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) if perfusion goal not met despite Hb >10

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

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

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.