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

1. 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
2. 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)
3. Septic shock = persistent hypotension despite adequate volume resuscitation (40-60cc/kg)
4. 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

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.