AGH WRH Emergency Department Management of Adult Sepsis Syndromes SIRs Criteria Met ? any TWO of the following present: INFECTION SUSPECTED ? 0 0 Temp >38 C or Temp <36 C Resp tract eg. pneumonia UTI Yes Heart rate >90 bpm Intra-abdominal CNS eg. meningitis Resp rate >20/min Bone / joint infection Skin eg.cellulitis WCC >12 or WCC <4 Endocarditis Neutropenia Line infection eg. CVP Wound / soft tissue Acutely altered mental state Spinal ENT BM>7.7mmol/L in absence on DM Implantable device Other / Not Known Non-Infective ‘SIRS’ MEASURE LACTATE IMMEDIATELY eg. ● Acute blood / fluid loss Yes No ● Pancreatitis Time taken ● Pulmonary Embolus Result (24hr clock) ● Myocardial infarction ● Mysenteric Ischaemia ● Anaphylaxis ● Burns / trauma ● Transfusion reaction Look for evidence of Severe Sepsis ● Autoimmune disorder any ONE of the following present: No Systolic BP <90mmHg or MAP <65mmHg SEPSIS Lactate >2mmol/L (see over) Investigate, treat & monitor Other evidence Organ Dysfunction: closely. (Creat >177, Bili >34, Pl <100, INR>1.5, APPT>60s, Re-start assessment if patient urine output <0.5ml/Kg/hr for 2hrs, SpO2<90%) deteriorates. Yes to any of the Complete Sepsis Six Bundle below within ONE HOUR of arrival above: Ensure SENIOR ED doctor aware of diagnosis of SEVERE SEPSIS Time Completed SEPSIS SIX (24hr clock) 1 100% Oxygen Give 15L/min via facemask with reservoir bag unless oxygen restriction necessary. 2 IV Fluid BOLUS Give a 500mL bolus of Crystalloid rapidly (<15mins) & repeat unless concerned regarding potential fluid overload – 250-500ml boluses. 3 Blood Culture Culture other sites as clinically indicated e.g. sputum, wound swabs. Consider urinalysis +/- CSU / MSU. 4 IV Antibiotic Use Trust antibiotic guideline. Inform nursing staff of stat dose and prescribe in ED notes or front of a drug chart. 5 Lactate & Bloods Lactate on venous or arterial sample, using blood gas machine. Request FBC, Coag, U&Es, LFTs and glucose. 6 Monitor Urine Output Consider catheter. Monitor urine hourly using fluid balance chart ● Any relevant Travel history ? Yes □ No □ (consider need for malaria film etc.) ● Any likelihood Neutropenic Sepsis ? (eg. recent Chemotherapy) Yes □ No □ (consider need for Merepenum 1g IV before WBC known) ● Risk factors for Immunosuppression (HIV / Steroids / Chemo)? Yes □ No □ ● Possibility of Hospital Acquired Infection ? Yes □ No □ ED doctor (Print): Designation: Date: WAHT-TP-013.2 Version 1 Further Considerations Yes No Comments Patient should be in the Resus Room Continuous monitoring of HR / SpO2 Recording of Resp Rate & BP every 15mins Imaging considered eg. CXR or CT Scan Surgical review considered where indicated ICU informed where indicated Need for assisted ventilation considered RESULT: TIME: REPEAT LACTATE if initially >4 or low BP (24hr clock) despite after 30ml/Kg Fluid Bolus Is Septic Shock Present ? (Yes if, despite 30mls/Kg of IV fluid AND both the following apply) Systolic BP <90mmHg or MAP <65mmHg Repeat Lactate >4mmol/L SEVERE SEPSIS Yes Investigate, treat & monitor No closely. Re-start assessment if patient deteriorates. Complete Septic Shock Bundle below within SIX HOURS of arrival This will involve joint management between ICU & Specialty team & ED teams Time Completed SEPTIC SHOCK BUNDLE (24hr clock) 1 Fluid Resuscitation Ensure patient has had 30ml/Kg bolus of crystalloid. 2 ICU assessment Arrange urgent ICU review. 3 CVP Line Insert multi-lumen CVP line urgently or seek help from senior / ICU. An arterial line will be required if vasopressors (eg. Noradr) are to be used. 4 ICU / HDU Care Ensure bed of appropriate care level allocated. 5 Source control Remove any infected urinary catheters or indwelling device; arrange for abscess drainage / laparotomy etc. as needed. 6 CVP 8-12mmHg Give 500-1000ml IV bolus of crystalloid every 30 min until goal achieved. 7 MAP 65mmHg Patient needs Noradrenaline if MAP<65mmHg despite adequate CVP (unless ICU care deemed inappropriate and reason has been recorded). 8 ScvO2 70% Blood gas samples from CVP line at regular intervals to determine central venous oxygen saturastion (ScvO2). Consider dobutamine in ICU if ScvO2<70% despite Hb>7 and adequate MAP / CVP. Notes – Lactate in Severe Sepsis and Septic Shock – a quick user’s guide (adapted from CEM) Obtaining serum Lactate is essential to identifying tissue hypoperfusion in patients who are not yet hypotensive but who are at risk for septic shock. A raised Lactate has prognostic value for survival, especially the rate of clearance . There are limitations to its use but in the ED the following should be used as a diagnostic guide in septic patients: Initial Lactate 0-2 normal >2 If criteria for sepsis are already met, this indicates SEVERE SEPSIS >4 If criteria sepsis are already met, this could indicate SEPTIC SHOCK if it does not respond to fluids Repeat Lactate if initially >4 or BP low (SBP<90 mmHg or MAP <65mmHg) despite 30ml/Kg fluid bolus Repeat Lactate 0-2 normal >2 If initial lactate was >2 but <4 then this SEVERE SEPSIS unless the BP is low (see below) >4 SEPTIC SHOCK (NB if the BP was never low then this is called ‘CRYPTIC SHOCK’) If, despite initial resuscitation (SEPSIS SIX / ONE HOUR BUNDLE), the BP remains low (SBP<90 or MAP<65) then this is SEPTIC SHOCK irrespective of the lactate. WAHT-TP-013.2 Version 1 .