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 www.rxmagazine.org 1 2 POLL: What is sepsis? POLL: What is sepsis? A. A bad infection in the blood A life-threatening condition when an infection causes the body to injure it’s own tissues and B. A life-threatening condition when an organs infection causes the body to injure it’s own tissues and organs C. An infection that is resistant to standard antibiotics www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 3 4 WHAT IS SEPSIS? • Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs 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 www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 5 6 1
06/08/2020 POLL: How do we recognise Sepsis? 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 HOW DO WE RECOGNISE SEPSIS? E. Urine output > 1 ml/kg/min www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 7 8 SCORING SYSTEMS POLL: How do we recognise Sepsis? 2 OR MORE = SEPSIS Which of these is NOT a sign of sepsis? qSOFA score (Sepsis-3) Modified SIRS Criteria (SSC) • Respiratory rate – Temperature >38.3 or Urine output > 1 ml/kg/min <36.0 o C ≥ 22/min – New confusion or • Altered mentation: drowsiness GCS <15 – Pulse >90/min • Systolic BP – RR >20/min 100 mmHg – WBC >12 or <4.0 x 10 9 /L – Blood glucose >7.7 mmol/L (not if diabetic) www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 9 10 SCORING SYSTEMS TRACK AND TRIGGER SYSTEMS NICE; 1 or more = At risk of sepsis • or NEWS2 • Endorsed by RCP Sepsis Trust; 1 or more = red flag sepsis • Rolled out nationally – Behaviour: objective evidence – SBP: < 90 mmHg OR > of new altered mental state via CQUIN 2018 40 mmHg below normal – Pulse: >130 bpm – Not passed urine in previous 18 • Sepsis screen when – RR ≥ 25 breaths per minute OR hours, or for catheterised score of 5 is reached new need for 40% oxygen or patients passed <0.5 ml/kg of • When score of 7 more to maintain saturation urine per hour more than 92% (or more than – Mottled/ashen appearance reached; medical 88% in COPD) – Cyanosis of skin/lips/tongue emergency – Non-blanching rash www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 11 12 2
06/08/2020 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 www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 13 14 • • RR = 19 RR = 19 • What is the NEWS2 • What is the NEWS2 score? Oxygen saturations = 94% on 2 L Oxygen saturations = 94% on 2 L • • SBP = 118 SBP = 118 score? • • Pulse = 111 Pulse = 111 6 • • GCS = 15 GCS = 15 • • Temp = 38.2 Temp = 38.2 www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 15 16 WHAT IS SEPTIC SHOCK? (Sepsis-3) • 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 WHAT IS SEPTIC SHOCK? >2 mmol/L (18 mg/dL) despite adequate volume resuscitation. • With these criteria, hospital mortality is in excess of 40% www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 17 18 3
06/08/2020 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? RISK FACTORS – WHO ARE WE WORRIED ABOUT? www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 19 20 POLL: who would be most at risk of RISK FACTORS (NICE) developing of sepsis? • < 1 year or > 75 years or people who are very frail • Patients who have impaired immune systems All of them are at risk: because of illness or drugs A. An 83 year old man • Patients who have had surgery in the last 6 weeks B. A pregnant women • People with any breach of skin integrity C. A liver transplant recipient • People who misuse drugs intravenously D. A patient with a Hickman line in situ • 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 www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 21 22 HOW DO WE TREAT SEPSIS? SEPSIS 6 www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 23 24 4
06/08/2020 GIVE OXYGEN IF REQUIRED ENSURE SENIOR CLINICIAN ATTENDS • • Dependent on the institution/setting: Start if saturations less than 92%. – ST3 or above or • Aim for saturations of 94-98%. – a senior nurse review or • If at risk of hypercarbia use target range of 88-92% – ACP • There’s a critical imbalance between oxygen supply & demand in sepsis. • Experience is essential to ensure the diagnosis is • correct and treatment appropriate Correcting low saturations helps to reduce tissue hypoxia www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 25 26 GIVE IV ANTIBIOTICS OBTAIN IV ACCESS & TAKE BLOODS • Include • Maximum dose broad spectrum therapy – cultures & … • Consider: – blood gas: glucose & lactate, – LIKELY SOURCE – FBC, – allergies – U&Es, – local policy – CRP, – antivirals – Clotting – Consider other samples as indicated www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 27 28 GIVE IV FLUIDS TIMING IS EVERYTHING • Give crystalloid fluid bolus of 500ml over 15 mins • Repeat if clinically indicated • Use lactate to help guide further fluid therapy www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 29 30 5
06/08/2020 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 www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 31 32 BACK TO OUR PATIENT ADMIT TO ICU/HIGH DEPENDENCY • 74 years old • Unit protocol is to start piperacillin-tazobactam • Admitted via ED with 2/7 history of UTI in patient triggering NEWS2 score ≥5 symptoms: • Patient has no allergies – Frequent urination – Cloudy urine • Doctor prescribes 4.5g TDS – Flank pain • What do you do? • NEWS2 score = 6 • Creatinine Clearance = 30 ml/min [Cockcroft- Gault] • Admit to ICU for observation +/- intubation www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 33 34 POLL: Antibiotic prescribing POLL: Antibiotic prescribing A. Screen and sign off as prescribed – drug is A. Increase the dose to QDS – some ITU’s will do appropriate this for the first 24 hours but this is off license B. Increase the dose to QDS B. Advise the nurse to administer as an extended C. Decrease the dose to BD infusion [3 or 4 hours as per protocol] – check local policy if there are restrictions regarding D. Advise the nurse to administer as an renal function and extended infusion. Do not extended infusion [3 or 4 hours as per use for first dose. protocol] C. Advise the nurse to administer as a 30 min E. Advise the nurse to administer as a 30 min infusion – will depend on the unit policy infusion www.ukclinicalpharmacy.org www.rxmagazine.org www.ukclinicalpharmacy.org www.rxmagazine.org 35 36 6
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