1.Sepsis | Tom Heaps 09:30-10:20

2.Oncological Emergencies | Clare Pollard 10:20-11:10

------------------------ BREAK 11:10-11:30 ------------------------

3.Diabetic Ketoacidosis | Tom Heaps 11:30-12:20

4.Close and Feedback 12:20-12:30

78-year-old male presenting to ED PMHx T2DM, CKD1, IHD, BPH 48h history of dysuria, confusion and malaise

T° 38.3C, HR 112, BP 103/55mmHg, RR 24, SpO2 93% o/a

delirious ++ warm extremities, bounding pulse R basal crackles suprapubic tenderness Hb 11.1, WCC 18, platelets 103, urea 12, creatinine 144 (baseline

~120), LFTs normal, CRP 273, clotting normal

Systemic Inflammatory Response Syndrome (SIRS) defined by ≥2 of the following;

› temperature >38°C or <36°C › HR >90min-1

› RR >20min-1 or PaCO2 <4.25kPa› new onset confusion› hyperglycaemia (CBG >7.7mmol/l) in absence of diabetes› WBC >12 x109 or <4 x109 or high CRP (if available)

infection, trauma, surgery, burns, pancreatitis

SEPSIS = SIRS + infection +/- bacteraemia mortality increases with number of SIRS criteria

oxygen (if required to achieve target SpO2)

blood cultures IV antibiotics IV fluids VBG or ABG (plus FBC, U&E, LFT, CRP, coagulation) urinary catheter and commence fluid balance urine cultures CXR

lactate on VBG correlates well with arterial lactate except in cases of severe shock

measure ABG if shocked or oxygenation/ventilation a concern

lactate levels correlate highly with mortality

› 40% if lactate >4mmol/l

› 15% if lactate <2mmol/l

serial measurements and lactate clearance in response to resuscitation more important than absolute values

hypovolaemia in sepsis is absolute (reduced fluid intake, fluid loss, insensible losses) and relative (vasodilatation)

500mL boluses up to 30mL/kg (~2L for 70kg person) over ≤30min repeated up to 60mL/kg (~4L for 70kg person) after senior review

Which fluid? crystalloid vs colloid› no evidence that albumin superior to saline (SAFE trial)› colloids are more expensive and risks of AKI (HES), anaphylaxis and coagulopathy

Which crystalloid?› balanced solutions e.g. Hartmann’s are more expensive› less risk of hyperchloraemic acidosis than with 0.9% NaCl› in vitro evidence only that hyperchloraemic acidosis is harmful

time to administration is critical factor

8% increase in mortality for every 1h delay after onset of hypotension

aim to administer IV broad spectrum antibiotics within 1h of presentation with severe sepsis

empirical choice governed by probable source of infection and local guidelines (available on intranet)

separate guideline for suspected/proven febrile neutropenia

ABG on air pH 7.36, pO2 9.2, pCO2 2.8, lactate 4.8, BE -5.6 blood cultures taken CXR unremarkable catheterized urine dipstick leucocytes 3+, nitrite +ve, RBC 2+, protein + IV co-amoxiclav and gentamicin given for suspected UTI IV 0.9% NaCl 2L prescribed each over 8h 2h later BP 91/44mmHg and urine output 50ml total

SEVERE sepsis = sepsis plus evidence of organ dysfunction (or tissue hypoperfusion);

alteration in mental state (confusion) hypoxemia (PaO2 <9.6kPa at FiO2 0.21 in absence of pulmonary disease) elevated plasma lactate (>4mmol/l), increased CRT or skin mottling oliguria (urine output <30ml or <0.5 ml/kg for 1h) hypotension (sBP <90mmHg, MAP <65mmHg or reduction in sBP of

40mmHg from baseline) creatinine >177umol/l bilirubin >34umol/l platelets <100, INR >1.5 or disseminated intravascular coagulation (DIC)

SEVERE SEPSIS = sepsis plus evidence of sepsis-induced tissue hypoperfusion or organ dysfunction;

alteration in mental state (confusion) hypoxemia (PaO2 <9.6kPa at FiO2 0.21 in absence of pulmonary disease) elevated plasma lactate (>4mmol/l), increased CRT or skin mottling oliguria (urine output <30ml or <0.5 ml/kg for 1h) sepsis-induced hypotension (sBP <90mmHg, MAP <70mmHg or reduction

in sBP of 40mmHg from baseline) creatinine >177umol/l bilirubin >34umol/l platelets <100, INR >1.5 or disseminated intravascular coagulation (DIC)

New concept introduced by latest guidelines from UK Sepsis Trust

Early detection (MEWS-based) of patients at risk of deterioration who may benefit from more aggressive treatment as ‘severe’ sepsis

Many markers of severe sepsis may not be evident / available at time of first presentation

1. Tachycardia: HR >125/min

2. Hypotension: systolic BP <90mmHg

3. Tachypnoea: RR >20

4. Hypoxaemia: SpO2 <90% (or only ≥90% with O2)

5. Drowsiness: AVPU of V, P or U

given fluid challenge of 2L Hartmann’s over 1h

total fluid input now 3L

repeat VBG shows lactate 6.2

no urine output in last 1h

BP 80/52mmHg

mottling of lower extremities

increasing confusion

SEPTIC SHOCK = SEVERE SEPSIS

+hypotension which is refractory to fluid replacement

WHAT NEEDS TO HAPPEN NOW? senior review decisions re. CPR/escalation (if not already made!) transfer to ITU if appropriate

› Invasive monitoring, vasopressors, ventilation etc.

Recognize and screen for sepsis1.Suspect Infection?

› MEWS ≥ 4› High temperature› Symptoms suggestive of infection› Risk of neutropenia/immunosuppression

2.Confirm diagnosis using SIRS criteria (≥2 positive)

3.Any features of ‘red flag’ or severe sepsis?

4.Obtain medical review (immediate if severe sepsis)

ELDERLY PATIENTS MAY PRESENT ATYPICALLY

Get the ‘SEPSI6’ trolley and initiate the ‘SEPSIS 6’ BUNDLE

3x Investigations1.VBG/ABG (and other bloods)2.Blood cultures (and other cultures)3.Urine output monitoring (insert catheter if severe sepsis)

3x Treatments4.Oxygen5.IV Fluids6.IV antibiotics

ALL WITHIN 1h OF RECOGNIZING ‘RED FLAG’ OR SEVERE SEPSIS› reduced mortality from 44% to 20% at GHH

Monitoring and Co-ordination of Careensure antibiotics given promptly and fluids running to time

hourly observations (for 1st 4h even if MEWS <4) and urine output / fluid balance chart

repeat VBG for lactate

involve CCOT early

prompt doctors to make escalation/CPR decisions

alert senior medical staff if condition deteriorates or fails to improve as expected

SEPSIS = SIRS + infection

SEVERE sepsis = sepsis plus ≥1 marker of organ dysfunction

RED FLAG sepsis should be treated initially as SEVERE sepsis

severe sepsis is a MEDICAL EMERGENCY which kills in 1/3 of cases

early RECOGNITION and RESUSCITATION are key

PROMPT antibiotics and ADEQUATE IV fluids will SAVE MORE LIVES than ITU

GRAB THE ‘SEPSI6’ TROLLEY AND CARRY OUT THE ‘SEPSIS SIX’ WITHIN 1h of recognition of SEVERE / RED FLAG sepsis

escalate to senior and involve CCOT EARLY if patient fails to respond

use the new AMU sepsis pathway and ‘Sepsis 6’ Stickers