Bad to Worse... SIRS, Sepsis and Shock...

The bread and butter of Resus, there are certain things you will see at work time and time again and this is one of the them. However it is not always something we manage as well as we should. Here is a three step approach to recognising sepsis:

Step 1:

The first concept you have to get your head round is the the Systemic Inflammatory Response Syndrome (SIRs)... Which requires two or more of the following:

• Hr >90
• RR >20
• Temp >38.3, <36
• WCC >12 or <4

SIRs does not mean sepsis but it does mean the patient is unwell (seems obvious), however it just means the body is reacting to an insult. This could be trauma/ post surgery/ PE/ infection/ autoimmune. I find my self documenting explicitly the sirs criteria present before my diagnosis for all my patients and this makes it easier to remember the exact criteria.

Step 2:

Does the patient have an infection or do you suspect they might? This deliberately includes the suspicion of infection as you may not have proof straight away but this should not delay treatment. It obviously requires you to have examined the patient and consider basic investigation. If the answer is yes the patient has sepsis.

Step 3:

Is there end organ dysfunction? Easy ones to quickly measure are renal function (urine output) and brain function (GCS).  If the answer is yes the patient has severe sepsis. You can also measure liver function (INR), Lactate, etc.

The final thing to know is the definition of SHOCK- which is inadequate tissue perfusion given end organ dysfunction and this clearly overlaps with our severe sepsis definition. The magic number to remember is a MAP <65.

What Next?

Its all good and well recognising SIRs/ Sepsis/ Shock but actually that is only half the story as we need to be able to treat these patients as well. Guidance exists on this from the surviving sepsis campaign: http://www.sccm.org/Documents/SSC-Guidelines.pdf

This can be summarised into initial management steps and some physiological targets: