Hello, thank you so much for the introduction. So yes, as you said, I'm Katie, and I work at the QMH and hopefully, this evening, you'll be interested to learn maybe some more about recognising sepsis and how best to do this in, your practises. So, this evening, just what we're going to be running through, so we're going to quickly go through the definitions of stairs and sepsis just as a little refresher.

And then understanding the physiology behind sepsis and again, hopefully just a bit of a refresher for you guys. We'll talk about current research into sepsis recognition in the human world. Obviously, they are 10 steps ahead of us.

So, just to see if that might relate to us and our veterinary patients. And then going through recognising the clinical signs associated with sepsis in the patients that we see. Some quick information about antibiosis, and if we get time, I've got a case study as well, so.

Fingers crossed. OK, so some definitions just so that we know all on the same page what we're talking about. So we have SERS, which is our systemic inflammatory response syndrome.

Sepsis is a term used to describe patients suffering from SARS, but also with the added complication of infection. And then septic shock is a septic patient that also has developed a life threatening organ dysfunction. And when those septic shock patients then develop more than one organ dysfunction, they're then classified as having mods, so multiple organ dysfunction syndrome or multiple organ failure.

And as part of that, they can get acute respiratory distress syndrome, which we'll refer to as ARS. And you can see more about that with survising sepsis Committee. So a quick refresher on some biology and some physiology.

So, the body experience is an insult, so whether that be a laceration, a burn, or even something that we do as vets and nurses. So and then a puncture, something that simple or just a surgery. The body has an acute reaction, which is completely normal, and anti-inflammatory mediators are released by the immune system.

And this tends to last 2 to 3 days and the tissues will begin to repair themselves normally. And then there's a subacute stage, and this is where we have our neutrophils released. And they perform vagocytosis.

So with phagocytosis, we obviously have our invading organism and in this case it's our bacteria. The neutrophils will attach themselves via proteins on the surface of that bacteria and begins to engulf it. It then releases lots of other chemicals and enzymes which then just eat away at the organism inside the neutrophil.

And then macrophages eradicate all the damaged cells and tissues so that new tissue has places to grow. And if this subacute stage is prolonged, so if this lasts more than a few days, then the inflammation is, is chronic, and that might lead to more of a systemic inflammation. So if our body has an insult, so any trauma, any wound, then it, it can be quite normal for us obviously to see that the skin becomes warm and red, and it might be a little bit swollen.

And that's completely normal. But it's then when the information is spread away from that initial focus, and there are more systemic signs that we, we refer to it as. So then looking at our coagulation cascades, so once this is triggered, the microthrombis so tiny little clots are released, and they travel via vessels around the body.

And they will block capillaries, so they'll travel down our arteries, and but they're just too too big for our capillaries. So they block those off. And that obviously reduces the oxygen availability down there and will cause cell damage and death.

And obviously, if our cells aren't working in, in our, in our body and in our extremities, then we'll have reduced organ function, and that will include our lungs as well. And then as our platelets are exhausted, they're not available for when the patient will suffer a further trauma. So then if that patient then suffers a further trauma such as just us taking a blood sample or placing an IV catheter, then that can lead to excess haemorrhage.

And obviously if this now becomes very widespread and we see lots of ecchymosis on the abdomen and we have patiki in the mouth, then this can be classed as DIC, which obviously has, some people will know as death is coming. So disseminated intravascular coagulopathy, and that is a very serious stage, but it's not necessarily something that we can't come back from. So just a little bit now about some research that's been going on, so.

So mortality in sepsis for humans is between 30 and 40% for severe septic patients. And when those patients are becoming shocky, that rises to 40 to 50%. It has been shown that early recognition of survival and early recognition of sepsis, sorry, will improve survival, and it's been done in a few ways.

So introducing sepsis bundles, which we'll go through in a second, educating the staff on those bundles, especially, and also by having nurse-led protocols. So lots of these bundles introduced into human hospitals are a nurse-led situation. So, the nurses will pick up on those at triage when patients come through.

So a bundle is basically a flow charts, I guess. It's a tool that they use in human hospitals and they use them everywhere to ensure that staff are following the same protocols for treating different conditions. And it's just so that there's not that much variability, and therefore, hopefully reducing the risk of missing anything.

Sepsis bundles have been used in hospitals for many, many years, and that's because it's the biggest killer of human patients. And so the same is probably true of our patients, but there's been no studies to really prove that. And I think it's around, I think the current number is around 44,000 people in the UK die a year from sepsis, so it's a really big killer.

So as I said, it's a, it's a flow chart, starts off with some presenting signs that are for the nurses to pick up on admission through triage, and then they're followed by suggested diagnostic tools and treatments. And when followed and all the staff are trained and they are very compliant, it has been shown to improve survival about 50% when they've been followed. So the first sort of bundle that we'll look at is sepsis 6, and many of you might have heard about this.

So, it was initially brought in to get patients treated within a 6 hour period of admission to hospital. And the treatments that they recommended was high flow oxygen, taking blood cultures, after that, starting them on broad spectrum antibiotics, starting them on some fluids if that was necessary, and measuring their serum lactate levels, haemoglobin and urine output. And then they kind of decided that actually 6 hours was a very long time, especially if these patients are severely septic.

So then they moved on to sepsis 3. And the new guidelines suggested that the bundle should be followed within 3 hours of admission to hospital, for any patient that has severe sepsis with an organ dysfunction, and then completing the 6 hour bundle after the, after that. They've now kind of moved on their, they're sort of thinking that actually SARS is far more commonplace, than they had once thought.

So, their thinking is that actually now every patient entering an ICU in a human hospital has SARS, so they I don't really feel that it's really a useful tool in describing a patient's status. So they're kind of replacing that now with something called sequential organ failure assessment. So now patients in human hospitals will actually be assigned like a sofa school, just to show how septic they are.

So here we have an updated human sepsis bundle. So hopefully you can see this, but I'll just quickly go through the different parts. So for severe sepsis, within 3 hours, they're expecting the doctors and nurses to have completed 2 sets of blood cultures on the patient, started them on broad spectrum antibiotics, and having done at least 1 lactate measurement.

And then they're saying that if the lactate is high, then they should be repeating that blood lactate. And if the patient presents with septic shock, then they should be having two sets of blood cultures, the antibiotics, having a lactate measurement, and then also a crystalloid bolus of 30 mL per kilo, and that's actually a prescribed bolus, that's not variable. And then within the 6 hours for the septic shock patients, they'd be repeating the lactate, starting vasopressors if the patient continues to be refractory to any fluid bonuses, and also then just reassessing how septic they are.

So these are a working document, and they'll just keep going through them until their patient becomes more, more stable. So there isn't actually any veterinary sepsis bundles out there yet at the moment and I had a go at developing one just for some research I did a couple of years ago, so it's, definitely not available, but, it needs work. So, it's basically following along the same lines.

So, we've just got some SERS criteria and sepsis because I think for us at the moment, SERS is still a relatively good term to use for our patients, and I definitely think it describes a lot of our patients. So having a SARS, SESI patient is, is fine. That's what we still use.

That's a term we still use regularly. So we've just got a table here, with some, clinical signs. So if your patient presents with 2 or 3 or more for cats of these clinical signs, then you go into the septic criteria, checking for a cause for infection.

And then if they do have a cause for infection, then performing blood pressures and blood gas samples, and then sort of going from there depending on what your results are, consider treating them for sepsis or septic shock. So now we'll go through the clinical signs. So hopefully this is the most important for all of us.

So, . As I've just said, SAS is very, very common. And basically any patient that presents to the hospital, if we're concerned about them having any sort of infection, then definitely sepsis should be at the back of everybody's mind all the time.

And the best way of recognising it is really to be observing trends. So by making good notes in the patient records and on their hospital sheets, then hopefully that will provide a really good trend setting so that we can see when things are are subtly changing, and that will help us pick up on things quicker. And, it goes without saying, obviously, to monitor the bloods and organ function with any patient that's that poorly.

So here we have some clinical parameters for dogs and cats that I think we're still using quite happily today, even though they are quite dated. And I think that they're all definitely clinical parameters that we have in the back of our minds all the time. And I'm just going to mention that obviously cats are difficult because they like to be difficult, and they often present much, much sicker than dogs.

So this is due to them having smaller intravascular spaces, and volumes and then poor regenerative capabilities. So when they do present to us and they're very sassy, then they're often actually quite collapsed. They might be in lateral recumbency, and they tend to be hypothermic, and kittens will be much worse.

So they'll be hypoglyceemic and bradycardic. But it is quite rare to see cats with SARS. Unfortunately, for whatever reason, maybe because they, they keep their illnesses hidden for longer periods than our dogs do, they do seem to have a higher mortality rate compared to dogs.

So they're, they're just very tricky. So moving on to some clinical signs. So our heart rate is actually quite variable depending on the stage of sepsis in our patients.

So we typically expect a patient that's got a systemic inflammation to be quite tachycardic. If the dogs we're looking at a heart rate of over 140 and cats a heart rate of over 220. .

We will have bradycardia feline patients generally if they are presenting to us with sepsis. So definitely a heart rate of under 140. And actually, with our canine patients, if they are presenting at a late stage of sepsis where their body isn't compensating as well, then we can, we can sometimes see that they might be bradycardic as well.

Because, we have bacteria in our cells, our cells are working overtime, so we actually have an increased use of oxygen in the tissue. So it might be that these patients are presenting to us with increased respiratory rates, and possibly respiratory efforts, depending on how, how sick they've been for how long. And, it's really worth thinking about having acute respiratory distress syndrome in any patient that has presented to us with severe sepsis or septic shock.

So then taking our blood pressures, so hypertension is extremely common. And if we are following on from the bundle ideas, then we should be treating initially with some fluid therapy or vasopressors if they become unresponsive. It's tend to we tend to recommend isotonic crystalloids whilst monitoring the BP really closely, and we'll often give dogs up to 60 to 90 mL per kg bolus and cats up to 40 to 60 mL per kilo.

But we would always do this in, in small amounts. So we'd start off with a 5 or 10 mL per kilo bolus and then reassess the whole patient to Check that they're OK and they're coping and we might actually have improved them with that much. It's not to say that actually we should be giving the dogs 90 mL per kilo as a bola straight off, because that might be way more than they need.

So just sort of noting that we, we should be checking these patients after very small bonuses. And I think it goes without saying that obviously with our cats, because they like to be so difficult, we would really be monitoring closely for signs of overload in case they've got undiagnosed heart disease. So with our white blood cell count, as with any infection, we increased, white blood cells as expected, as we're fighting the infectious agent.

And again, we'd look back at that table just to see whether the number of white blood cells, sort of fits in with our septic patient according to the table. So then our lactate, so lactates so useful. So we tend to take lactate from our blood samples and it's that if a lactate is over 2.5 mm per litre, then actually that can indicate a hypo perfusion before other clinical signs such as your respirator or heart rate change.

So, that's really interesting actually. And even if we have a patient that may be presents in a consult and we do some bloods and they don't actually seem that sick yet, if they've got an elevated blood lactate, then it's really something to think about. These patients actually maybe they're hyper perfused and they're just coping well at the moment.

. Lactate in general is a great indicator of this, but it's not to say that actually a patient with a lactate of 3, when they're very unwell, compared to a patient with a lactate of 7, that's not really the indicator of how well that patient will do, but actually with our lactate, we should be looking at the trends. So this is when it comes to making good clinical notes. So if we have a patient that's got a lactate of 7, and actually, after some fluid bonuses and some supportive care, that lactate comes down relatively quickly, then that patient actually has a better prognosis than the patient who's got a blood lactate of 3, but actually, well, with lots of intervention and fluids, that doesn't come down as quickly.

So it's a really good prognostic indicator. And it's also possible that we're measuring fluid lactate, so we can take the lactate of other fluids in the body. So if the fluid contains bacteria, so if we, we have this patient that's presented to us and we think they've got a septic effusion, then we can actually do a lactate on that sample, and the lactate will be high in the sample because of anaerobic respiration by the bacteria.

So this can be used when we are diagnosing our patients. So if you do an abdominocentesis, then definitely it's worth looking at that lactate. And that was shown in a study in 2003, so it's, it's definitely been something that's been around for a while.

So then further on with our bloods, we'll be checking our blood glucose, and it's obviously very common for patients with sepsis to present hypoglycemic, and that's due to again, the higher consumption of glucose by the cells and, and the bacteria in the body. So we expect to see hypoglycemia in these patients, but again, we can actually be doing our Blood, sorry, our glucose measurements on other fluids, very, very similar to how we discussed with the lactate. And it was in the same study that they did this, but they showed that actually blood glucose levels were always higher than the glucose levels in the fluid sample, if the patient was septic.

And in felines as well, that was found to be 100% accurate. And if the patient had a non-septic effusion, the glucose was either the same level or higher than the peripheral value. So it's definitely worth thinking about as a diagnostic tool for this.

So there are hyperglycemia. So although it's very uncommon, some patients might present septic with hyperglycemia, and it's not fully understood why this happens, but it is thought to be brought on by, the inflammatory cascade, some sort of insulin resistance. So even though it's very, very rare, it's definitely something to have in your, in your mind if, if you have a patient you think they're septic, but they're not hypoglycemic, not to just rule out sepsis.

So they, they still might be. And it's been shown that actually by maintaining a normal blood glucose, you will decrease the morbidity and mortality rates. So we often will do that with CRIs of dextrose and or insulin, definitely, depending on that patient's status and how hyper or hypoglycemic they've been to maintain an adequate level.

And then neurological signs. So it's been shown in humans that we would have an altered mentation once we become septic, and then people often become quite confused. They might slur their words, and they might not sort of get their words out in the, in the way that they want them to.

And that's due to loss of cerebral blood flow in sepsis. With our patients, we tend to see that when they're septic, that they will be stuporous or obtunded. But it is quite difficult to assess them as people are assessed.

Obviously they're not talking to us, we can't decide if they look confused. So it is a little bit more subjective in how their mentation might change over the course of treatment period. So what we tend to use is our modified Glasgow home skill, and that just enables us to give a value to their mentation and also kind of prevents it from being too subjective, especially if these patients are moving from one shift to another shift.

So if you've got another vet and another nurse coming in for the night shift, if they are also doing the Glasgow home schools, then actually it's less likely that they're going to interpret the mentation of the animals. And again, just really following trends. So, yes, the patient might have a very poor prognostic value on their Glasgow Coma school, but if they start to improve quicker, then actually they, they might have a better prognosis.

So just following all these trends and trying to pick up on little signs is really beneficial. So then our CRP, so some of you might already test CRP, it's a C reactive protein, and it's an inflammatory marker which is used very, very commonly in human medicine every day. It's a protein that's synthesised by the liver, and it's a part of the acute phase response by the pro-inflammatory cytokines.

And in human medicine, they'll always measure CRP and actually they use that as a sepsis marker, very reliably. With our patients, and so far it has been found to be useful if you monitor it along with other signs of sepsis, but it's not yet been shown to have a good correlation between the levels of CRP and the rates of survival in septic patients. So it's not something that we rely on a lot, but hopefully in the future we can maybe get more information from it and use it more, more reliably.

So with these patients again, we'll be testing their blood quite regularly and it's really important that we check on their liver and renal parameters. So we want to be running them. Pretty often, depending on how sick the patient might be.

And creatinine increase of just 0.5 mg per deciliter might actually indicate that this patient suffered an AKI. And if they've suffered an AKI, and that's their first organ sort of dysfunction, then yes, they're they're septic, but actually that AKI could be pushing them into mods.

So just really thinking about how, how poorly they are and monitoring all of their values and very closely. And the sepsis might trigger the coagulation cascade, which obviously we've talked about earlier on. So they will first become hypercoagulable and develop these little microthrombi, which damages the organs, and that causes them then to be hypercoagulable.

So we want to be checking our coagulation times, which some people are very lucky. We can do that in our practise, and it might be that we have to send that away. But just checking the PT and APTT to just see whether our patients are developing any coagulopathies.

And it might be that if this patient has developed a coagulopathy and it's a new thing for this patient that actually they might be leading into DIC. And again, that's just where the microthrombi have damaged the cells of organs, and they then have haemorrhages everywhere. So as you can see with this patient, obviously, you can see where they've got excess bruising, where they've had some bea punctures, and just some ecchymosis, and this patient was, covered in petiy in their gums as well.

So, just really not a good state to be in. And once we've progressed to this, then we have our multiple organ dysfunction syndrome. And once we have reached that, unfortunately, mortality or morbidity rate is much, much higher, and up to 90% of human admissions to ICU are confirmed, sir.

So as I said before, we are now just equaling sepsis, to infection, basically. So they developed a new definition in 2016 just to say that a life threatening organ dysfunction caused by a dysregulated host's response to infection. And so that's how they're defining sepsis now.

So, obviously we have sepsis, and we've got lots of infections. So we're going to want to treat that infection, and so, basically what antibiosis are we going to be choosing? So we want to be choosing the most appropriate antibiotic for each patient.

And the gold standard would be that we are culturing these patients before we're starting them on any antibiotics at all, so that we can really get a very good selection on our antibiotic choices. And it's advising human medicine to take blood cultures as standard before administration of anything. And I think that's less so in in veterinary practise, maybe for cost reasons, but also for timing.

I know that it takes quite a long time to get our blood cultures back. So if we do Have a septic patient, definitely at our hospital, we will try to do blood cultures before we administer any antibiotics, and we will at least do maybe a swab of an area if we think that the septic focus might be something external, just so that we can try and see what the bacteria will be sensitive to. It's really important that unless we have no idea that we avoid giving broad spectrum antibiotics where possible, and we try to narrow that down.

And we have protocols in place to only give fluoroquinolones or 3rd or 4th generation cephalosporins when they're really indicated. So by having a hospital protocol in place and ensuring everyone follows it, then hopefully we should all be on the same page with that. Because I think we are, everybody's aware, we're entering a little bit of a crisis in terms of our antibiotics, and our multi-drug resistance.

So, just if everybody is slightly more careful with antibiotics, hopefully we can try and overcome that. This is BVA's poster and that they have full practises to put up on just the responsible use of antimicrobials. And it's all really important, but I do think that these three for us, when we're talking about sepsis is definitely very important.

So choosing the right drug, and definitely using narrow spectrum antimicrobials, and Continuing to monitor the bacterial culture and sensitivity trends as well in these patients. So if we have a patient that we have, cultured and started on antibiotics, and then two days later, maybe they are slightly better, maybe they're the same, or, or maybe they are worse, and actually just reculturing that site, and sending it off just to see whether we're developing a multi-drug resistant infection. And minimising the use.

So obviously, in these patients, we know that they have an infection, so we really want to be providing them with antibiosis so that we can try and fight that infection for them. But definitely also combining that with strict aseptic techniques with all of the patients, and especially with all of their instrumentation. So I just think that's really important and definitely by you can go on to BVA's website and have a look at this more closely and maybe print off some posters for the practise or order some because they, they are definitely very useful.

So now we're just going to talk about some patient care. So these patients are often really, really poorly, and we want to be able to do everything for them. So, we may have talked about this before.

So this is Kirby's rule of 20, and I quite like it because it is basically a comprehensive list of everything that one patient will need in a at least a 24 hour period. So, the whole 20 of them are listed there on the right hand side, and we definitely don't have time to go through them all today, but they're all definitely invaluable. In assessing our septic patients.

And it just provides us with this, I guess, a crutch really to fall back on, because these patients take up so much of our time and so much of our energy, and it could be quite easy to then forget about nutrition, for example, because we're so focused on their oxygenation and on their fluid balances. So actually, by just referring back to this list, we can just think, have I missed anything? Do I need to revisit everything?

And it's definitely been vet driven, but it's really useful for nurses to also have in mind. And by using the, the rule of 20 actually in our nursing care plans, then we can also ensure that we're really covering everything in our nursing care plans. And I know that we have been learning about nursing care plans for some time now, and, they can often be misconstrued.

As sort of very time wasting. I think especially with patients that maybe aren't so sick, that are in for elective procedures, but definitely when we are thinking about patients that are septic that will be in with the with us for a time, I think it's really important that actually these are the patients that we do do care plans for, just so that we can monitor their progress. So the Academy of Veterinary Emergency and Critical Care techs and defines critical care nursing as the care taken or required in response to a crisis.

And because sepsis is a rapidly progressing condition, these patients might need minute by minute care. So, I guess, preferentially, we'd like to have a nurse by that patient's side the whole time, which obviously isn't always possible. And for that reason, they might be best nursed in an ICU facility, or at least a hospital that has 24 hour facilities.

These patients are not the type of patients that we can be leaving overnight. We really want to be making sure that we're with them the whole time. And, nurses are definitely spending the most time with patients, and are more likely to pick up subtle changes.

And it's been shown in human medicine that actually the nurses spend up to 60, 60% more time, patient bedside than the doctors do. And I think that it's Probably slightly less for our patients, but it's really something that is still true. So just by having a really good clinician, nurse understanding and trust, hopefully we can build a really good bond and therefore do the best for our patients as well if we're making that communication channel really open and honest.

So our septic patient, we will want to be monitoring the clinical signs very closely, taking regular rectal temperatures, monitoring heart rate and respirate, and also effort. And to do this, actually, it might be useful to have these patients on a multi-parameter monitor. So if you do, if you have one of these in your practise, then that's really great.

And definitely for these patients, if we are not able to afford to have a nurse to sit next to this patient, the whole time, then actually by putting them on multi-parameter monitor, hopefully if you're, with another patient and you're Looking at that, then it hopefully will alert us to any changes that we're not expecting. And that's not to say that we should rely on multi parameter monitors at all, because we definitely shouldn't. But just use them sort of as part of your tools and so that we can really be doing the best for these patients, especially if we've got a busy clinic and there are other patients that we need to be looking after as well.

And we really need to be making good patient notes. Obviously it's a legal thing as well, but, just the following trends as well in these patients, I just really can't stress that enough. So these patients tend to be the ones that will be very well instrumented.

And nurses as well are able to place and care for the tubes, lines, and drains that the patients might have. So starting off with our intravenous catheter, every patient will need one of those. And it might be that actually the patient will require to have a central venous catheter or an arterial catheter.

The peripheral catheters are absolutely great and obviously we can administer fluids and medication through those. But if we have for a very, for example, a very large dog and we might want higher rates of fluids or higher volumes, and maybe higher concentrations of CRIs and of medications, then maybe a central venous catheter or a long stay catheter might be, might be better off. We sometimes will place arterial catheters in these patients in order to check their invasive blood pressure constantly and also to provide us with access to have regular sampling as well.

But these catheters and all the lines and tubes in any of these septic patients need really well dressing and double checking at least twice a day because they're really more susceptible to have any complications. So now looking onto our fluids and medications, we really sure that we have the correct fluid types at all times, and we want to be labelling them. So, It depending on, on what crystalloid we want to be choosing, just making sure that that is the correct one and maybe double signing them if we've got a large team, especially, and deciding whether we want crystalloids versus colloids.

So maybe these patients actually might benefit more from having fresh frozen plasma, to having crystalloids, depending on how septic they are and if they might have, some coagulopathy. We will obviously be starting these patients on antibiotics. These patients are typically quite painful, so starting them on an opioid is really recommended, especially maybe one that we can change quickly or escalate if we need to.

But a note on obviously non-steroidals, we tend to want to hold off those just in case we do end up having an AKI. We don't want to be putting them under any more strain. These patients might end up on vasopressors, and definitely if their blood pressure is low, and remains refractory to any fluid bonuses, then these patients will be started on norepinephrine possibly.

And it might be that actually these patients require more than one CRI. So we've mentioned the norepinephrine and, and maybe this patient requires fentanyl CRI, but they might also require a dextrose infusion as well. So making sure that these are being calculated well and double checked because there there's so many room for errors when we're calculating lots of drugs.

And if this patient's going to go on to a lot of different drugs, then just ensuring that you know which drugs are compatible with one another. And if there are any drugs that we really shouldn't be putting through the same line as compound sodium lactate, for example, we, we wouldn't want any precipitation of calcium. So definitely not giving phosphate with compound sodium lactate is really important.

So just by knowing the, the drug combinations and just checking them in the drug formulary, just to check that they're really safe to go in together. And also labelling our lines, really clearly. And this avoids us doing any incompatible combinations, unknowingly because we'll see that we have this going into this line, so we know not to bolus anything.

But also to prevent us from doing any accidental bolus thing of norepinephrine, and we tend now in our hospital to try to put that on a peripheral IV catheter and label that and just have a dedicated catheter for the norepinephrine because we do not want that going into a jugular port where we might be then giving a fluid bolus, and then inadvertently giving a norepinephrine bolus. And then also thinking about our nutrition. So again, these patients really need nutrition, but a lot of them might not be able to eat and they might not want to eat, they might be regurgitating.

So maybe considering enteral nutrition if this patient is expected to be poorly for quite some time. So especially if we have a recumbent patient, we're going to want to place a urinary catheter. We want to do this to make the patient more comfortable so that they're not soiling themselves, but we also really want to be monitoring their urine output really regularly along with their specific gravity.

And that will enable us to check for an AKI and will also give us the first indication of an AKI maybe if their urine output does start to drop. And that might indicate to us that this patient's developing AKI or or MODS. These catheters will need extra cleaning and care, and that's because, neutropenia in septic patients is obviously very common, so we want to prevent them from developing any UTIs.

And to do this, we would dilute, dilute some heavy scrub, and do 4 hourly cleaning or more depending on the patient, but just starting at the vulva or the prep piece and wiping down the system, but we would never wipe back up. And that prevents tracking of bacteria up to the outside of the system. And then just to note, just to say that actually, aside from obviously aseptically emptying urine in order to measure it, we really don't want to be opening a system at all, unless the catheter for whatever reason gets blocked, if they, if they've got a sludgy bladder, or if they've got stones, then yes, sometimes we might need to aseptically disconnect them and flush it.

But every time that we're opening this is another, chance for bacteria to get in. So really, we don't want to be doing that too often. And foley catheters are really great as well.

We will sometimes use them as faecal collection systems. So, this is very clinician dependent and definitely something to have a look into if it's not something you've done before. There are faecal catheters available in human medicine that we can buy for our patients, but they are extremely expensive.

And actually we found that we can use very wide bore Foley catheters to the same effect for patients that have very liquidy hemorrhagic diarrhoea. And if they're very recumbent, it's actually just really nice for them not to soil themselves constantly. And I think we've all had those patients that have been really tricky to nurse because they have been leaking diarrhoea constantly.

And, you know, they end up getting quite sore and quite distressed and, and it's obviously difficult work for us as vets and nurses as well. So maybe something to think about in patients and that might tolerate them. So patients, they might already have some drains or they might be having some surgery and come out with drains in place.

So we want to ensure that all drains placed in these patients are done aseptically and maintained aseptically. And I really like the use of needle-free bungs with things like chest strains, because it really does reduce the incidences of human error. So I know that three-way taps are normally what we put on the end of these, but actually, the instances of human error with three-way taps is quite large.

So just by replacing that with a needle-free valve actually just gets, gets rid of that, that concern. So I, I quite like the use of those. And we want to be measuring the output, so air versus fluid, depending on what our patient is here for.

And if they're septic because they've got a pyothorax, then we'll lavage them with saline to help reduce the volume of bacteria present. So we'll warm up the saline and then do that. And depending on the size of the patient, depends on how much we lavage them with.

But normally we'll do so in small volumes, so maybe 10 or 20 mL syringes, lavaged in, and then, drawing out, and we'll normally do it until the fluid sort of comes out much clearer. And then for our wound drains, we'll have active versus passive. So, in a septic abdomen, we tend to try and place active drains such as Jackson Pratt's because that just enables us to be able to empty them really aseptically, and prevents bacteria entering the drain and tracking up into the abdominal cavity, for example.

It's not. Uncommon to have, Penrose drains in lots of wounds, but, they really should be dressed, with dressings if you're going to have those because they, are just providing, a really great tract for bacteria to go up. So just dressing them really appropriately is, is fine.

And then back to our nutrition of our patients. So we might actually want to be placing nasogastric tubes. And again, this is something that nurses can do once we've been trained.

And we just measured to the last rib, make sure we've got some local anaesthetic and lubricant to aid the placement, and we tend to put it down the nostril, but also into the eye so that it goes down the medial canthus and just gives us a little bit more numbing. And in these patients actually, they are normally quite poorly and so they might be stuporous or obtunded. So actually it's quite well tolerated to have an NG tube placed.

So we will suture or staple in place depending on, who, whatever you prefer to do. And then definitely do thorough checks to ensure that we're in the stomach and not the airway. So this might just be some rads, you might stick a catnograph on the end.

If you want to do the catnograph on the end, obviously, you shouldn't have a trace at all because if you're in the stomach, there shouldn't be any air flow. And then the most obvious one would be to aspirate because if we're aiming to go into the stomach, then we should have some sort of residuals down there. And then preventing patient interference.

So depending again on how sick these patients are, we might want to place a buster collar if they're conscious, but if they're not, then we might just want to leave them and just monitor them really closely. Label them so that there's no confusion over where that tube is going. And I especially like nasogastric tubes over nasal esophageal tubes, because we can use them to empty the gastric fluid and actually then reducing their nausea.

And especially if these patients have been regurgitating a lot and they've been very nauseous, it can be really difficult to get on top of that with medication. But just by aspirating their stomachs quite regularly, we can hopefully sort of rid them of that nausea. And again, it will help them, sort of reduce that instance of aspiration pneumonia, which obviously would be very, very serious for these patients.

So just really, they're just a good thing to do. And then once the patient is stable enough, and we've still got our NG tube in place, and we think that they could tolerate some nutrition, then we might be able to trickle feed the sensitive CRI. We tend to start off with these patients on a CRI, so it's just a few miles an hour, just so that we are, Not sort of bombarding them and making them feel really nauseous with Ebola feed.

So then other instrumentation that these patients might have. So we'll want to be monitoring their ECG if that's something that we're able to do. So we'll place them on the feet normally or possibly on the thorax if it's a large patient.

We can use a temperature probe. So if we're lucky enough to have a multi-parameter monitor, then that just means that by doing that, we, we don't have to keep taking rectal temperatures, which obviously can be quite distressing for the patient. We want to be monitoring the SPO2, especially if this patient is quite collapsed, and obviously checking that this doesn't drop too low.

So, an SPO2 reading of 5 that the equivalent to an a partial arterial oxygen of over 90, should be 95 or above in a healthy patient. And Actually, a 90% SO indicate severe hypoxemia, which actually would be when we would start to consider mechanical ventilation in these patients. And so an SPO2 of 90% is actually very serious and can definitely indicate that the patient might have acute respiratory distress syndrome.

And it really doesn't hurt, even if we've got a good SPO2 reading on these patients. It doesn't hurt to provide them with some oxygen therapy. The patients are really going through a lot and all of our cells using much more oxygen when we've got an infection like this.

So, even if we wanted to just give them a little bit of flow by, that would definitely help them. And it's worth also then thinking along the lines of prongs or cannula if the patient is quite collapsed, or if we're worried about aspiration pneumonia, and their oxygenation status. And then I guess even further on, if this patient does need intubating, we might want to just check their capography and just assess that they've got a normal reading.

So we want to be turning these patients really frequently if they are recumbent. We will do that as part of physiotherapy, and also provide them with nebulization as well, especially if they've got any respiratory pathology. Taking care of any wounds or any drainage.

And checking the bandages for strike through. These patients also will benefit us, doing some oral care. So, if we've got a patient that's intubated, we will want to do regular cleansing of the mouth and teeth, with either very dilute chlorhexidine or a corsidol solution, which we tend in our hospitals to do, via a fifty-fifty solution.

And that just works. Really nicely to sort of cleanse all of the teeth and mouth, and also serves to actually, stop a buildup of bacteria in their mouths, which is another aspiration risk. So by just cleaning their mouths really regularly, you're actually lowering the risk of them having any aspiration of horrible bacteria from their oral cavities.

These patients, if they're recumbent might require some eye care, so regular saline flushes and lubrication. And again, nutrition, definitely we should be thinking about that whether this patient needs enteral versus parentin or if they really can't tolerate any feeding. And we will always stick to our strict infection control with these patients, so having bear below the elbow at all times and barrier nursing them.

So I think we've got time. So, just to run through a little case study, that we had in not too long ago. So this little dog was Penny.

She was a 3 year old female neutered Labradoodle that presented to us after having an ex lap and a foreign body removal, which I believe was a sock, an event and end anastomosis at her referring vets 2 days prior to her referral. She had no previous relevant medical history at all. She'd up until this time been a very happy, healthy little puppy.

and I think was just a cheeky monkey and known for eating things that she definitely shouldn't have done. So when she arrived to us at the hospital, she was obtunded and non-responsive to any auditory stimuli, and she had one IV catheter in place in her left cephalic leg. So, on presentation to the emergency room, we did some initial diagnostics, and our vets did, an abdominal fast scan.

And by looking at that, they saw that she had a vast peritoneal effusion, which they did an abdominocentesis on and, and they checked that and it was definitely septic. She had some intracellular bacteria. They did a thoracentesis as well, and she had a septic, I haven't put that there actually.

She had a septic effusion there. And on her TA, she also had multiple beelines, with, consolidated lung tissue. And the thought was that she had aspirated and got aspiration pneumonia.

I think she'd been quite poorly up until going to her referring vets as well. So, having a lot of vomiting. So I think the thought was that she'd aspirated it maybe a couple of days prior to her presentation.

We did a blood gas and electrolytes report, and she was hypoglycemic, hyper lactatemic, azotemic with a low partial arterial oxygen levels, and she had hypertension as well. So her blood pressure was around 60 on arrival. So initially we stabilised her prior to surgery.

She needed revision surgery on her abdomen. We did this with multiple bonuses of crystalloid fluids. She was started on a fentanyl CRI, and she was started on oxygen supplementation.

She went into theatre, and they had to do, quite a large resection, of intestines, and then revision end to end anastomosis, and they brought her out. And that site had definitely broken down and that was their septic focus. So they did lots of lavage before bringing her out into ICU.

She had been quite well instrumented before she came to us, so she had now two cephalic IV catheters, and they'd also placed a central line in her jugular, in order for her medications that she was on, and also to give her high rates of fluids as well. They had also helpfully placed an arterial line so we could do regular arterial blood samples with her and we were also monitoring her invasive blood pressure from that as well. And then on her wound or abdominal wound, she had an active Jackson Pratt drain to empty that, effusion.

So this was her in ICU. She was, as you can see, very poorly puppy. She deteriorated very markedly once she'd left theatre.

She didn't do very well in theatre either, but that was no surprise. So she was on vasopressors because she had a very low blood pressure that really wasn't improving at all. She was on norepinephrine.

Her hyperlactictemia increased, so she was given further crystalloid bolus, and she was hypoglycemic. So she had been on a 2.5% dextro CRI going into theatre, and she came out and needed to go up to a 5% dextro CRI, on her way out.

She was really deteriorating with her lungs. So, we believed that she had os and initially we started her with nasal prongs, which were very well tolerated because she was so flat. But actually, we then had to progress to high flow nasal oxygen.

And you can just see that in the top right corner. She was on 8 litres a minute at the time the photo was taken, but she did go on to, 12 litres a minute, up to 15, I think, eventually, to try and support her, which definitely worked for a short period of time. She then had elevated COAG, so her PT and APTT were elevated and so she received 3 units of fresh frozen plasma relatively quickly.

But unfortunately, her razotemia was worsening and her lungs were worsening. So she had definitely developed mods and odds. And so it was elected to euthanize her before she really suffered any further, which was an absolute shame, but really goes to show you that actually, even though she had excellent care and, everybody was on the ball with her from the start, that actually it's not a good outcome once they've already reached having some sort of, sepsis.

So obviously, when she presented to us, she was already aotemic. So hopefully, you've enjoyed this evening. We've gone through our definitions of sepsis.

The basic understanding of the path of physiology of sepsis, gone through some clinical signs, so hopefully we can recognise those signs more clearly in our patients, in the hospitals. We've discussed careful antibiotic therapy. And how best to care for these patients as well.

And so by understanding how it will show itself in our patients, hopefully we can pick it up much earlier and treat their symptoms, which will hopefully therefore increase the likelihood of survival. So thank you very much. Fantastic.

Thank you very much for that, Katie. That was a great, webinar, and I think it's always really useful at the end, to have a case study because it really helps sort of contextualise some of the theory that you've been going through at the beginning, etc. So hopefully, everyone listening in today is I really enjoyed that.

Now, as I say, Katie has finished in good time, so we do have a bit of time for some questions. We already have had a couple come in, so we'll crack on with them shortly. But if there's anyone else who got any other questions or any comments they'd like to make, then please do, put them either in the Q&A box or in the chat box.

. Just to let you know, there is gonna be a short survey at the end of this, so we really would appreciate you to complete that because it helps to give feedback to Katie, but also helps us plan our programme for the forthcoming year as well. OK, so on with the questions, Katie, are you ready for this? Thank you then, yeah, but Katie has said that, obviously she's a very highly qualified nurse, but if there's any more veterinary, questions, then Katie's more than happy to take them back to the, back to work and, get the, relevant answers, but.

I'm sure you'll be absolutely fine. So, we've got one question here, it says in human medicine, they're starting to move away from 02 therapy as research suggests that it can actually drive the septic process. Do we have any research from the veterinary medicine at the moment?

No, unfortunately not. Our research is still quite far behind. And I think for the meantime, definitely, where I'm at the moment, we are still giving these patients oxygen therapy.

We haven't definitely in our experience with our septic patients, have any reason to believe that by giving them oxygen therapy, we are worsening them at all. And, We can only think that at the moment it's providing them with some help or benefits. So at the moment, no, but it's definitely something that maybe there should be more research into.

No problem. Got a question from Hillary. Hillary said, would you do a blood culture for a suspected sepsis?

And if so, can it be done without special media? So yes, we do. We do often take blood cultures for patients that we are suspecting are septic.

But it does have to be done in a special blood culture medium. So, we do order those bottles from the lab. So I think they are relatively expensive.

I can't remember how much, but, Obviously, I think it's just something that if we're going to be moving on to having gold standard care for these patients, it's going to have to be a cost that's transferred to the client in terms of providing the best care for that patient and also the best welfare on choosing our antibiotics more wisely, rather than just sort of throwing antibiotics at them, without having Sort of indication as to what they might be sensitive to. So it'd be about having that on open and nice conversation with the owner initially and explaining the reason behind why you're doing what you're doing. Exactly, yeah.

And I think in human medicine, it's obviously something that they have to do. And with us, we don't a lot of the time because it's not, yet something that owners expect of us. But I think that as we're moving on with providing better and better care, it will be something that we really should be expected to be doing.

No problem. Christiana's asked, what is the pathho mechanism of bradycardia in septic cats? So, because cats have lower circulating volumes, they just tend to actually decompensate much, much quicker than the dogs.

So it might be that they actually start off more tachycardic, but as I said, when they present to us, they are often much more sick. And the dogs present to us. So it's just that they're later on in their stage that they present bradycardic.

No problem, thank you very much. Couple of, people just commenting, excellent presentation. Thank you for a wonderful lecture and overview, thank you and superb.

And that was just your mum and dad saying that's me. I mean, they, they generally people coming in saying thank you. They're really useful.

Got a couple more questions before we let you go. Sure. Laura's asking, did you say to administer local anaesthetic into I so it travels down the, nasal, nasal cream or ducts when placed in nasogastric tube?

Yes, so we often give a little bit of proxy mecaine into the nostril and also into the side, and the eye of the side that we want to be placing the tube, so that it will travel down and just provide some with extra numbing and we seem to have good, good outcomes with that. Thank you very much. That's a really useful tip there.

Well, just reading another couple of questions, . So, er, Ian's said, well done, but I've always thought that a bit of luck is worth an awful lot of skill. Ultimately you have any idea how much better your survival rates are compared to mine, which tend to be based on little but on hope and a lot on prayer, so.

Yeah. Unfortunately, these patients, I mean, as the case study indicates, it really sometimes doesn't matter how much you throw at them, they're not going to do well, but it's just about knowing and trying your best. Yeah, no problem, thank you very much.

Well, unless anyone has got any last minute questions. What I'd just like to say is, for those of you who attended our virtual congress last weekend, well, I hope you enjoyed it. And those of you who missed it, do not worry.

We are hoping that by tomorrow we're very confident, the recordings will be available on our website. So all you need to do is log in, go to courses, search for Virtual Commerce 2019, and you'll be able to find all 50 hours of content that has been taking place over last weekend available for you to watch. We will be sending out an email to let you know when it's up there, but, yeah, please do.

Obviously take time to check that out because some other great webinars on there. So that is the, my notices. So all it leads me to do is to say thank you to Libby for being on hand to set Katie up and to answer any queries that anyone's had.

Thank you obviously to yourselves for attending tonight's webinar. I hope you have found it useful, and as I say, please do take time to complete the survey at the end and look forward to welcoming you on a webinar soon. And obviously, last but not least, thank you to Katie for such a fantastic presentation this evening.

I think a lot of you are going away with some really useful tips and, putting some things in place there. What, oh sorry, one question before you go, Katie, and apologies if you did cover it. Do you know you were saying at the very beginning about the bundles in hospitals?

Yes. Now, if there's not, if people, you know, people listening haven't got those sort of bundles in place in the practise at the moment, how would you suggest it, is it the role of the vet, is the role of nurse, or is it more of a multi-disciplinary team where you get together as a team and discuss how you put those bounds together and what's required in them? Yeah, absolutely.

So I think if you wanted to head to one of the sepsis, resources that I've just highlighted there that they will have the human bundles on there that you can have a look at more closely and they'll show you kind of how they've been developed. And you can see the sepsis 6, which was the first one, and how they've moved on from that. And I, when I've developed mine, I basically took that as a basis, and decided to go on our clinical signs that we're looking at in our dogs, and cats, and then With help definitely from one of our internists, we then developed the further sort of flow chart part.

So I think it's definitely a multidisciplinary thing. And I think there's no reason why nurses shouldn't get involved, in deciding on how they interpret it because, in the end, actually, obviously we can't prescribe and we have to do what our vet is prescribing us to do. But if it means that we can treat patients more quickly, if there's a standard protocol in place, then actually that's a really good thing.

So, yeah, just getting everyone involved. Fantastic. Well, thank you very much, enjoy the rest of the evening and I look forward to welcoming on our webinar soon.

All the best. Good bye. Bye bye.