Sepsis (main): Difference between revisions
Line 59: Line 59:
*?CT head/LP
*?CT head/LP


==Management==
==Time Specific Management==
===Time Related Goals===
''Time of presentation is defined as the time of triage in the emergency department''
''Time of presentation is defined as the time of triage in the emergency department''
====3 hour goals<ref name="suriving sepsis update">Surviving Sepsis Updated Bundles in Response to New Evidence [http://emcrit.org/wp-content/uploads/2015/04/SSC_Bundle.pdf full text]</ref>====
===3 hour goals<ref name="suriving sepsis update">Surviving Sepsis Updated Bundles in Response to New Evidence [http://emcrit.org/wp-content/uploads/2015/04/SSC_Bundle.pdf full text]</ref>===
*Measure lactate level
*Measure lactate level
*Obtain [[blood cultures]] prior to administration of antibiotics
*Obtain [[blood cultures]] prior to administration of antibiotics
Line 68: Line 67:
*Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
*Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L


====6 hour goals====
===6 hour goals===
*Apply [[vasopressors]] (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
*Apply [[vasopressors]] (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
*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:
*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:
Line 79: Line 78:
''A central line and measurement of ScvO<sub>2</sub> is not required and does not impact mortality<ref>ProCESS Investigators,Yealy DM, Kellum JA, Juang DT, et al.A randomized trial of protocol-based care for earlyseptic shock. N Engl J Med 2014;370(18):1683-1693 [[ProCESS_Trial|Full Text]] </ref><ref>The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med2014; 371:1496-1506</ref><ref>Mouncey PR, Osborn TM, Power GS, et al for the ProMISe trial investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015:DOI: 10.1056/NEJMoa1500896</ref>
''A central line and measurement of ScvO<sub>2</sub> is not required and does not impact mortality<ref>ProCESS Investigators,Yealy DM, Kellum JA, Juang DT, et al.A randomized trial of protocol-based care for earlyseptic shock. N Engl J Med 2014;370(18):1683-1693 [[ProCESS_Trial|Full Text]] </ref><ref>The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med2014; 371:1496-1506</ref><ref>Mouncey PR, Osborn TM, Power GS, et al for the ProMISe trial investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015:DOI: 10.1056/NEJMoa1500896</ref>


===Circulation===
==Circulation==
*[[IVF]] - Reassess after each bolus
*[[IVF]] - Reassess after each bolus
**Average is 5-6L w/in first 6hr
**Average is 5-6L w/in first 6hr
**Careful reassessment of volume status is required in in patients with significantly depressed ejection fraction.
**Careful reassessment of volume status is required in in patients with significantly depressed ejection fraction.
====[[Pressors]]====
===[[Pressors]]===
*Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
*Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
*Best if given when the vascular space is filled; ok if it's not
*Best if given when the vascular space is filled; ok if it's not
Line 91: Line 90:
**[[Vasopressin]] (0.03 units/minute fixed dose) can be added to norepinephrine (NE)
**[[Vasopressin]] (0.03 units/minute fixed dose) can be added to norepinephrine (NE)


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


====Steroids====
===Steroids===
*[[EBQ:CORTICUS_Trial|Controversial and only shown to relieve shock faster]] in those who have resolution of shock but may increase the risk of infection
*[[EBQ:CORTICUS_Trial|Controversial and only shown to relieve shock faster]] in those who have resolution of shock but may increase the risk of infection
**Consider [[hydrocortisone]] 50-100mg in ED (200-300 mg qd in 2-4x/d dosing) if pressor/fluid resistant (SBP < 90 persistently)
**Consider [[hydrocortisone]] 50-100mg in ED (200-300 mg qd in 2-4x/d dosing) if pressor/fluid resistant (SBP < 90 persistently)
Line 102: Line 101:
*Do not administer steroids for the treatment of sepsis in the absence of shock
*Do not administer steroids for the treatment of sepsis in the absence of shock


===Infection Control===
==Infection Control==
*Source Control
*Source Control
*Remove infected lines, surgery if indicated
*Remove infected lines, surgery if indicated


====[[Antibiotics]]====
===[[Antibiotics]]===
*Administer within 3 hours
*Administer within 3 hours
*See [[Initial Antibiotics in Sepsis (Main)]]
*See [[Initial Antibiotics in Sepsis (Main)]]


===[[Blood Products]]===
==[[Blood Products]]==
====[[RBCs]]====
===[[RBCs]]===
Only transfuse RBCs when hemoglobin decreases to <7.0 g/dL (goal is 7.0 –9.0 g/dL in adults)  
Only transfuse RBCs when hemoglobin decreases to <7.0 g/dL (goal is 7.0 –9.0 g/dL in adults)  
====Erythropoietin====
===Erythropoietin===
Do not use erythropoietin as a specific treatment of anemia associated with severe sepsis  
Do not use erythropoietin as a specific treatment of anemia associated with severe sepsis  
====[[Platelets]]====
===[[Platelets]]===
*In severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 10<sup>9</sup>/L) in the absence of apparent bleeding
*In severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 10<sup>9</sup>/L) in the absence of apparent bleeding
*If < 20,000/mm3 (20 x 10<sup>9</sup>/L) and significant risk of bleeding then administer platelets.
*If < 20,000/mm3 (20 x 10<sup>9</sup>/L) and significant risk of bleeding then administer platelets.

Revision as of 17:50, 5 April 2015

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

Clinical Presentation

SIRS

  • 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

  • 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
    • PaO2/FIO2 <250 in absence of PNA as infection source
    • PaO2/FIO2 <200 in presence of PNA as infection source

Septic shock

  • SBP <90 after adequate fluid challenge OR
  • Lactate >4

Differential Diagnosis

Shock

Diagnosis

Work-Up

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

Time Specific Management

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

3 hour goals[1]

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

6 hour goals

  • Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
  • 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:
    • Repeat focused exam OR any two of the following:
      • Measure CVP
      • Measure ScvO
      • Bedside cardiovascular ultrasound
      • 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[2][3][4]

Circulation

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

Pressors

  • Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
  • Best if given when the vascular space is filled; ok if it's not
  • Options:

Inotropes

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

Steroids

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

Infection Control

  • Source Control
  • Remove infected lines, surgery if indicated

Antibiotics

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

See Also

References

  1. ↑ Surviving Sepsis Updated Bundles in Response to New Evidence full text
  2. ↑ ProCESS Investigators,Yealy DM, Kellum JA, Juang DT, et al.A randomized trial of protocol-based care for earlyseptic shock. N Engl J Med 2014;370(18):1683-1693 Full Text
  3. ↑ The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med2014; 371:1496-1506
  4. ↑ Mouncey PR, Osborn TM, Power GS, et al for the ProMISe trial investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015:DOI: 10.1056/NEJMoa1500896
Retrieved from "https://www.wikem.org/w/index.php?title=Sepsis_(main)&oldid=35501"