SEPSIS Recognition,

Treatment and Referral

Dr. Vida Hamilton
National Clinical Lead Sepsis
Surviving sepsis campaign

 First Published : 2004, update version 2008, 2012, most recent 2016

 Convened by SCCM and ESICM

 2016 : Sepsis is redefined by the task force as a life threatening organ

dysfunction caused by a dysregulated host response to infection.
 Novel scoring system to rapidly screen for patient outside the ICU who at risk
developing sepsis ; the quickSOFA (qSOFA)
 ‘Hyperinflammatory response’
Sepsis – 1

 Control inflammation – improve outcome

 Multiple studies
 Steroids
 Anti- TNF
 Anti-IL1
 Anti-IL6
 Other monoclonal antibodies
 At best – no improvement
 Often – increased mortality
 Actors

 Micro-organism
 Virulence
 Innoculation dose
 Multi-drug resistance

 Host
 Genetic polymorphisms
 Co-morbidities
 Age

 Chronic health status

 Immuno-modulatory medications
More pathophysiology

 Hotchkiss 2013
 Sepsis - 2

 A dysregulated immune response to infection

 Regulated
 Innate & Adaptive
 Cellular: Dendritic cells, T-cells, B-cells
 PAMPs that bind TLR 2,3,4, Mannin-binding lecithin receptors
 (DAMPs)
 Molecular: complement, acute phase, cytokines
 Anti-viral: Interfon, local cellular immunity, apoptosis
 Regulated?

 Local inflammation
 Vasodilation, capillary leak

 Systemic inflammation
 SIRS, CARS
 Sepsis-3: A life threatening organ dysfunction
caused by a dysregulated host response to
infection
 SOFA score
 Respiration: PaO2/FiO2 or SaO2/FiO2
 Coagulation: Platelets
 Liver: Bilirubin
 Cardiovascular: Hypotension or vasopressor
 CNS: GCS
 Renal: Creatinine or urinary output
 qSOFA
 RR> 22, Altered Mental status, SBP <100
1o outcome: increased specificity in predicting
Mortality > 10%; ICU LOS > 3 days
 Dysregulated?

 Multi-organ dysfunction then failure

 Little necrosis
 Apoptosis of the cellular immune system
 Anti-inflammatory phase ‘ immunoparalysis’
 D4 persistent lymphopenia
 ‘Stimulate immune system improve outcome’
 National Sepsis Guidelines

 Aim for decrease in in-hospital mortality by

20% for severe sepsis
 Care pathway for every patient diagnosed with
sepsis in Ireland
 Recognition, Resuscitation, Referral
 Education, audit
 Diagnostic criteria for sepsis

Sepsis Severe Sepsis Septic Shock

SIRS
•Sepsis plus •Sepsis-induced
•Infectious & •SIRS plus
•Sepsis-induced hypo-perfusion or
non infectious •Presumed hypotension
causes or organ
dysfunction or persisting despite
•Clinical confirmed 30 mls/kg fluid
response infection tissue
hypoperfusion rescusitation
arising from a
non specific
insult
 SIRS Criteria

 T > 38.3, < 36

 HR > 90
 RR > 20
 WCC > 12, < 4
 BSL > 7.7 mmol/l in non-diabetic
 Altered mental status
 Common mistake - 1

 Other inflammatory parameters

 CRP, PCT

 Organ dysfunction parameters

 Hypoxia, Oliguria, Creatinine, Coag, Platelet,
Bilirubin, Ileus
 Tissue perfusion parameters
 Mottling, capillary refill, lactate
 Haemodynamic variables
 BP <90, MAP < 70, SBP  > 40mmHg from baseline
 Sources of sepsis

 Respiratory 38%
 Urinary tract 21%
 Intra-abdominal 16.5%
 CRBSI 2.3%
 Device 1.3%
 CNS 0.8%
 Others 11.3%
Give 3 Take 3
1.OXYGEN: Titrate O2 to saturations 1. CULTURES: Take blood cultures
of 94 -98% or 88-92% in chronic lung before giving antimicrobials (if no
disease. significant delay i.e. >45 minutes)
and consider source control.

2. FLUIDS: Start IV fluid 2.BLOODS: Check point of care

resuscitation if evidence of lactate & full blood count. Other
hypovolaemia. 500ml bolus of tests and investigations as per
isotonic crystalloid over 15mins & history and examination.
give up to 30ml/kg, reassessing for
signs of hypovolaemia, euvolaemia,
or fluid overload.

3. ANTIMICROBIALS: Give IV 3. URINE OUTPUT: Assess urine

antimicrobials according to local output and consider urinary
antimicrobial guidelines. catheterisation for accurate
measurement in patients with
severe sepsis/septic shock.
NEJM
 Sepsis screening

 Early recognition
 2% of all ED referrals are due to sepsis
 NSW audit of NEWS: sepsis is the cause of 30%
of triggered reviews
 UK: NEWS > 5; 52% sepsis
 ED vs In-patient

ED Ward
 Community acquired  Hospital acquired
 Less co-morbidities  Co-morbidities
 Generalised training  Second – Hit
 Mortality 20%  Specialist training
 Mortality ??? Higher
 Prompt treatment

 Sepsis is a time-dependent medical emergency

 Mortality increases by 7.6% for each hour delay

to appropriate antibiotics (Kumar CCM 2006)
Management of sepsis in
adult in-patient