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

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

• 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. 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

• MDCalc - SIRS, Sepsis, and Septic Shock Criteria

See Also

• Initial Antibiotics in Sepsis (Main)
• Sepsis (Peds)

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