Sepsis. A word often associated with a deep sinking feeling in your gut and a very poorly looking patient. This members webinar gives you a bit of a helping hand to manage that sinking feeling and (hopefully) replace it with a feeling of hope. Chloe Fay BSc (Hons) RVN CertVN ECC VTS (ECC), who has previously presented on traumatic brain injury and acute kidney injury, walks us through the approach and management of our septic patients.
A Poorly Patient
WHAT DOES SEPSIS LOOK LIKE?
One of the most critical things in a sepsis case is to know when things have been pushed over the edge. You have to know when the patient is septic because it means you really have to ramp up treatments, monitoring and measuring progress (or decline).
To be classified as an animal with sepsis, cats have to show three+ criteria and dogs two+ criteria of the following:
One of the first instances where we may recognise that something is seriously wrong is after an investigatory CBC or Biochemistry reading. Some of the most common findings are detailed in the table below. Chloe Fay also covers what you may see in coagulation tests, radiography, and ultrasonography.
Is my patient improving?
GOAL-DIRECTED THERAPY IN SEPTIC CASES.
What path do you take if you don’t know what your goal is? That’s one of the underlying keys to early goal-directed therapy. In septic patients, the goals generally are related to controlling the results of the inflammatory cascade. These results are what leads to the catastrophic organ failure that we dread.
“Goal-Directed therapy is a technique used in critical care medicine involving intensive monitoring and aggressive management of preoperative harm-dynamics in patients with a high risk of morbidity and mortality.”
Goals in septic patients are usually related to central venous pressure, mean arterial blood pressure, urine output, mixed venous oxygenation saturation, and haematocrit.
Keeping up the pressure!
VENTRAL VENOUS PRESSURE & MEAN ARTERIAL PRESSURE IN SEPTIC CASES.
Your goal in this section is haemodynamic stability. This translates to a central venous pressure (CVP) or 8-12mmHg. The mean arterial pressure should be more than or equal to 65mmHg, and the urine output should be more than or equal to 0.5ml/kg/hour. Use a short wide-bore catheter and shock fluid rates and in the case that there’s no adequate response to therapy then consider TFAST or AFAST scans to see if the fluid is third spacing. If there’s distributive shock present, vasopressin may be needed.
Early use of inopressor agents is also recommended in cases of sepsis. There’s a hypoperfusion of tissues due to a hypovolaemia and vasodilation so you want to remedy that as soon as possible. It makes sense – no blood means no oxygen means no life. Chloe covers inopressors that are contraindicated, inopressors that are the first choice, and inopressors that are okay but not great.
Getting rid of the bugs.
ANTIBIOSIS IN SEPTIC CASES.
Here’s a startling statistic. Mortality is significantly increased for every hour of delay before the start of antibiotic therapy. Although general broad-spectrum therapy is your friend, specific therapy is going to be incredibly helpful to ensure that all that invading bacteria is really and truly gone. While your pathogen is being identified, your antibiosis should cover staphylococcus, streptococcus and e.coli.
A breath of fresh air!
OXYGENATION IN SEPTIC CASES.
Your goal with oxygenation is much more than ‘is the patient breathing’. You want to have a goal SVO2 of >70%. It’s not just about making sure that they’re ventilating (and you can definitely turn to mechanical ventilation for that), remember what I said earlier – no blood means no oxygen? The distributive shock that may be present can affect perfusion and oxygenation so no matter how much oxygen is entering the body, not all of it is being used.
Something to chew on.
GI SUPPORT IN SEPTIC CASES.
Animals have to eat. That’s simple, and obvious, and we know that. Septic patients are often anorexic and I get it. If I was feeling that horrible, I wouldn’t want to be eating either. There’s a secondary reason to have GI support in septic cases. It’s that horrible hypo perfusion that we mentioned before. Gastric ulceration is frequent, and we want to protect the mucosa as much as possible. Usage of H2 antagonists and PP inhibitors can be useful, and if there’s any GI haemorrhage then sucralfate 1-5ml PO TID is indicated. Enteral nutrition is your best choice when it comes to nutrition, and if the patient still isn’t eating despite protective and antiemetic drugs then consider your options with feeding tubes.
What’s going on?
MONITORING IN SEPTIC CASES
There’s a lot of things to be keeping an eye on in septic cases. Chloe mentions the top five – urine output, thermoregulation, glucose regulation, pain assessment, and blood pressure monitoring / CVP monitoring.
In summary & useful links!
Treatment of sepsis can become very overwhelming, very fast. There’s a lot of different things going on. In this webinar, Chloe runs us through the most important things to keep an eye on and what goals you should be setting. Not only that, but she walks us through how we manage the patient on the way to achieving the goal. For much more detail on how to manage your septic patients, you can find the webinar here. The webinar is free to attend for our unlimited members, or thanks to the kind sponsorship of VetsNow, you can get access for just £20+VAT.