Sepsis (main): Difference between revisions

Revision as of 07:52, 15 September 2011

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

Sepsis = documented or suspected infection with two or more of the following:
1. Temp >38.3 or <35
2. HR >90
3. Resp rate >20 or CO2 <32
4. WBC >12K, <4K, or >10% bands
Severe sepsis = sepsis + 1 or more of the following signs of organ dysfunction:
1. Lactate >2 mmol/L
2. Urine output <0.5 mL/kg for at least one hour
3. Abrupt change in mental status
4. Plt <100K
5. Areas of mottled skin
6. Cap refill >3s
7. DIC
8. Acute lung injury/ARDS
9. Cardiac dysfunction (TTE)
Septic shock = persistent hypotension despite adequate volume resuscitation (40-60cc/kg)
Refractory septic shock
1. Need for dopamine at >15 mcg/kg/min, norepi or epi at >0.25 mcg/kg/min to maintain MAP>60

Airway
1. Careful - sedatives for intubation may worsen hypotension
2. Careful - PPV reduces preload and CO
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
Circulation
1. IVF - Reassess after each bolus
  1. Average is 5-6L w/in first 6hr
  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)
Delivery
1. Measure ScvO2, lactate to assess adequacy of oxygen delivery
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
7. Lactate clearance of at least 10%
Infection Control
1. Source Control
  1. Remove infected lines, sx if indicated
2. Abx
  1. Give ASAP
  2. See Sepsis (Initial Abx)
Coagulation
1. Consider FFP if INR >1.5
2. Consider plts if <50K
Steroids
1. Consider hydrocortisone 100 mg if pressor resistant

Tintinalli

International Sepsis Definitions Conference. 2003.

@@ Line 9: / Line 9: @@
 ==Diagnosis==
-*Sepsis = documented or suspected infection with two or more of the following:
+#Sepsis = documented or suspected infection with two or more of the following:
-**Temp >38.3 or <35
+##Temp >38.3 or <35
-**HR >90
+##HR >90
-**Resp rate >20 or CO2 <32
+##Resp rate >20 or CO2 <32
-**WBC >12K, <4K, or >10% bands
+##WBC >12K, <4K, or >10% bands
-*Severe sepsis = sepsis + 1 or more of the following signs of organ dysfunction:
+#Severe sepsis = sepsis + 1 or more of the following signs of organ dysfunction:
-**Lactate >2 mmol/L
+##Lactate >2 mmol/L
-**Urine output <0.5 mL/kg for at least one hour
+##Urine output <0.5 mL/kg for at least one hour
-**Abrupt change in mental status
+##Abrupt change in mental status
-**Plt <100K
+##Plt <100K
-**Areas of mottled skin
+##Areas of mottled skin
-**Cap refill >3s
+##Cap refill >3s
-**DIC
+##DIC
-**Acute lung injury/ARDS
+##Acute lung injury/ARDS
-**Cardiac dysfunction (echocardiography)
+##Cardiac dysfunction (TTE)
-*Septic shock = persistent hypotension despite adequate volume resuscitation )40-60cc/kg)
+#Septic shock = persistent hypotension despite adequate volume resuscitation (40-60cc/kg)
+#Refractory septic shock
+##Need for dopamine at >15 mcg/kg/min, norepi or epi at >0.25 mcg/kg/min to maintain MAP>60
 ==DDx==