Sepsis (main)

Background

• Pancreatitis may appear identical to sepsis
• Infection sources:
  • Pulm, skin, GU (account for 80%), abd, CNS
    • Childbearing age woman: septic abortion, postpartum endometritis
    • No obvious source: consider bacteremia, endocarditis

Diagnosis

SIRS

1. 2 or more of the following:
   1. Temp >38.3 or <36
   2. HR >90
   3. Resp rate >20 or CO2 <32
   4. WBC >12K, <4K, or >10% bands

Sepsis

1. SIRS + documented or suspected infection

Severe sepsis

Sepsis AND 1 or more of the following signs of organ dysfunction:

1. Lactate > upper limit of normal
2. Urine output <0.5 mL/kg for >2hr, despite adequate fluid resuscitation
3. Cr >2 (presumed to be new)
4. Bilirubin >2 (presumed to be new)
5. Plt <100K (presumed to be new)
6. INR >1.5 (presumed to be new)
7. Acute Lung Injury
   1. PaO2/FIO2 <250 in absence of PNA as infection source
   2. PaO2/FIO2 <200 in presence of PNA as infection source

Septic shock

1. SBP <90 after adequate fluid challenge OR
2. Lactate >4

DDx

• Adrenal Insufficiency
• Salicylate Toxicity
• Anticholinergic Toxicity
• Neuroleptic Malignant Syndrome
• Malignant Hyperthermia
• Thyrotoxicosis
• Other shock
  • Cardiogenic
  • Hypovolemic
  • Anaphylactic Shock
  • Neurogenic
  • Obstructive

Work-Up

• CBC
• UA/UCx
• Blood cx
• CXR
• Chem
• LFT
• Lipase
• VBG
• Lactate
• Coags
• DIC panel (fibrinogen, D-dimer, FDP)
• T&S
• ?CT head/LP

Time Related Goals

Time of presentation is defined as the time of triage in the emergency department

3 hour goals

1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L

6 hour goals

1. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
2. If persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, reassess volume status and tissue perfusion:
   1. Repeat focused exam OR any two of the following:
      1. Measure CVP
      2. Measure ScvO
      3. Bedside cardiovascular ultrasound
      4. Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

A central line and measurement of ScvO₂ is not required and does not impact mortality

Circulation

1. IVF - Reassess after each bolus
   1. Average is 5-6L w/in first 6hr
   2. Careful reassessment of volume status is required in in patients with significantly depressed ejection fraction.

Pressors

1. Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
2. Best if given when the vascular space is filled; ok if it's not
3. Options:
   1. Norepinephrine (5-20mcg/min) - 1st line
   2. Epinephrine (1-20 mcg/min) - 2nd line
   3. Vasopressin (0.03 units/minute fixed dose) can be added to norepinephrine (NE)

Inotropes

1. Dobutamine (2-20mcg/kg/min) may be added if:
   1. Myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output
   2. Ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP

Steroids

1. Controversial and only shown to relieve shock faster in those who have resolution of shock but may increase the risk of infection
   1. Consider hydrocortisone 50-100mg in ED (200-300 mg qd in 2-4x/d dosing) if pressor/fluid resistant (SBP < 90 persistently)
2. ACTH cosyntropin testing likely unreliable in critically ill patients
3. Do not administer steroids for the treatment of sepsis in the absence of shock

Infection Control

1. Source Control
2. Remove infected lines, surgery if indicated

Antibiotics

1. Administer in 3 hrours
2. See Initial Antibiotics in Sepsis (Main)

Blood Products

RBCs

Only transfuse RBCs when hemoglobin decreases to <7.0 g/dL (goal is 7.0 –9.0 g/dL in adults)

Erythropoietin

Do not use erythropoietin as a specific treatment of anemia associated with severe sepsis

Platelets

• In severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding
• If < 20,000/mm3 (20 x 10⁹/L) and significant risk of bleeding then administer platelets.
• <50,000/mm3 [50 x 10⁹/L) if there is active bleeding, planned surgery or other procedures.

External Links

• MDCalc - SIRS, Sepsis, and Septic Shock Criteria

See Also

• Initial Antibiotics in Sepsis (Main)
• Sepsis (Peds)
• EBQ:ProCESS Trial

Sources

• Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af.