Early Recognition of Sepsis

and Sepsis Bundle

Vera Irawany
 CASE

Man, 70 yo, came to ER with decrease of

consiousness. He complained abdominal pain
since 3 days. 2 weeks ago he underwent
laparotomy because of appendix perforation
But he was sent home for a week, the day
before admitted to hospital, his wife said that he
easily fallen asleep and going into deep sleep.
What’s the Problem??
WHICH PATIENT IS IN SEPTIC CONDITION? SIRS SEPSIS

Man, 55 y/o, multiple fractures due to a

motorcycle accident. Clinical findings: he still
able to answer question in a short sentence, BP
170/70 mmHg, HR 120 bpm, RR 25 tpm, T ✓ NO
38’C, SpO2 96%. Laboratories finding: Hb
10g/dl; leuco 18.000/uL
Woman, 50 y/o, complain of dyspnea, fever
with productive cough. Clinical findings:
apatis, BP 100/60 mmHg, HR 115 bpm, RR
30 tpm, T 38,9 , SpO2 94%. Laboratories
◦
✓ ✓ YES
finding: Hb 10g/dL; leuco 19.000/uL
Man, 70 y/o, with abses at his right calf, with
history of DM. Clinical findings: arouse ,
lethargic, BP 90/60 mmHg, HR 70 bpm, RR
25 tpm, subfebrile, SpO2 96%. Laboratories _ ?
finding: Hb 10g/dL; leuco 9.000/uL
The Result:

87.9% 12.1%

Miss 1 in 8
Sequential [Sepsis-Related] Organ Failure Assessment Score (SOFA)

qSOFA
 Operationalization of Clinical Criteria Identifying
Patients With Sepsis and Septic Shock

qSOFA >= 2?

SOFA >=2?
 MESSAGE

➤ Sepsis criteria: no more SIRS, but SOFA score

more than 2
➤ qSOFA as a risk stratifier
We are running out of time….
 Why failure to prevent in-hospital cardiac arrest?

airway problem abnormality of breathing & circulation

failure to monitor

failure to involve senior staff & lack of

insufficient plans teamwork and poor communication
 Timeline Critical ILL
Redistribution blood flow to
vital organ (saving Heart &
Brain) Post operative,
post chemoth/,

☠
post parum,
failure/ Preeclampsia,
decompensation sign & Infection,
symptoms shock
Compensation; hemmorhagic,
Preserve brain and heart Trauma etc

Onset of
Compensatory phase illness
Depends on;
Cardiac tachypnea
severe • Age tachycardiardia
arrest/ bradichardia • Severity of illness hipertension
↓ pH
death hypotension • Preexisting disease lactate↑
alkalosis CRP↑
severe acidosis
≈ Normal leucocyte↑ or ↓

When should we start intervention?

HYPOTENSIVE HAPPEN WHEN AUTOREGULATION
IS LOST IN SEPSIS

150 Any increase in organ

pressure is
Organ Blood Flow (% baseline)

likely to blood
Normal
augment flow o s t
autoregulation is l
n
t i
a is o
100 u l
g eps
r e
u to in s Need
A
How toEvery decreasing
vasopressor
Increase Flow
pressure will decrease
the organ flow
50 Increasing
Pressure Simple math

20 40 60 80
100
0
Organ Artery Pressure (mmHg)
 CASE

Man, 70 yo, came to ER with decrease of

consiousness. He complained abdominal
pain since 3 days. 2 weeks ago he
underwent laparotomy because of
appendectomy. But he was home for a
week, the day before admitted to hospital,
his wife said that he easily fallen asleep and
going into deep sleep.
 STEPS

1. RECOGNIZE THE CRITICAL ILLNESS PROBLEMS

(IS IT A SEPTIC PATIENT? IS HE IN COMPENSATED
SHOCK STATE?) —> DIAGNOSTIC CRITERIA FOR
SEPSIS
2. INITIAL RESUSCITATION AND STABILIZATION
3. IMPLEMENTATION SEPSIS BUNDLE
MONITOR

141 O2 10 L/m
via face
91 mask

90/50 (60)

29

37.5
?
REASSESS VOLUME STATUS AND THE GOAL’S ARE…
 Consider 1 hour bundle!
Vasopressor can’t be delayed!
 NEXT

1. Measure lactate

2. Ceftriaxone 2x2 g iv + Metronidazole 1x 1500 mg

3. Loading crystalloid 250-500 cc in 10-15 minute, start NE 0.1 mcg/kg/min

4. Intubation and IPPV

5. Monitoring vital sign, urine output

6. Blood and sputum culture

 NEXT

1. Remeasure lactate

2. Consult the surgeon

3. Prepare to undergo laparotomy exploration within 12 hours

4. Continue monitoring vital sign, urine output

5. Take tissue sampling intraoperatively for culture

6. Admitt to Intensive care unit post operatively and assess tissue perfusion
3 PILLARS OF SEPSIS MANAGEMENT:

1. FLUID RESUSCITATION
2. BROAD SPECTRUM ANTIBIOTIC
3. SOURCE CONTROL
THANK YOU..

SALAM