3b SEPSIS Year 4 Internal Medicine Notes OmpathStudy

3b SEPSIS Year 4 · Internal Medicine Collection: 4TH YEAR ALL NOTES / IMED / IMED 4.3 / MOGERE -- Slide 1 SEPSIS Slide 2 DEFN Sepsis is the body’s immune system response to an infection Bacteria, virus, protozoan Instead of a localized response to an infection (like a pneumonia), sepsis is a systemic response that can be catastrophic Slide 3 NEW SEPSIS DEFN; q SOFA An alteration in mental status (not the GCS) A decrease in SBP of less than 100 mm Hg A respiratory rate 22 bpm Slide 4 SIRS(systemic inflammatory response syndrome) An exaggerated defense response to the body to a noxious stressor – infection, trauma, surgery, acute inflammation, ischemia, or reperfusion or malignancy etc Slide 5 SIRS(systemic inflammatory response syndrome) SIRS is considered to be present when patients have more than one of the following clinical findings: •Body temperature higher than 38°C or lower than 36°C •Heart rate higher than 90/min •Hyperventilation evidenced by respiratory rate higher than 20/min or PaCO2 lower than 32 mmHg WBC count 12,000 cells/ μl or lower than 4,000/ μl Slide 6 SEPSIS 1 Sepsis- SIRS plus infection Severe sepsis - sepsis associated with organ dysfunction, hypoperfusion or hypotension Septic shock - sepsis with arterial hypotension despite “adequate” fluid resuscitation Slide 7 SIRS LIMITATIONS SIRS lacks sensitivity for defining sepsis 1 in 8 ICU patients with infection and organ dysfunction do not have 2 or more SIRS critieria • SIRS not specific • 4 in 5 ICU patients without infection have ‘SIRS’ criteria • Different sources of infection are associated with different mortality rates • SIRS criteria do not account for the dynamic time-course of sepsis (e.g. rise and fall in white cell count over time, fluctuations in vital signs) Slide 8 SEPSIS 2 Unchanged concepts of sepsis, severe sepsis, and septic shock • Original SIRS overly sensitive and nonspecific - increased complexity of scoring system Slide 9 EXPANDED SIRS CRITERIA Slide 10 SEPSIS 3 Sepsis is ’life-threatening organ dysfunction due to a dysregulated host response to infection.’ • Layperson definition ‘a life-threatening condition that arises when the body’s response to infection injures its own tissue.’ • ‘Severe sepsis’ no longer exists as a concept, there is simply ‘sepsis’ and ‘septic shock.’ Slide 11 SEPSIS Sepsis clinical criteria:\norgan dysfunction is defined as an increase of 2 points or more in the Sequential Organ Failure Assessment (SOFA) score for patients with infections, an increase of 2 SOFA points gives an overall mortality rate of 10% Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside with qSOFA (“HAT”); i.e. 2 or more of:\nHypotension: SBP less than or equal to 100 mmHg Altered mental status (any GCS less than 15) Tachypnoea: RR greater than or equal to 22 Slide 12 SEPTIC SHOCK Septic shock is ‘a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.’ Septic shock clinical criteria: Sepsis and (despite adequate volume resuscitation) both of: Persistent hypotension requiring vasopressors to maintain MAP greater than or equal to 65 mm Hg, and Lactate greater than or equal to 2 mmol/L With these criteria, hospital mortality is in excess of 40% Slide 14 qSOFA Sequential Organ Failure Assessment Definition was developed from a data set of 148 907 patients (USA/Germany) with suspected infection who had body fluids sampled for culture and received antibiotics • Internally validated (AUROC = 0.81) • Significance of ‘new onset’ versus ‘established’ qSOFA points is unknown • Addition of lactate did not meaningfully improve predictive validity of qSOFA but ‘may’ help identify pts at intermediate risk Slide 15 Ct.qSOFA Slide 16 Why use qSOFA Identifies patients outside the ICU with suspected infection that are at a high risk for in-hospital mortality. (Patients ≥18 years old in a non-ICU setting (i.e. pre-hospital, ward, emergency department, or step-down unit) with confirmed or suspected infection). Can help increase suspicion or awareness of a severe infectious process and prompt further testing and/or closer monitoring. Slide 17 Method of predicting outcomes in critically ill patients An initial SOFA score of < 9 predicted a mortality of < 33% A SOFA 11 predicted mortality of 95% Slide 18 sofa Slide 20 MEWS: Modified Early Warning Score, validated in adult medical surgical pts Validated to identify risk of clinical deterioration and mortality when the MEWS is greater than or equal to 5 NEWS: National Early Warning Score The score ranges from 0-20: low score(1-4),medium score(5-6), high score(NEWS /7) Slide 22 SUMMARY The lack of a reliable definition of sepsis makes assessment of incidence and changes in outcomes difficult to quantify reliably. Consider sepsis even when qSOFA score is <2 as it has a poor sensitivity is a late indicator of deteriora