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 mechanical ventilation
      1. Ensures efficient oxygenation
      2. Decreases O2 demand by respiratory muscles
3. Circulation
   1. IVF - Reassess after each bolus
      1. 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
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
      3. MAP 65-90
      4. ScvO2 >70%

Trendelenburg position is not helpful

1. 1. 1. Passive leg raising can be effective

1. Fluid resucitation (avg 5L in first 6hrs) (CVP 8-12mmHg or 12-16 intubated) (UOP 0.5-1mL/kg/hr)
2. Vasopressors (SBP <70)
   1. Norepinephrine (5-20mcg/min)
      1. (consider 0.01 units/min gtt adjunct)
   2. Dopamine (5-20mcg/kg/min)
3. Abx
4. Steroids
   1. corticotropin stim
      1. (give 50mg hydrocortisone IV + ?fludrocortisone if <9cg/dL increase, or 4mg dexamethasone empirically)
5. Keep Hb > 10 (consider FFP if INR >1.5; platelets if <50,000)
6. Tight glycemic control
7. Central O2 >70 (ABG)

Source

2/17/06 DONALDSON (adapted from Rosen)