Intern Boot Camp: Sepsis

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Intern Boot CampSepsis

• Cassie Kovach
• PGY-3

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Outline/Objectives

• Identification of sepsis
• Work up of sepsis
• Triaging sepsis
• Treatment of sepsis

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Outline/Objectives

• Identification of sepsis
• Work up of sepsis
• Triaging sepsis
• Treatment of sepsis

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Sepsis is a continuum

• SIRS (Systemic Inflammatory Response Syndrome)
• Sepsis
• Severe sepsis
• Septic shock

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SIRS Physiology

• Inflammatory state affecting the whole body
• Release of cytokines
• ? acute phase reaction? fever, leukocytosis
• ? vasodilation/vascular leak? hypotension,
  tachy, edema, hypoxemia, tissue
  hypoperfusion
• Non-specific

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SIRS Criteria

• Temperature
• gt 38.0 or lt 36.0
• HR
• gt 90
• Respiratory status
• RR gt20 or PaCO2 lt32
• WBC
• gt12,000 or lt4,000 or gt10 bands

BP IS NOT A SIRS CRITERIA
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Sepsis

• 2/4 SIRS criteria identified or suspected
  infection

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Severe sepsis

• Sepsis with organ dysfunction
• Cardiovascular
• Sepsis-induced hypotension SBP lt90 or MAP lt70
  mmHg or SBP decr gt40 or lt2 SD below normal for
  age in absence of other causes
• Elevated lactate
• UOP lt 0.5 mg/kg/hr for 2 hrs despite adequate
  hydration
• Pulmonary
• ALI with PaO2/FiO2lt250 in the absence of PNA
• ALI with PaO2/FiO2lt200 in the presence of PNA
• Liver
• Bili gt 4.0
• Renal
• Cr gt2.0 (incr gt0.5)
• Hematologic
• Plt lt 100,000
• INR gt 1.5

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Septic shock

• Sepsis hypotension despite adequate fluid
  resuscitation

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Sick or not sick?

• Severe sepsis/septic shock mortality 18-46
• 10 of all pts in ICU
• Most common cause of death in ICU

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Case 1

• 38 yo F just finished running marathon, goes to
  medical tent because of lightheadedness
• VS 37.4, 130, 88/60, 24, 97 RA
• Labs not available

• How many SIRS criteria?
• 2
• Does this patient have sepsis?
• No

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Case 2

• 65 yo M presents with productive cough, fever,
  chills.
• VS 38.1, 92, 120/80, 16, 90 RA
• Labs WBC 3.8, Hb 9, plt 180
• RFP WNL, HFP WNL, lactate WNL, coags WNL

• How many SIRS criteria?
• 3
• Does this patient have sepsis?
• Yes
• Would it make a difference in diagnosis of sepsis
  if had CXR which showed LLL infiltrate?
• No
• Does this patient have severe sepsis?
• No
• Does this patient have septic shock?
• No

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Case 3

• 89 yo F sent from NH with confusion, diarrhea
• VS 35.8, 98, 22, 85/45, 97 RA
• Labs WBC 10,000 with 12 bands, Hb 10, plt 160
• bicarb 15, Cr 1.3 (baseline 0.7), lactate 4.1
• ABG 7.29/25/89

• How many SIRS criteria?
• 4
• Does this patient have sepsis?
• Yes
• Does this patient have severe sepsis?
• Yes
• Does this patient have septic shock?
• Possibly- will need to see how her BP
  responds to IVFs

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SIRS Criteria

• Temperature
• gt 38.0 or lt 36.0
• HR
• gt 90
• Respiratory status
• RR gt20 or PaCO2 lt32
• WBC
• gt12,000 or lt4,000 or gt10 bands

BP IS NOT A SIRS CRITERIA
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Outline/Objectives

• Identification of sepsis
• Work up of sepsis
• Triaging sepsis
• Treatment of sepsis

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History?

• Source
• Severity

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History?

• Source
• Lung
• Cough, sore throat, rhinorrhea
• Sick contacts
• Blood
• Fatigue, lines in place, IVDU
• Urine
• Dysuria, hematuria, flank pain
• GI
• Diarrhea, nausea, vomiting, abd pain
• Recent abx or hospitalization, recent travel,
  sick contacts
• Other Skin/soft tissue, bone/joint, ascites,
  CNS, heart
• Skin changes, rash, joint pain, HA, confusion,
  back pain, neck stiffness, photophobia

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History?

• Severity
• Fevers/chills, appetite, po intake
• Progression
• Onset

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Labs?

• Source
• Severity

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Labs?

• Source
• Lung
• sputum cx
• Blood
• Bcx 2 peripheral 1 from each line the pt has
  (central lines, HD lines, art lines, etc)
• Urine
• UA Ucx
• GI
• C diff, fecal leuks, stool cx
• Other
• culture of any drainage, diagnostic paracentesis,
  LP, ESR, CRP

ALWAYS CULTURE BEFORE STARTING ANTIBIOTICS

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Labs?

• Severity
• Does patient have evidence of any organ damage?
• ? Need to evaluate organ systems to determine
• CBC
• RFP
• HFP
• Lactate
• Coagulation screen
• ABG
• ScvO2

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Studies?

• Source
• Severity

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Studies?

• Source/Severity
• Lung
• CXR, CT chest
• Blood
• TTE
• Urine/GI
• CT abd
• Other
• CT head, MRI (for OM)

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Outline/Objectives

• Identification of sepsis
• Work up of sepsis
• Triaging sepsis
• Treatment of sepsis

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When to transfer to MICU

• Sepsis
• Usually can treat on the floor
• Severe sepsis
• Floor or MICU depending on how severe the organ
  dysfunction is
• Severe lactic acidosis? MICU
• Respiratory distress requiring intubation? MICU
• Septic shock
• MICU

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Outline/Objectives

• Identification of sepsis
• Work up of sepsis
• Triaging sepsis
• Treatment of sepsis

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Treatment

• Early Goal Directed Therapy
• Rivers et al 2001
• Surviving Sepsis Campaign
• International guidelines last came out in 2012
• Recently updated in April 2015 to incorporate new
  studies on sepsis

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Early Goal Directed Therapy

• Single center, 263 enrolled patients
• Purpose evaluate efficacy of 6 hrs of EGDT prior
  to admission to ICU
• Results
• 30.5 mortality in EGDT group compared to 46.5
  mortality in standard therapy (p0.009)
• During interval from 7-72 hrs, pts in EGDT had
  higher mean ScvO2, lower lactate, higher pH than
  standard therapy
• We typically follow a version of the algorithm
  from this trial in the ICU

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Early Goal Directed Therapy algorithm
EARLY Initial 6 hrs of resuscitation in the ED
GOAL DIRECTED
CVP gt 8
MAP gt65
ScvO2 gt70
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CVP??

• Approximation of R atrial pressure
• Gives an idea of volume status
• Measured by the nurses off of a central line
  (terminates in the SVC near the R atrium)
• Mechanical ventilation increases CVP (because of
  PEEP)

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MAP??

• Mean arterial pressure
• Approximates average blood pressure throughout
  the cardiac cycle
• MAP 2/3 DBP 1/3 SBP
• Automatically calculated in our EMR and on BP
  monitor

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ScvO2??

• Central venous O2 saturation
• the oxygen saturation of blood that is
  returning to the R atrium (lowest O2sat in the
  body before going to lungs)
• Drawn from a central line
• Indication of tissue hypoxia (more tissue hypoxia
  ? more oxygen extraction at tissue level ?
  decreased O2 saturation of blood returning to
  heart)

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Early Goal Directed Therapy algorithm
EARLY Initial 6 hrs of resuscitation in the ED
GOAL DIRECTED
CVP gt 8
MAP gt65
ScvO2 gt70
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ProCESS Trial

• Published in NEJM May 1, 2014
• Multicenter, 1341 patients enrolled
• Purpose to determine if EGDT is generalizable
  and if all aspects of protocol are necessary
• Results
• At 60 days no sig difference between EGDT and
  either protocol-based standard therapy group or
  usual-care group
• No sig difference in 90 day mortality, 1 yr
  mortality, or need for organ support
• Conclusion protocol-based resuscitation of
  patients in whom septic shock was diagnosed in
  the emergency department did not improve
  outcomes.

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ARISE Trial, ProMISE Trial

• Published in NEJM in Oct 2014 and April 2015
• Also multicenter, large trials (ARISE Australia,
  New Zealand, ProMISE England)
• General conclusion from both Strict EGDT
  protocol did not improve outcome

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Surviving Sepsis Campaign

• Takes several studies into account when
  developing international guidelines for treating
  sepsis
• Splits care in to 2 bundles one to be
  completed within 3 hrs and the other within 6
• Note all groups in ProCESS trial essentially
  followed the 3 hr bundle
• Updated in April 2015 to take into account the 3
  new trials evaluating EGDT

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Surviving Sepsis Campaign Update
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Initial Treatment

• Antibiotics
• If source is known, cater abx to the source
• If source is unknown, use broad spectrum
• Vanc/zosyn
• Fluids
• Fluids
• Fluids
• Remove potential source (line holiday) within 12
  hrs
• Obtain labs to help determine severity (lactate)

WHEN GIVING FLUIDS, KEEP IN MIND PTS RENAL
FUNCTION AND EF
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Hypotension

• If not responsive to adequate hydration, will
  need pressors in the MICU
• Adequate 30 cc/kg (in 70 kg person, 2 L)

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Pressors

• Need central line
• Aggressive fluid resuscitation
• Administration of pressors
• Measure CVP
• Need arterial line
• More accurate BP monitoring
• Know second-to-second changes in BP

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Pressors

• Norepinephrine (Levophed) is 1st pressor used in
  sepsis
• Others you can add on if necessary
• Vasopressin
• Epinephrine
• Phenylephrine
• Dopamine

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Goals for treatment

• MAP gt65
• CVP 8-12 (not intubated), 12-15 (intubated)
• ScvO2 gt70
• Normal lactate
• UOP gt 0.5 ml/kg/hr

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Tools for treatment

• Fluids
• Antibiotics
• Pressors
• Blood products- if Hb lt7, plt lt10,000
• (Albumin)
• Steroids- only if fluids/pressors not adequate
• Mechanical ventilation
• Central lines/arterial lines
• Nutrition- in first 48 hrs
• DVT/stress ulcer ppx

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Summary

• SIRS criteria Tgt 38.0 or lt 36.0, HRgt 90, RR gt20
  or PaCO2 lt32, WBC gt12,000 or lt4,000 or gt10 bands
  
• Sepsis workup should focus on identifying source
  and severity
• Initial treatment cx, abx, fluids
• Patients with septic shock and some with severe
  sepsis require MICU