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
• UA/UCx
• Blood cx
• CXR
• Chem
• LFT
• Lipase
• VBG
• Lactate
• Coags
• DIC panel (fibrinogen, d-dimer, FDP)
• 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 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)
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
   7. Lactate clearance of at least 10%
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

See Also

Sepsis (Initial Abx)

Source

Tintinalli

International Sepsis Definitions Conference. 2003.