Sepsis (main)

Definition

SIRS

• Requires 2 of the following:
  • Temp >38 or <36
  • HR >90
  • Resp rate > 20 or PaCO2 <32
  • WBC >12K, <4K, or >10% bands

Sepsis

• SIRS + infection

Severe sepsis

• Sepsis + one of the following:
  • Mottled skin
  • Cap refill >3s
  • Urine output <0.5 mL/kg for at least 1hr
  • Lactate >2
  • Abrupt change in MS
  • Abnormal EEG
  • Plts <100K
  • DIC
  • ARDS
  • Cardiac dysfunction (via echo or CI)

Septic Shock

• Severe sepsis + one of the following:
  • MAP<60 (or <80 if pt has HTN) despite NS 40-60 mL/kg
  • MAP>60 (or >80 if pt has HTN) only with adequate fluid AND:
    • Dopamine >5mcg/kg/min OR
    • Norepinephrine <0.25mcg/kg/min OR
    • Epinephrine <0.25mcg/kg/min

Refractory Septic Shock

• MAP>60 (or >80 if pt has HTN) only with adequate fluid AND:
• Dopamine >15 mcg/kg/min OR
• Norepinephrine >0.25 mcg/kg/min OR
• Epinephrine >0.25 mcg/kg/min

Early Goal Directed Therapy

• Indicated for severe sepsis and septic shock

1. Airway
   1. Careful - sedatives for intubation may worsen hypotension
   2. Careful - PPV reduces preload and CO
2. Breathing
   1. Maintain O2 sat >93%
   2. Maintain PaCO2 at 35-40
   3. Consider early mechanical ventilation
      1. Ensures efficient oxygenation
      2. Decreases O2 demand by respiratory muscles
3. Circulation
   1. IVF - Reassess after each bolus
      1. Average is 5-6L w/in first 6hrs
      2. Can be harmful in cardiogenic shock + pulm edema
   2. Pressors
      1. Indicated if IVF are not sufficient to maintain MAP >60
      2. Best if given when the vascular space is filled; ok if its not
      3. 1st Line
         1. Norepi (5-20mcg/min)
      4. 2nd Line
         1. Dopamine (5-20mcg/kg/min)
4. Delivery
   1. Tranfuse pRBCs to maintain Hb >10
   2. Measure ScvO2, lactate to assess adequacy of oxygen delivery
   3. End Points
      1. Urine output >0.5mL/kg/hr
      2. CVP 8-12 (12-16 if intubated)
      3. MAP 65-90
      4. ScvO2 >70%

1. Source Control
2. Coagulation
   1. Consider FFP if INR >1.5
   2. Consider plts if <50K
3. Steroids
   1. Consider if hypotension is pressor resistant
      1. Hydrocortisone 100 mg IV

Source

2/17/06 DONALDSON (adapted from Rosen)