Sepsis (main): Difference between revisions

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*?CT head/LP
*?CT head/LP


==Early Goal Directed Therapy==
==Time Related Goals==
#Goals
''Time of presentation is defined as the time of triage in the emergency department''
##Preload Goal: CVP >8 (>12 if intubated)
===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>===
##Afterload Goal: MAP >65
#Measure lactate level
##Perfusion goal: ScvO2 >70% OR lactate clearance >10%
#Obtain blood cultures prior to administration of antibiotics
##Hb >10 (if ScvO2 target not otherwise met)
#Administer broad spectrum antibiotics
##Lactate clearance of at least 10%
#Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
##Urine output >0.5 mL/kg/hr
 
#Airway
===6 hour goals===
##Careful - sedatives for intubation may worsen hypotension
#Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
##Careful - PPV reduces preload and CO
#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:
#Breathing
##Repeat focused exam OR any two of the following:
##Maintain O2 sat >93%
###Measure CVP
##Maintain PaCO2 at 35-40
###Measure ScvO
##Consider early mechanical ventilation
###Bedside cardiovascular ultrasound
###Rationale:
###Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
####Ensures efficient oxygenation
 
####Decreases O2 demand by respiratory muscles
''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>
###Settings
===Circulation===
####Tidal volume 6mL/kg ideal wt
#IVF - Reassess after each bolus
####Plateau pressure <30
##Average is 5-6L w/in first 6hr
#Circulation
##Careful reassessment of volume status is required in in patients with significantly depressed ejection fraction.
##IVF - Reassess after each bolus
====Pressors====
###Average is 5-6L w/in first 6hr
#Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
###IVF can be harmful in cardiogenic shock or in pts w/ pulm edema
#Best if given when the vascular space is filled; ok if it's not
##Pressors
#'''Options:'''
###Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
##Norepi (5-20mcg/min) - 1st line
###Best if given when the vascular space is filled; ok if it's not
##Dopamine (5-20mcg/kg/min)
###Options:
====Inotropes====
####Norepi (5-20mcg/min) - 1st line
#Dobutamine (2-20mcg/kg/min) if perfusion goal not met despite Hb >10
####Dopamine (5-20mcg/kg/min)
====Infection Control====
##Inotropes
#Source Control
###Dobutamine (2-20mcg/kg/min) if perfusion goal not met despite Hb >10
#Remove infected lines, surgery if indicated
#Infection Control
===Antibiotics===
##Source Control
#Administer in 3 hrours
###Remove infected lines, surgery if indicated
#See [[Initial Antibiotics in Sepsis (Main)]]
##Abx
===Coagulation===
###Give ASAP
#Consider FFP if INR >1.5
###See [[Initial Antibiotics in Sepsis (Main)]]
#Consider plts if <50K
#Coagulation
====Steroids====
##Consider FFP if INR >1.5
#[[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 plts if <50K
#Steroids
##Controversial
##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)
##ACTH cosyntropin testing likely unreliable in critically ill pts
#ACTH cosyntropin testing likely unreliable in critically ill patients


==External Links==
==External Links==

Revision as of 14:52, 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

Diagnosis

  1. 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
  2. Sepsis
    1. SIRS + documented or suspected infection
  3. Severe sepsis
    1. 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. ALI
        1. PaO2/FIO2 <250 in absence of PNA as infection source
        2. PaO2/FIO2 <200 in presence of PNA as infection source
  4. Septic shock
    1. SBP <90 after adequate fluid challenge OR
    2. Lactate >4

DDx

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]

  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[2][3]

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. Norepi (5-20mcg/min) - 1st line
    2. Dopamine (5-20mcg/kg/min)

Inotropes

  1. Dobutamine (2-20mcg/kg/min) if perfusion goal not met despite Hb >10

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)

Coagulation

  1. Consider FFP if INR >1.5
  2. Consider plts if <50K

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

External Links

See Also

Source

  • Tintinalli
  • Surviving sepsis campaign 2012
  • Backer et al. Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis. Crit Care Med. 2012;40(3):725
  • PEER VIII Q&A
  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
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