepsisAn overview

• Only 60% of severe sepsis/septic shock cases are associated with confirmed infection

• The most common infection sites are: the lung, abdomen or urinary tract.

Gram negative

Gram positive

Fungal infection

Mixed bacterial

Other mixed

Unconfirmed

22%

19%13%

40%

3% 3%

Patient history suggestive of an existing infection may include :

Pneumonia, Empyema, Urinary tract infection,

Acute abdominal infection, Meningitis,

Skin/soft tissue inflammation, Born/joint infection,

Catheter or device infection,

Endocarditis,Wound infection,

What is VitalPAC?

Modified Early Warning Score (MEWS) –useful tool in recognition of patients with presumed infection

Score 3 2 1 0 1 2 3

BP SYS < 80 80-89 90-109 110-160 161-180 181-200 >200

PULSE < 40 - 40-50 51-100 101-110 111-129 >130

RESP. < 8 - - 8-20 21-25 26-30 >30

TEMP. - <35 - 35.1-37.9 38.0-38.4 >38.5 -

AVPU Alert Voice Pain Unrespon

sive

-----------------------------------------------------------------------------Think infection if Score 3 in one category or total Score 4

New

Weakness New

Confusion

Clinical Progression – Severe Sepsis

• Circulatory failure• Respiratory failure• Haematological failure• Renal failure• Hepatic failure• “Brain failure” …

Infection SSI Sepsis Infection SSI Sepsis Severe SepsisSevere Sepsis MOF Death MOF Death

Severe sepsis:Severe sepsis: sepsis + one organ dysfunction sepsis + one organ dysfunction

Severe sepsis – examples of organ dysfunction

Systolic BP < 90mmHg or MAP < 65 mmHg (or a reduction in SBP 40 mmHg from baseline)

O2 saturation (SpO2)<90% on air or on Oxygen,PaO2:FiO2 < 40 kPaPlatelets< 100.103 or INR > 1.5 or APTT > 60sBilirubin > 34 µmol/LUrine output < 0.5 ml/kg/hr for > 2 hrs Creatinine > 176 µmol/LAcute alteretion in mental status

Clinical Progression – Septic Shock

Septic shock: Acute circulatory failure that is refractory to adequate volume resuscitation and unexplained by other causes

Circulatory failure is defined as persistent arterial hypotension (SBP < 90 mmHg, MAP< 65, or a reduction in SBP 40 mmHg from baseline) despite adequate volume resuscitation.

Infection SSI Sepsis Severe Sepsis MOF DeathInfection SSI Sepsis Severe Sepsis MOF Death

Septic Shock

Septic ShockInitially is suggested by evidence of end organ hypoperfusion:

• Hemodynamic instability• mottled skin, • decreased urine output,• altered level of consciousness,• Lactic and metabolic acidosis…

Later - circulatory failure leading to multi-organ failure:• Slightly increased and than decreased Cardiac Output• Significantly reduced SVR, Leaking capilaries• Coagulopathy with throbmocytopenia.• ARDS, ARF, Liver failure, Hypoglycaemia,

Although most patients in shock will be hypotensive, some patients will have preserved systolic pressure early in shock as a result of excessive catecholamine release.

Goal directed therapy in Sepsis

Surviving Sepsis Campaign Guidelines 2004 – 2007

Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients

GIFTASUP 2008

Trail results• 263 p-ts presented to A & E with Sepsis (Rivers et al.,)

• Randomised, two groups:I - Early Goal Directed Therapy Group (EGDT)II - Control Group (similar, excluding Scv O2 data);

• Initial Resuscitation was performed in A&E over the first 6 hour period then transferred to in-patient bed or ICU;

• Evaluated for a further 72 hours.

Rivers et al., New Eng J Med 2001, 345

EGDT Group - What are the goals and why? To ensure the Presumptive Diagnosis is made

within 2 hours of admission; Fluid resuscitation 20-40 mls/kg within the recommended

target of 6 hours from presentation Cultures drawn before antibiotics given Antibiotics within 3 hours of a presumptive diagnosis of a

severe sepsis or 1 hour if patient already in hospital Early CVP monitoring and Central venous O2 Saturation

measurement (Scv O2) Vasopressors given much earlier after initial fluid

resuscitation based on end points review

What are the end points and why? Aims to restore impaired perfusion and Oxygen delivery

(D-O2) and prevent from vital organ failure ASAP:

Indicators for adequate perfusion:

CVP 8-12 mmHg MAP > 65 mmHg UO > 0.5 ml/kg/hr

Indicators for D-O2 insufficiency: Scv O2 < 70 % Lactate > 2.0 mmol/L

Regular reassessment and continuous appropriate monitoring

Trail results

• EGDT group Received significantly more iv fluids ( + 3L ), blood and inotropic support at the end of 6 hrs period;

• After 6 hrs EGDT group had:- Higher BP- Higher Scv O2- Lower Base Deficit (BE)

• By the end of 72 hrs both group had received the same volume of fluid and amount of inotropic support;

• In-hospital mortality 30 vs 46 %• 60 day mortality 50 vs 70 %

Surviving Sepsis Campaign

6 hour bundle(resuscitation bundles)

24 hour bundle(management bundles)

6 Hour Septic Shock Bundle Immediate fluid resuscitation using crystalloids or colloids Obtain blood cultures and Lactate ASAP after diagnosis of sepsis Antibiotics administered within 1 hour of presumptive diagnosis Obtain CVP if BP is not responsive to fluids or if serum lactate is

elevated Repeated boluses of crystalloid/colloid 250-500 ml every 30 min

until CVP 8-12 mmHg Vasopressors via central line if MAP < 65 mm Hg during and after

adequate fluid resuscitation - Noradrenaline (4 mg in 50 ml of 5% Dextrose - start at 0.05 mcg/kg/min) or Dopamine

If Scv O2 < 70 % after fluid replacement and Noradrenaline - start Inotropes (Dobutamine at 2.5 mcg/kg/min or Adrenaline infusion via central line) and/or give RBC’s (to keep Ht above 30)

GIFTASUP 2008GIFTASUP 2008

Table: Contents of common crystalloids in mmol/LTable: Contents of common crystalloids in mmol/L

NaNa K K Ca Ca Cl HCO3 Osmolality pH Cl HCO3 Osmolality pH

PlasmaPlasma 140140 4.34.3 2.32.3 100100 26 285-300 7.426 285-300 7.4

Na Cl 0.9%Na Cl 0.9% 154 154 0 0 0 0 154154 0 0 308 308 5.05.0

Dextrose 5%Dextrose 5% 0 0 0 0 0 0 0 0 0 0 278 278 4.0 4.0

Dextrose Saline Dextrose Saline (4%/0.18%)(4%/0.18%) 3030 0 0 0 0 30 30 00 283 283 4.0 4.0

Hartmann’s solutionHartmann’s solution 131 131 5.05.0 2.02.0 111111 0 0 275 6.5 275 6.5

Lactate 29 Lactate 29

Lactated Ringer’sLactated Ringer’s sol’nsol’n 130 130 4.04.0 2.22.2 109109 0 0 273 6.9 273 6.9

Lactate 28Lactate 28

Na Bicarbonate 1.2%Na Bicarbonate 1.2% 150 150 0 0 0 0 0 0 150 150 300 300 8.0 8.0

Na Bicarbonate 8.4%Na Bicarbonate 8.4% 10001000 0 0 0 0 0 0 10001000 20002000 8.0 8.0

Fluid requirements in illnessFluid requirements in illness

The volume of fluid (water) within a The volume of fluid (water) within a compartment is determined by its membrane compartment is determined by its membrane

properties and solute concentrationsproperties and solute concentrations

Intracellular fluids

K + 100, Na + 10As a result of amembrane-bound

ATP-dependent pump ex changes Na for K+

potassium is the most important de terminant of

intracellular osmotic pressure

ICF – 60% of TBW

TBW = 60% of body weight in male, 50-55% in female

ECF – 40% of TBW

80%

Interstitial

fluids

Na + 140

K + 4

Cl – 105

HCO3 - 28

20%

Intra

vascu

lar P

las

ma

pro

tein

s (a

lbu

min

)

Cell m

emb

rane

Va

scu

lar en

do

the

lium

!<------------------------------------------------------------------------------------------------------------------------ 5% Dextrose/Dextrose Saline!<------------------------------------------------ 0.9% Na Cl / Ringer’s Lactate

!<------------------- Colloids

GIFTASUP recommendationsGIFTASUP recommendations

Number RecommendationEvidence

level

1 Don’t use ‘Normal Saline’ 1b

2 Don’t use Dextrose/D. Saline 1b

3 For maintenance, use low Na+, high K+ 5

8

‘Normal saline’ for hypochloraemiaReplace stomach losses with potassium in a crystalloidReplace bowel losses with balanced crystalloid

2,5,5

9 Use ‘Goal-directed therapy’ 1b

10Use invasive monitoring, preferably ‘Flow-based’If unavailable, clinical and laboratory measurements

1b

11Treat blood loss with blood; treat hypovolaemia with crystalloid or colloid

1b

12 If diagnosis of hypovolaemia in doubt, fluid challenge 1b

Fluid requirements in illnessFluid requirements in illnessCrystalloids:Crystalloids:

Pro:Pro: cheap, convenient to use, free of side effectscheap, convenient to use, free of side effects

Con: Con: volume expansion transient (half-life 20-30 min) volume expansion transient (half-life 20-30 min) fluid accumulates in interstitial spacefluid accumulates in interstitial space

pulmonary oedema may resultpulmonary oedema may result ((initial resuscitation: 20 ml/kg bolus over 30 mininitial resuscitation: 20 ml/kg bolus over 30 min))

Colloids:Colloids: (starch - Volulyte, gelatin - Isoplex) (starch - Volulyte, gelatin - Isoplex)

Pro:Pro: greater increase in plasma volumegreater increase in plasma volume

more sustained (half-life 3-6 hrs) more sustained (half-life 3-6 hrs)

Con:Con: costcost

allergic reactionsallergic reactions

clotting abnormalities clotting abnormalities ((initial resuscitation: 0.2-0.3g/kg bolus over 30 mininitial resuscitation: 0.2-0.3g/kg bolus over 30 min))

Fluid requirements in illnessFluid requirements in illnessBlood Blood andand blood products: blood products:

Pro:Pro: clearly indicated in haemorrhagic shockclearly indicated in haemorrhagic shock

maintain Hb concentration at an acceptable level*maintain Hb concentration at an acceptable level*

Con:Con: costcost

rare infection risk (small, but significant rare infection risk (small, but significant consequences)consequences)

(keep Hb>7g/dl unless patient has ischaemic heart disease, then 10g/dl)(keep Hb>7g/dl unless patient has ischaemic heart disease, then 10g/dl)

AlbuminAlbumin Pro:Pro: similar to colloid in terms of long half-lifesimilar to colloid in terms of long half-life

possibly some benefit from transport function of possibly some benefit from transport function of albuminalbumin

Con:Con: costcost

((should be used only in special circumstances - for example: burns, cirrhotic liver should be used only in special circumstances - for example: burns, cirrhotic liver disease and children with septic shock)disease and children with septic shock)

Fluid Therapy - General principlesFluid Therapy - General principles

• The appropriate rate of fluid administration should be guided by clinical reassessment and sensible limits

• Where a fluid deficit is present (e.g. haemorrhage, diarrhoea, vomiting, insensible or renal losses), the nature (content) of this deficit should be identified

• Choose the type of fluid which will best treat the existing deficit and/or maintain euvolaemia

• Use “Goal Directed Therapy” - implementation of the proposed clinical endpoints and monitoring of fluid status

Case 3A young woman arrives in the medical admissions unit with

diarrhoea, which she has had for several days. She is drowsy and has mottled skin; She also has a high fever 38.9 C She has a systolic BP - 70 mmHg, pulse 130 b/min. Her blood tests show WBC – 3.45, an elevated urea and

creatinine with low platelets.

The picture is of a young person with severe sepsis/septic shock.

Q: What is your management plan?

Case 3This patient has severe sepsis/septic Shock according to

definitions of SSC.

Immediate management in this case includes A-B-C-D…

• A - assessment of the airway, giving a high concentration O2 (for example, 15 L/min via a reservoir bag mask),

• B - examining the chest and respiratory rate,• C - assessment of the circulation (pulse, blood pressure, skin

temperature, etc.) and attempt IV cannulation ABG and Blood Culture should be taken before Antibiotics given

• D – GCS (she is alert) Temperature, etc.

Case 3

There is a history of diarrhoea for several days, which implies severe volume depletion – stat fluid boluses up to 20 ml/kg may require;

Choose the type of fluid which will best treat the existing deficit and/or maintain euvolaemia – Hartmann’s solution (not 0.9% NaCl) +/- Potassium supplements

But in the context of severe sepsis, an abnormally low systemic vascular resistance means that the hypotension may not respond to fluid alone, single shots of vasopressors - metaraminol or ephedrine

An invasive monitoring and vasopressor infusion may be required early.

Summary Immediate tests and management in acutely ill patients

with severe sepsis always consists of:• Arterial blood gases and a bedside glucose measurement.

• When intravenous access is obtained - haematology, and biochemistry can be taken at the same time as well as blood cultures, before antibiotics given (ASAP), in many cases the urine should be cultured as well.

• Successive fluid challenges are required to restore organ perfusion and the attending doctor should stay with the patient and reassess her until satisfied…,

• If this fails, invasive monitoring is indicated and the patient should be referred to ITU for treatment with vasoactive drugs.