Sepsis (main)

Background

• Abdomen is most common source of infxn
• Pancreatitis may appear identical to sepsis
• Infection source
  • CNS, pulm, abd, GU, skin,
    • Childbearing age woman - septic abortion, postpartum endometritis
    • GB - Suppurative cholangitis, empyema
    • No obvious source - consider bacteremia, endocarditis

Diagnosis

• 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

DDx

• Cardiogenic, hypovolemic, anaphylactic, neurogenic, obstructive shock
• Adrenal insufficiency
• Thyroid storm

Work-Up

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

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 (Tv = 6mL/kg ideal wt)
      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. IVF can be harmful in cardiogenic shock + pulm edema
   2. Pressors
      1. Indicated if MAP<60 despite adequate IVF or e/o overload
      2. Best if given when the vascular space is filled; ok if it's not
      3. 1st Line
         1. Norepi (5-20mcg/min)
      4. 2nd Line
         1. Dopamine (5-20mcg/kg/min)
      5. Low cardiac output
         1. Dobutamine (5-20 mcg/kg/min)
4. Delivery
   1. Measure ScvO2, lactate to assess adequacy of oxygen delivery
5. End Points
   1. Urine output >0.5mL/kg/hr
   2. CVP 8-12 (12-16 if intubated)
   3. MAP 65-90
   4. ScvO2 >70%
   5. Hb >10 (if ScvO2 target not otherwise met)
   6. Non-collapsible IVC on utz
6. Infection Control
   1. Source Control
      1. Remove infected lines, sx if indicated
   2. Abx
      1. Give ASAP
      2. See Sepsis (Initial Abx)
7. Coagulation
   1. Consider FFP if INR >1.5
   2. Consider plts if <50K
8. Steroids
   1. Consider hydrocortisone 100 mg if pressor resistant

Source

Tintinalli International Sepsis Definitions Conference. 2003.