Table of Contents Include in assessmentIdentifying a patient with sepsisParameters suggesting risk of severe illness/death from sepsisEnd organ dysfunction due to sepsisManagementSepsis Six Other aspects to managementTest yourself with some questionsAnd here are some OSCE stations Include in assessment Observations Sepsis signs (capillary refill, skin temp, pulse etc.) Look for infection sources (multi-system exam; iatrogenic sources, e.g. surgical wounds, drains, cannulas, lines; exposure e.g. look at skin, joints etc.) Investigations: to find source (septic screen) and to look for complications/organ dysfunction Bloods (especially look at Hb, WCC/neutrophils, platelets, INR, bilirubin)VBG (lactate) Blood cultures Capillary glucose Urine dip and culture any other fluids CXR Other relevant imaging (e.g. CT abdomen if possibility of surgical collection) Sepsis is an infection with a systemic response. Identifying a patient with sepsis Think about it in any patient who has a suspected infection Use clinical judgement to determine whether a patient has sepsis They must have a suspected infection (e.g. symptoms, fever) and a systemic response causing life-threatening organ dysfunction Risk factors = very young, frail/elderly, recent surgery/trauma (<6weeks), impaired immunity (illness or immunosuppression), indwelling catheters/lines, IV drug use, breaks in skin integrity Lactate correlates with severity (<2mmol/L = mild; 2-4mmol/L = moderate; >4mmol/L = severe) Parameters suggesting risk of severe illness/death from sepsis High risk Moderate to high risk Mental statusObjective altered metal stateHistory of altered mental state/behaviour or deterioration of functional abilityRespiratory rate≥25 (or new oxygen requirement)>20Heart rate>130>90Systolic blood pressure≤90 (or >40 below normal)≤100Urine output<0.5ml/kg/hour (or no urine in >18 hours)<1ml/kg/hour (or no urine in >12 hours)OthersCyanosis or mottled/ashen appearanceImpaired immunity (illness or immunosuppression) Reference: NICE ‘NG51 sepsis: recognition, diagnosis and early management’ 2017 End organ dysfunction due to sepsis SystemConditionSignsManagementRespiratory Acute respiratory distress syndromeImpaired oxygenation, tachypnoea, infiltrates on CXRMechanical ventilationCardiovascularMyocardial dysfunction/failure, hypovolaemia, septic shockPersistent hypotension (SBP<90)Inotropes/vasopressorsKidneysAcute kidney injuryUrine output <0.5ml/kg/hour or creatinine >50% baselineRenal replacement therapy if requiredLiverLiver dysfunctionBilirubin ≥35µmol/L and ALP/ALT >2x normalNo specific treatmentCoagulationCoagulopathy/disseminated intravascular coagulationThrombocytopenia, prolonged PT, low fibrinogen, high D-dimerBlood products (red cells, platelets, FFP, cryoprecipitate)Nervous systemEncephalopathyNew confusion/↓GCSNo specific treatmentNB: septic shock is sepsis with refractive hypotension despite adequate fluid resuscitation. Management Sepsis Six Should be performed within 1 hour… 3 IN: Oxygen Fluids (adequate fluid resuscitation is normally 20-30ml/kg quickly) Antibiotics Choice depends on hospital protocol Target source of infection if clear Broad-spectrum if source unclear 3 OUT: Blood cultures Lactate and Hb Catheterise (to measure urine output, i.e. renal end-organ dysfunction) Other aspects to management Use an ABCDE approach (see ABCDE management) Some sources may require surgery (abdominal collections, joints, necrosis) Support organ failure (may require ICU, e.g. for vasopressors, intubation, or renal replacement therapy) If patient is still hypotensive despite adequate fluid resuscitation (20-30ml/kg) or becoming fluid overloaded, they need vasopressors/inotropes Test yourself with some questions Which are the common bacteria to cause sepsis in immunocompetent patients? Oops! This section is restricted to members. Which antibiotics would be appropriate for neutropaenic sepsis and why? Oops! This section is restricted to members. Which types of IV fluid are appropriate for fluid resuscitation for patients with sepsis? Oops! This section is restricted to members. What is the problem with giving excess 0.9% saline? Oops! This section is restricted to members. And here are some OSCE stations Sepsis Neutropenic sepsis prescribing Find lots more here!