SEPSIS

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SEPSIS

• Intern Bootcamp
• Scott Denstaedt, PGYIII

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Sepsis /'s?ps?s/ from the Greek s???? the state
of putrefaction and decay
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Background

• local inflammation? systemic inflammatory
  response ? tissue hypoperfusion and multi-organ
  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
• gt750000 cases/year, mortality rate of 1 in 4

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• Sepsis is a spectrum of illness that requires
  early intervention to prevent complications and
  progression

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Definitions

• Systemic Inflammatory Response Syndrome (SIRS)
  criteria
• response to infectious and non-infectious insults
• 2 criteria needed to meet SIRS
• Temp gt38, lt36
• HR gt90
• RR gt20, PaCO2 lt32 (differs depending on
  textbook)
• WBC gt12k or lt4k or 10 bands
• NO BLOOD PRESSURE IN SIRS CRITERIA

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Definitions

• Sepsis
• 2 SIRS criteria source of infection (you dont
  necessarily need concrete evidence high level
  of clinical suspicion is enough)

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Definitions

• Severe Sepsis
• Sepsis with organ dysfunction (dont memorize the
  list below)
• Sepsis-induced hypotension
• Lactate above upper limits laboratory normal
• Urine output lt0.5 mL kg/h for more than 2 h
  despite adequate fluid resuscitation
• Acute lung injury with PaO2/FiO2lt250 in the
  absence of pneumonia as infection source
• Acute lung injury with PaO2/FiO2lt200 in the
  presence of pneumonia as infection source
• Creatinine2.0 mg/dL (176.8 lmol/L)
• Bilirubin2 mg/dL (34.2 lmol/L)
• Platelet count lt100,000 lL
• Coagulopathy (INR gt1.5)

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Definitions

• Septic Shock
• Sepsis induced hypotension despite adequate fluid
  resuscitation
• Sepsis induced hypotension SBP lt90mmhg or
  40mmhg change from baseline

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• 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

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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

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Rivers et. al 2001

• Initial 6 hours of resuscitation in ED
• 1-1.5 hours to identification of sepsis on avg.

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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!!)

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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

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• Diagnosis
• 2 sets of blood cultures from separate sites
  (culture ALL vascular devices unless lt48 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)

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• 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)

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• 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)

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• 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 lt7g/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 lt10k or
  lt20k if significant risk of bleeding, goal of
  gt50k if active bleeding, surgery or invasive
  procedure (2D)

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• 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 gt180 (insulin gtt), target
  goal lt180 1A
• DVT prophy and Stress ulcer prophy
• LMWH when possible in severe sepsis 1B,
  Dalteparin if CrCl lt30
• 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

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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

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Your Septic Patient HP

• 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

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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!

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Your Septic Patient Labs

• 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 lt7.2-7.25
  --gt patient belongs in ICU)
• U/A, Urine culture
• Blood cultures from two different sites
• Culture other sites as necessitated by history
  and exam

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Your Septic Patient Imaging

• CXR
• Other imaging depending on your clinical
  suspicion (usually CT with contrast)

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Your Septic Patient Treatment

• Empiric therapy based on suspected source of
  infection
• Supportive Care
• Early Goal Directed Therapy
• Surviving Sepsis Campaign, update 2012

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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

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Clinical Pearls

• Managing Sepsis on the floor
• Use defined endpoints for fluid resuscitation
• U/O gt0.5cc/kg/hr
• MAP gt65
• Normalization of lactate
• KNOW the patients Ejection Fraction and renal
  function
• Fluid resuscitation is the priority!!!
• Start pressors if MAP lt65, 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

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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?vMceGURfXdR0

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