Download Sepsis

SEPSIS
Intern Bootcamp
Scott Denstaedt, PGYIII
Sepsis /ˈsɛpsɨs/; from
the Greek σῆψις: the
state of putrefaction
and decay
Background
• local inflammation systemic inflammatory
response  tissue hypoperfusion and multiorgan failure  DEATH
– release of specific toxins eg. Gram Negative Bacteria
lipid A, Staph. aureus TSST-1
– Host cytokine response eg. TNF-alpha
• Septic shock with multi-organ failure is most
common cause of death in ICU
• >750000 cases/year, mortality rate of 1 in 4
***Sepsis is a spectrum of illness that requires early intervention
to prevent complications and progression***
Definitions
• Systemic Inflammatory Response Syndrome
(SIRS) criteria
–
–
–
–
–
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response to infectious and non-infectious insults
2 criteria needed to meet SIRS
Temp >38, <36
HR >90
RR >20, PaCO2 <32 (differs depending on textbook)
WBC >12k or <4k or 10% bands
• *NO BLOOD PRESSURE IN SIRS CRITERIA
Definitions
• Sepsis
– 2 SIRS criteria + source of infection (you don’t
necessarily need concrete evidence – high level of
clinical suspicion is enough)
Definitions
• Severe Sepsis
– Sepsis with organ dysfunction (don’t memorize the list below)
• Sepsis-induced hypotension
• Lactate above upper limits laboratory normal
• Urine output <0.5 mL kg/h for more than 2 h despite adequate fluid
resuscitation
• Acute lung injury with Pa /Fi <250 in the absence of pneumonia as
infection source
• Acute lung injury with Pa /Fi <200 in the presence of pneumonia as
infection source
• Creatinine[2.0 mg/dL (176.8 lmol/L)
• Bilirubin[2 mg/dL (34.2 lmol/L)
• Platelet count <100,000 lL
• Coagulopathy (INR >1.5)
O2
O2
O2
O2
Definitions
• Septic Shock
– Sepsis induced hypotension despite adequate
fluid resuscitation
• Sepsis induced hypotension = SBP <90mmhg or
40mmhg change from baseline
• Each term describes the the intensity of infectious insult
• Increase in # of SIRS criteria associated with decreased interval
to progression of severe sepsis and septic shock
***CAVEATS***
• Elderly, uremic, and patients with end-stage
liver disease or those receiving corticosteroids
may NOT have fevers.
• SIRS Criteria are entirely non-specific
– EG. Everyone met SIRS criteria on day one of
intern year
• Clinical picture must be taken into account
Rivers et. al 2001
• Initial 6 hours of
resuscitation in ED
• ~1-1.5 hours to
identification of
sepsis on avg.
Early Goal Directed Therapy Outcomes
• Severe Sepsis and Septic Shock
– Randomized to standard therapy (iv fluids, abx) v.
Early Goal Directed Therapy
• RESULTS (Patients with EGDT):
– Elevated CVP, MAP, Scv02
– Decreased Lactate
– Improved Mortality (almost 50% reduction in
mortality compared to standard therapy!!)
Surviving Sepsis Campaign
• Global initiative to reduce mortality from
sepsis
• Evidence based guidelines for the
management of sepsis
• Evidence graded based on LEVEL OF
RECOMMENDATION (strong v. weak) and
QUALITY OF EVIDENCE (ABCD)
• First published 2003, revised 2008, revised
again 2012
• Diagnosis:
– 2 sets of blood cultures from separate sites (culture ALL
vascular devices unless <48 hours old) BEFORE antibiotics
(1C)
– Imaging studies promptly performed to confirm potential
source (UG)
• Antimicrobial Therapy:
– Administration of effective antimicrobials within 1 hour of
recognition of septic shock (1B) or severe sepsis (1C)
– Initial empiric therapy against all likely pathogens and that
penetrate adequately into tissue presumed to be the
source of sepsis (1B)
– DAILY reassessment for de-escalation (1B)
• Source Control:
– seek and diagnose a source - if possible remove it within
12 hours (1C)
• Initial resuscitation:
– Protocolized resuscitation (Early Goal Directed
therapy) during first 6 hours (1C)
– Abnormal lactate should be re-checked, and
normalization sought (2B)
– Crystalloids initial fluid of choice (1B)
– Hydroxyethyl starches for fluid resuscitation
should not be used (1B)
– Albumin in severe sepsis and septic shock in
patients who require substantial amounts of
crystalloid (2C)
– Initial fluid challenge = 30ml/kg (1C)
– Continue fluid challenge technique as along as
there is hemodynamic improvement (UG)
• Vasopressors:
– Norepinephrine initial pressor (1B)
– Epinephrine added to or as substitute for
norepinephrine (2B)
– Vasopressin 0.03 added to NE to reach MAP or
decrease dosage of NE (UG)
– Dopamine only in highly selected patients (due to
risk of arrhythmia) (2C)
– Pheynlephrine only if arrhythmia with NE or as a
salvage therapy (1C)
– Low dose dopamine for renal protection should
not be used (1A)
– All patients on vasopressors should receive
arterial catheters (UG)
• Steroids:
– NO STEROIDS if initial resuscitation
(fluid/pressors) adequate. If this is not achievable,
we suggest intravenous hydrocortisone alone at a
dose of 200 mg per day (2C).
• Blood product administration:
– transfuse only when Hgb <7g/dl to target of 7-9 in
the absence of extenuating cricumstances (1B)
– FFP should not be used to correct coagulopathy in
the absence of bleeding or planned procedure
(2D)
– transfuse prophylactically when platelets <10k or
<20k if significant risk of bleeding, goal of >50k if
active bleeding, surgery or invasive procedure
(2D)
• Mechanical ventilation (ARDS)
– another lecture all together
• Sedation:
– minimize sedation and titrate to sepcific endpoints 1B
– Neuromuscular blocking agents avoided if possible if no ARDS
1C
• Glucose control:
– initialize protocolized glucose management when 2 blood
glucose levels >180 (insulin gtt), target goal <180 1A
• DVT prophy and Stress ulcer prophy:
– LMWH when possible in severe sepsis 1B, Dalteparin if CrCl <30
– PPI or H2RA in severe sepsis, septic shock 1B
• Nutrition:
– enteral or oral feeding as tolerated in first 48 hours 2C
• Goals of care:
– set goals of care 1B
– address as early as feasibile, no later than 72 hours after
admission 2C
2008 compared to 2012
•
•
•
•
•
Crystalloid initial fluid of choice
Epinephrine 2nd pressor of choice
Dopamine no longer recommended
Activated protein C no longer recommended
Normalization of lactate as an endpoint in sepsis
induced hypoperfusion
• Use of 1,3-B-D Glucan and antigalactomannan
antibodies if concern for invasive candidal
infection
Your Septic Patient: H+P
• age
• infectious review of systems: fever/chills, fatigue,
myalgias, cognition, HA, sensitivity to light,
rhinorrhea, sore throat, neck stiffness, cough,
sob, cp, n/v/d, abdominal pain, back pain,
dysuria, frequency, skin changes or wounds,
recent sick contacts, recent antibiotics
• medical comorbidities (chronic diseases etc.)
• medications: immunosuppressants
Your Septic Patient: Exam
• vitals Temp, HR, RR, BP (stable or not)
• head and neck (meningeal signs, oropharynx,
sinuses), cardiac (murmurs!), respiratory
(signs of consolidation), back (CVA,
spinal/paraspinal) tenderness, abdomen,
ascites, skin exam for wounds, feet!
Your Septic Patient: Labs
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WBC - %PMN, %bands
Hgb and Plt (important for sepsis and DIC)
BUN/Cr
Anion Gap
LFT (Hyperbilirubinemia in sepsis, also shock liver)
INR (to assess for DIC)
Lactate if hypotension, anion gap, ill appearing
ABG if anion gap, hypoxic, obtunded (pH <7.2-7.25 -->
patient belongs in ICU)
• U/A, Urine culture
• Blood cultures from two different sites
• Culture other sites as necessitated by history and exam
Your Septic Patient: Imaging
• CXR
• Other imaging depending on your clinical
suspicion (usually CT with contrast)
Your Septic Patient: Treatment
• Empiric therapy based on suspected source of
infection
• Supportive Care
– Early Goal Directed Therapy
– Surviving Sepsis Campaign, update 2012
Clinical Method
• Identify your septic patient (based on the
definitions)
• Triage level of care (Floor v ICU)
• Work-up and treat their underlying infection
• Resuscitate according to EGDT and Surviving
Sepsis Campaign
– Initial fluid resuscitation 30mL/kg as fast as
possible, unless CHF/low EF
• If in MICU place central line, arterial line
Clinical Pearls
• Managing Sepsis on the floor:
– Use defined endpoints for fluid resuscitation
• U/O >0.5cc/kg/hr
• MAP >65
• Normalization of lactate
•
•
•
•
KNOW the patients Ejection Fraction and renal function
Fluid resuscitation is the priority!!!
Start pressors if MAP <65, even if CVP not yet known
Transfer to MICU:
– Hypotension resistant to fluid resuscitation (Septic shock) –
usually after 4-6L fluid
– Severe lactic acidosis (pH 7.2-7.25)
– Severe or acutely worsening hypoxia or obtundation
Sources
• Rivers et. al Early Goal Directed Therapy, NEJM
2001
• Dellinger et. al Surviving Sepsis Campaign
2012, Intensive Care Med 2013
• Current Diagnosis and Treatment: Critical
Care, 3rd Edition
• http://www.youtube.com/watch?v=MceGURf
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