Sepsis (main)

Background

• Sepsis = infection and some of the following:
  • General variables
    • Temp >38.3 or <36
    • HR >90
    • Resp rate > 30
    • AMS
    • Hyperglycemia in absence of DM
  • Inflammatory variables
    • WBC >12K, <4K, or >10% bands
  • Hemodynamic variables
    • SBP <90 OR MAP <70 w/ inadequate perfusion
    • Need for pressors to maintain BP
  • Organ dysfunction variables
    • Arterial hypoxemia (PaO2/FIO2 <300)
    • PaCO2 >65
    • Oliguria (<0.5mL/kg/hr for at least 2hr despite fluids)
    • Cr incr >0.5
    • INR >1.5
    • Plt <100K
    • Bilirubin >4
  • Tissue perfusion variables
    • Lactate >3 or base deficit >5
    • Cap refill >3s
    • Mottled skin

Early Goal Directed Therapy

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

Tintinalli International Sepsis Definitions Conference. 2003.