Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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19 Critical Care
Box 19.4
Surviving sepsis campaign
Sepsis resuscitation bundle
• Serum lactate measured.
• Blood cultures obtained prior to antibiotic administration.
• From the time of presentation, broad-spectrum antibiotics administered within three hours for
emergency department (ED) admissions and one hour for non-ED ICU admissions.
• In the event of hypotension and/or lactate >4 mmol/L (36 mg/dl):
– Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)
– Apply vasopressors for hypotension not responding to initial fl uid resuscitation to maintain mean
arterial pressure (MAP) ³65 mm Hg
Sepsis management bundle
• Low-dose steroids administered for septic shock in accordance with a standardised ICU policy
• Drotrecogin alfa (activated protein C) administered in accordance with a standardised ICU policy
(See note below)
Although at fi rst sight these seem complex, and indeed the management bundle is applied differently from
one unit to another, the resuscitation bundle is applicable to both ward and HDU based patients as well.
The failure to respond to fl uid resuscitation should trigger an urgent critical care referral.
The use of activated protein C is associated with an increase in bleeding in some groups of patients and
trials in children have been halted. The balance of risks and benefi ts at present remains unclear.
Box 19.5
Critical care learning points: severe sepsis
Severe sepsis can develop quickly and when accompanied by septic shock kills previously fi t women.
Serum lactate, blood gases and blood cultures should be measured early in suspected cases of systemic
sepsis.
Fluid resuscitation should be prompt and the effect noted without delay.
Failure to respond to 20mls/kg of intravenous fl uids should trigger an urgent critical care referral.
Resuscitation
In the majority of cases reviewed where cardiopulmonary resuscitation took place this was delivered to a very high
standard and current advanced life support (ALS) guidelines were followed, although there were exceptions:
A woman had labour induced for post dates. This was accompanied by a marked rise in blood
pressure, a sudden reduction in her conscious level and twitching of her limbs. Her observations
were recorded as blood pressure 200/106 mm/Hg, pulse 20 bpm and saturations of 64% on 4
lpm of oxygen. An in-and-out urethral catheter was inserted following which her saturations fell
and the on call anaesthetist was fast bleeped. An assisted delivery failed. Shortly afterwards
her observations became unrecordable and an arrest call was put out. She was transferred to
HDU with a blood pressure of 71/58 mm/Hg and saturations of 58%. Approximately an hour after