Sepsis is often unrecognised and under-treated. It kills more patients in the USA than acute MIs. Recent studies have shown that early goal directed therapy reduces mortality by 14.5%. The number of patients needed to treat (NNT) to save one life is 7. This compares with 23 for thrombolysis in AMI. The Sepsis 3 guidelines replaced SIRS with qSOFA, but sensitivity has been as low as 54%^
SIRS – Systemic Inflammatory Response Syndrome
Patients with any 2 of the following:
- Temperature >38oC or <36oC
- Pulse >90 beats/min
- Resp rate >20 breaths/min or PaCO2 < 4.3kPa
- WBC >12x109 or < 4x109
Sepsis
Life-threatening organ dysfunction caused by dysregulated host response to infection
Septic shock
Subset of sepsis with circulatory and cellular/metabolic dysfunction associated with higher risk of mortality Persistent hypotension i.e. any of following SBP < 90mmHg MAP < 60mmHg Fall in SBP ≥ 40mmHg i.e. hypertensive patient whose SBP is normally 160 is in shock when SBP< 120mmHg
Work up
- Septic screen, including blood cultures. Consider atypical sources.
- Measure lactate level (can be done on blood gas machine in resus)
Management
- High flow O2
- Aggressive correction of Hypotension with IV fluids +/- vasopressors
- Early and appropriate antibiotics (See microbiology guidelines)
- Inform senior ED doctor
- Early involvement of ICU/HDU staff
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*Rivers M et al. Early Goal-Directed Therapy in the Treatment of Septic Shock. NEJM Volume 345:1368-1377 November 8, 2001
Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit.
Raith EP, Udy AA, Bailey M, McGloughlin S, MacIsaac C, Bellomo R, Pilcher DV; Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcomes and Resource Evaluation (CORE).
JAMA. 2017 Jan 17;317(3):290-300. doi: 10.1001/jama.2016.20328.