Sepsis – A Short Synopsis for Foundation Year (FY) doctors
Lola Eid-Arimoku (surgical registrar to Mr Moore 2014) writes here about sepsis
In terms of clinical importance, incidence, prevalence, health burden (morbidity and mortality), sepsis is one of the most important conditions that you will come across in your daily practice. Septic patients deteriorate rapidly, and the prospect of managing these often unstable patients can be quite daunting, particularly out of hours. This is a short synopsis of an important topic. The aim is not to be a comprehensive account, nor to teach you what you already know, but to provide a short reference and educational tool for your FY surgical post.
There are numerous definitions of sepsis, severe sepsis and septic shock. In essence, sepsis is a sytemic inflammatory response syndrome that occurs in response to infection. The manifestation is an acutely unwell patient. The degree of severity of sepsis is often correlated to hypotension, failure to respond to fluid resuscitation, inadequate tissue perfusion and organ failure. The aim is to identify affected patients before these ensue.
More people die of severe sepsis in the UK than of breast and colorectal cancer combined. There is a 50% mortality associated with surgical patients who are admitted to the ITU with severe sepsis. It is therefore crucial to recognise signs of sepsis early and to institute the appropriate treatment. This requires a triad of knowledge, awareness and vigilance.
Most patients will exhibit one or a combination of:
- acutely altered mental state
- pyrexia or hypothermia
- hyperglycaemia in non-diabetic patients
However, some surgical patients may only exhibit these signs when physiological decompensation has occurred so remember the following:
1. The end-of-the-bed test
Does this patient look unwell? Many of the patients that you are asked to review will be known to you so compare the current with the previous clinical picture.
2. The trend of observations
Chart review is an integral part of the initial assessment of every unwell patient. Temperature, respiratory rate, heart rate and blood pressure will always be documented for surgical patients. Examine the trend and actively look for any signs of deterioration. This will help avoid the ‘pitfalls’ quoted in the literature.
At Risk Groups
Every surgical patient is at risk of sepsis. The protective skin barrier has been breached, the body has been subjected to iatrogenic trauma and cannulas and in-dwelling catheters are pervasive and many of these patients will be co-morbid and elderly.
Antibiotics – the Golden Hour
The early administration of antibiotics is directly related to reducing mortality in patients with severe sepsis. The recommendation is to give antibiotics within one hour of the onset of sepsis or as soon as possible. Ideally appropriate cultures – blood samples included – should be taken before antimicrobial therapy is given but this should not delay administration. The choice of antibiotics will depend on a variety of factors including the likely or identified source of infection, previous culture results, type of surgery and microbiology advice. Broad spectrum antibiotics are a sensible choice in the absence of specific direction.
The Sepsis Six
The following steps may double your patient’s chance of survival.
- Administer high flow oxygen
- Take blood cultures
- Give broad spectrum antibiotics
- Give intravenous fluid challenges
- Measure serum lactate and haemoglobin
- Measure accurate hourly urine output
ABC – my version
The standard ABC approach to assessing any sick patient has been well described elsewhere. These principles still apply and I have developed a modified version to be used in conjunction with this.
Action – If a patient is deteriorating, a change in management is required. This may require further investigations but this should not delay optimisation of airway, breathing and circulation. High flow oxygen in patients with COPD and fluid resuscitation in the elderly are two interventions that many junior doctors will deliberate over. Giving high flow oxygen to unwell patients or a rapid crystalloid infusion to an acutely hypotensive patient (whatever the age) is more likely to help than harm in the few minutes before senior help arrives. If in doubt, ask the nursing staff to get the necessary equipment ready to avoid delays later. Safety is paramount so please ensure that any action you take is within the confines of your clinical knowledge.
Bravery – Trust your knowledge and ability to assess and institute initial management. Senior help and advice should always be available to you. If in doubt, ask for help, and do so without hesitation. Remember that every time you ask, you will have learnt something new.
Collaboration – The management of any sick patient involves a multidisciplinary team approach. Septic patients often require the expertise of your senior surgical colleagues, the medical registrar, the outreach team, HDU, ITU and microbiology to name a few. Their early involvement is the key to improving prognosis.
A Brief History Lesson
This account would not be complete without a mention of those who paved the way for us.
- Joseph Lister 1867 – ‘On the Antiseptic Principle in the Practice of Surgery’
- William Halsted 1889/90 – rubber gloves
- Ignaz Philip Semmelweis 1847 – Hand disinfection
- Joseph Grancher 1888 – ‘Barrier nursing’
Daniels, R. (2011) ’Surviving the first hours in sepsis: getting the basics right (an intensivist’s perspective)’, J. Antimicrob. Chemother [Online], 66 (2), ii11-ii23, doi: 10.1093/jac/dkq515. (Available from: http://jac.oxfordjournals.org/content/66/suppl_2/ii11.full)
Loftus, I. (2010) Care of the Critically Ill Surgical Patient. 3rd ed.London. Arnold.
Gaieski, D., Mikkelsen, M., Band, R., Pines, J. et al (2010) ‘Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department’, Crit Care Med [Online], 38(4), pp. 1045-1053, doi: 10.1097/CCM.0b013e3181cc4824. (Available from: http://www.ncbi.nlm.nih.gov/pubmed?term=20048677)
Mcpherson, D.,Griffiths, C., Williams, M., Baker, A. et al (2013) ‘Sepsis-associated mortality in England: an analysis of multiple cause of death data from 2001 to 2010’, BMJ Open [Online], 3:e002586 doi:10.1136/bmjopen-2013-002586 . (Available from: http://bmjopen.bmj.com/content/3/8/e002586.abstract)
Schmidt, G. and Mandel, J. (2014) ’Evaluation and management of severe sepsis and septic shock in adults’, UpToDate [Online]. (Available from:http://www.uptodate.com/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults)
Lola Eid-Arimoku, Surgery Registrar to Mr Moore, March 2014