Difference between revisions of "Sepsis (Main)"

(Circulation Managment)
 
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==Background==
 
==Background==
 
*Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection<ref name="sepsis definition">Singer, Melvyn  et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287</ref>
 
*Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection<ref name="sepsis definition">Singer, Melvyn  et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287</ref>
*The infection is most commonly by bacteria, but can also be by fungi, viruses, or parasites<ref>Jui, Jonathan (2011). "Ch. 146: Septic Shock". In Tintinalli, Judith E.; Stapczynski, J. Stephan; Ma, O. John; Cline, David M. et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide (7th ed.). New York: McGraw-Hill. pp. 1003–14. </ref>  
+
*The infection is most commonly by [[bacteria]], but can also be by [[fungi]], [[viruses]], or [[parasites]]<ref>Jui, Jonathan (2011). "Ch. 146: Septic Shock". In Tintinalli, Judith E.; Stapczynski, J. Stephan; Ma, O. John; Cline, David M. et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide (7th ed.). New York: McGraw-Hill. pp. 1003–14. </ref>  
 
*Risk of death from sepsis being as high as 30%, severe sepsis as high as 50%, and septic shock as high as 80% <ref>Jawad, I; Lukšić, I; Rafnsson, SB (June 2012). "Assessing available information on the burden of sepsis: Global estimates of incidence, prevalence and mortality". Journal of Global Health 2 (1): 010404. doi:10.7189/jogh.02.010404 (inactive 2015-02-02). PMC 3484761. PMID 23198133 [http://www.jogh.org/documents/issue201201/12-Article%20Jawad.pdf full text]</ref>  
 
*Risk of death from sepsis being as high as 30%, severe sepsis as high as 50%, and septic shock as high as 80% <ref>Jawad, I; Lukšić, I; Rafnsson, SB (June 2012). "Assessing available information on the burden of sepsis: Global estimates of incidence, prevalence and mortality". Journal of Global Health 2 (1): 010404. doi:10.7189/jogh.02.010404 (inactive 2015-02-02). PMC 3484761. PMID 23198133 [http://www.jogh.org/documents/issue201201/12-Article%20Jawad.pdf full text]</ref>  
*The most common primary sources of infection resulting in sepsis are the lungs, the abdomen, and the urinary tract<ref>Munford, Robert S.; Suffredini, Anthony F. (2014). "Ch. 75: Sepsis, Severe Sepsis and Septic Shock". In Bennett, John E.; Dolin, Raphael; Blaser, Martin J.. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (8th ed.). Philadelphia: Elsevier Health Sciences. pp. 914–34.</ref>
+
*The most common primary sources of infection resulting in sepsis are the [[pneumonia|lungs]], the abdomen, and the [[UTI|urinary tract]]<ref>Munford, Robert S.; Suffredini, Anthony F. (2014). "Ch. 75: Sepsis, Severe Sepsis and Septic Shock". In Bennett, John E.; Dolin, Raphael; Blaser, Martin J.. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (8th ed.). Philadelphia: Elsevier Health Sciences. pp. 914–34.</ref>
*Sepsis caries a 40% in hospital mortality<ref name="sepsis definition"></ref>
+
*Sepsis carries a 40% in hospital mortality<ref name="sepsis definition"></ref>
 +
*Positive cultures are not obligatory in the diagnosis of sepsis
 +
*[[Pneumonia]], abdominal abscess and [[pyelonephritis]] are common primary causes of sepsis
 
===Definition Changes===
 
===Definition Changes===
''In 2016 new definitions were adopted for the evaluation and diagnosis of Sepsis, Sever Sepsis and Septic shock<ref> Seymour, C. Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.</ref>''
+
''In 2016 new definitions were adopted for the evaluation and diagnosis of Sepsis, Severe Sepsis and Septic shock<ref> Seymour, C. Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.</ref>''
 
{| {{table}}
 
{| {{table}}
 
| align="center" style="background:#f0f0f0;"|
 
| align="center" style="background:#f0f0f0;"|
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|-
 
|-
 
| '''Sepsis'''||2 [[SIRS]] + suspected infection||Life threatening organ dysfunction caused by dysregulated host response to infection. Suspected/documented infection + 2 on the [[qSOFA]]:
 
| '''Sepsis'''||2 [[SIRS]] + suspected infection||Life threatening organ dysfunction caused by dysregulated host response to infection. Suspected/documented infection + 2 on the [[qSOFA]]:
*Hypotension with SBP <100 or
+
*[[Hypotension]] with SBP <100 or
 
*altered mental status  or
 
*altered mental status  or
*Tachypnea (RR >/=22) OR
+
*Tachypnea (RR >/=22) '''OR'''
 
*Increase in [[SOFA]] score by 2 points
 
*Increase in [[SOFA]] score by 2 points
 
|-
 
|-
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===[[SOFA]] Score===
 
===[[SOFA]] Score===
 
*The [[SOFA]] is generally used in the ICU and can stratify the mortality of patients based on the initial score and subsequent changes in score
 
*The [[SOFA]] is generally used in the ICU and can stratify the mortality of patients based on the initial score and subsequent changes in score
 +
 +
===MEDS score===
 +
*The Mortality in Emergency Department Sepsis (MEDS) prediction rule is a proposed method to risk stratify ED patients with sepsis
 +
 +
===NEWS 2 Score===
 +
*National Early Warning Score (NEWS) 2 determines degree of critically ill patient, in non-pregnant patients ≥16 years old<ref>Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: RCP, 2017.</ref>
 +
*Used by the UK NHS to identify acutely ill patients, including those with sepsis
 +
*Not reliable in spinal cord injury patients due to disturbance of autonomic responses
 +
*Combination of:
 +
**Respiratory rate
 +
**Presence of hypercapnic respiratory failure
 +
**Presence of supplemental O2
 +
**Temperature
 +
**SBP
 +
**Pulse rate
 +
**Consciouness
 +
*See below for MDCalc link
  
 
{{SIRS Score}}
 
{{SIRS Score}}
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===Sepsis===
 
===Sepsis===
 
''Life-threatening organ dysfunction caused by a dysregulated host response to infection. This only needs to include one of the following:<ref> Seymour, C. Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.</ref>''
 
''Life-threatening organ dysfunction caused by a dysregulated host response to infection. This only needs to include one of the following:<ref> Seymour, C. Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.</ref>''
*Hypotension with SBP <100 or
+
*[[Hypotension]]with SBP <100 or
*altered mental status or
+
*[[Altered mental status]] or
*Tachypnea (RR >/=22) OR
+
*[[Tachypnea]] (RR >/=22) '''OR'''
 
*Increase in SOFA score by 2 points
 
*Increase in SOFA score by 2 points
  
===Septic shock===
+
===[[Septic shock]]===
 
Patients with sepsis and any of the following:<ref name="sepsis definition"></ref>
 
Patients with sepsis and any of the following:<ref name="sepsis definition"></ref>
#Vasopressor requirement to maintain a mean arterial pressure > 65 mm Hg  
+
#[[Vasopressors|Vasopressor]] requirement to maintain a mean arterial pressure > 65 mm Hg  
#Serum lactate level greater than 2 mmol/L (>18mg/dL) in the absence of hypovolemia.
+
#Serum [[lactate]] level greater than 2 mmol/L (>18mg/dL) in the absence of [[hypovolemia]].
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
Line 61: Line 80:
  
 
{{Shock DDX}}
 
{{Shock DDX}}
 
{{altered mental status and fever DDX}}
 
  
 
==Evaluation==
 
==Evaluation==
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*[[CXR]]
 
*[[CXR]]
 
*Chem
 
*Chem
*LFT
+
*[[LFTs]]
 
*Lipase
 
*Lipase
*VBG
+
*[[VBG]]
*Lactate
+
*[[Lactate]]
*Procalcitonin
 
 
*Coags
 
*Coags
*DIC panel (fibrinogen, D-dimer, FDP)
+
*Consider:
*T&S
+
**[[Procalcitonin]]
*?CT head/LP
+
**[[DIC]] panel (fibrinogen, [[D-dimer]], FDP)
*?TSH (thyroid storm)
+
**T&S
*?Cosyntropin stim vs. random cortisol (adrenal insufficiency)
+
**[[CT head]] and/or [[LP]
 +
**TSH ([[thyroid storm]])
 +
**Cosyntropin stim vs. random cortisol (adrenal insufficiency)
 +
**Pelvic exam ([[toxic shock syndrome]], tampon)
 +
**[[Influenza]] rapid testing
 +
**CT Abd/Pelvis (abscess, other)
 +
**spine imaging ([[epidural abscess]], other)
  
 
==Time Specific Management==
 
==Time Specific Management==
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*Apply [[vasopressors]] (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
 
*Apply [[vasopressors]] (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
 
*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:
 
*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:
**Repeat focused exam OR any two of the following:
+
**Option 1: Focused Exam
 +
***Vital signs
 +
***Cardiopulmonary Exam
 +
***Capillary Refill
 +
***Peripheral Pulse
 +
***Skin Exam
 +
**Option 2: Two of the following
 
***Measure CVP ([[IVC ultrasound]]) with following goals:
 
***Measure CVP ([[IVC ultrasound]]) with following goals:
 
****>8 cmH2O, not intubated
 
****>8 cmH2O, not intubated
Line 106: Line 134:
 
==Circulation Managment==
 
==Circulation Managment==
 
===[[IVF]]===
 
===[[IVF]]===
*Reassess after each bolus
+
*Guidelines recommend initial 30 cc/kg bolus (generally 2L in average adult)
*Average is 5-6L within first 6hr
+
*Reassess patient's volume status after initial bolus. Auscultate for pulmonary edema.  Evaluate peripheral circulation.  Consider IVC ultrasound
*Careful reassessment of volume status is required in in patients with significantly depressed ejection fraction
+
*Septic patients can be euvolemic but remain hypotensive due to vasodilation. Consider early vasopressors.
*Consider assessing [[diastolic dysfunction]] via echo in [[CHF]] patients in whom IVC US is not reliable
+
*Increasing evidence that excessive fluid resuscitation can be harmful.
 +
**Positive fluid balance on day 3 of hospital admission independently associated with increasing mortality  <ref>Sakr Y et al. Higher Fluid Balance Increases the Risk of Death From Sepsis: Results From a Large International Audit. Critical care medicine. 45(3):386-394, Mar 2017.</ref>
 +
**Protocolized fluid administration (e.g. traditional Early Goal Directed Therapy) has no mortality benefit over usual care. <ref> Yealy DM, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370:1683-93. DOI: 10.1056/NEJMoa1401602 </ref> <ref> Mouncey PR, et al. Trial of Early, Goal-Directed Resuscitation for Septic Shock. N Engl J Med 2015;372:1301-11. DOI: 10.1056/NEJMoa1500896 </ref>
 +
**High volume (5+ L) resuscitation associated with increased mortality. <ref>Marik PE, et al. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive Care Med (2017) 43:625–632 DOI 10.1007/s00134-016-4675-y </ref>
 +
*Consider assessing [[diastolic dysfunction]] via echo in [[CHF]] patients in whom IVC [[ultrasound]] is not reliable
 +
 
  
 
===[[Pressors]]===
 
===[[Pressors]]===
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*Best if given when the vascular space is filled; ok if it is not
 
*Best if given when the vascular space is filled; ok if it is not
 
'''Options:'''
 
'''Options:'''
*[[Norepinephrine]] (5-20mcg/min) - 1st line
+
*[[Norepinephrine]] (5-20mcg/min) - 1st line<ref>[[EBQ:SOAP II Trial]]</ref>
 
*[[Epinephrine]] (1-20 mcg/min) - 2nd line
 
*[[Epinephrine]] (1-20 mcg/min) - 2nd line
 
*[[Vasopressin]] (0.03 units/minute fixed dose) can be added to norepinephrine (NE)
 
*[[Vasopressin]] (0.03 units/minute fixed dose) can be added to norepinephrine (NE)
 +
**as a 2nd line agent may reduce arrhythmia's compared to other pressors with catecholamine properties<ref>McIntyre, W. F., Um, K. J., Alhazzani, W., Lengyel, A. P., Hajjar, L., Gordon, A. C., … Belley-Côté, E. P. (2018). Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock. JAMA: The Journal of the American Medical Association, 319(18), 1889.</ref>
 
*''[[Dopamine]] should be used hesitantly and only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia)
 
*''[[Dopamine]] should be used hesitantly and only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia)
**Do not use Low-dose dopamine for renal protection
+
**Do not use Low-dose [[dopamine]] for renal protection
**Dopamine may have increased mortality rates compared to other vasopressors<ref>Ventura AM, Shieh HH, Bousso A, Goes PF, Fernandes IC, de Souza DC, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015;43:2292-302. </ref>  
+
**Dopamine may have increased mortality rates compared to other vasopressors, especially in the pediatric septic patient<ref>Ventura AM, Shieh HH, Bousso A, Goes PF, Fernandes IC, de Souza DC, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus [[Epinephrine]]as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015;43:2292-302. </ref>  
 
*''[[Phenylephrine]] should not be used for treating septic shock except if:
 
*''[[Phenylephrine]] should not be used for treating septic shock except if:
 
**Norepinephrine is associated with serious arrhythmias
 
**Norepinephrine is associated with serious arrhythmias
 
**Cardiac output is known to be high and blood pressure persistently low
 
**Cardiac output is known to be high and blood pressure persistently low
 
**As salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target
 
**As salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target
 +
*[[Milrinone]]
 +
*[[Methylene blue]] consideration for septic shock refractory to catecholaminergic pressors
  
 
===[[Vasopressors|Inotropes]]===
 
===[[Vasopressors|Inotropes]]===
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===[[Steroids]]===
 
===[[Steroids]]===
*[[EBQ:CORTICUS_Trial|Controversial and only shown to relieve shock faster]] in those who have resolution of shock but may increase the risk of infection
+
*Controversial and only shown to relieve shock faster in those who have resolution of shock but may increase the risk of infection
**Consider [[hydrocortisone]] 50-100mg in ED (200-300mg qd in 2-4x/d dosing) if pressor/fluid resistant (SBP < 90 persistently)
+
**Consider [[hydrocortisone]] 50-100mg in ED (200-300mg QD in 2-4x/d dosing) if pressor/fluid resistant (SBP < 90 persistently)
 
*ACTH cosyntropin testing likely unreliable in critically ill patients
 
*ACTH cosyntropin testing likely unreliable in critically ill patients
 
*Do not administer steroids for the treatment of sepsis in the absence of shock
 
*Do not administer steroids for the treatment of sepsis in the absence of shock
 +
 +
===[[Esmolol]]===
 +
*One single-center RCT showing ~40% reduction in mortality when [[esmolol]] paired with [[norepinephrine]] infusion, with goal HR 80 - 95 BPM<ref>Andrea Morelli et al. Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock: A Randomized Clinical Trial. JAMA. 2013;310(16):1683-1691.</ref>
 +
*All patients were fluid resuscitated, intubated, given hydrocortisone 300 mg/day
 +
*Will require further multi-center RCTs to confirm findings
  
 
==Infection Control==
 
==Infection Control==
*Source Control
+
===Source control===
*Remove infected lines, surgery if indicated
+
*Remove any infected lines
 +
*Drain [[abscesses]]
 +
*Consult surgery or other specialists if indicated (e.g. for [[appendicitis]], [[cholangitis]], etc.)
  
 
===Antibiotics===
 
===Antibiotics===
 
*Administer within 3 hours
 
*Administer within 3 hours
 +
*Initial choice dependant on suspected source, local antibiogram, and severity of illness
 
*See [[Initial Antibiotics in Sepsis (Main)]]
 
*See [[Initial Antibiotics in Sepsis (Main)]]
  
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*If < 20,000/mm3 (20 x 10<sup>9</sup>/L) and significant risk of bleeding then administer platelets.
 
*If < 20,000/mm3 (20 x 10<sup>9</sup>/L) and significant risk of bleeding then administer platelets.
 
*<50,000/mm3 (50 x 10<sup>9</sup>/L) if there is active bleeding, planned surgery or other procedures.
 
*<50,000/mm3 (50 x 10<sup>9</sup>/L) if there is active bleeding, planned surgery or other procedures.
 +
 +
==Disposition==
 +
*Admit, possibly to step-down or ICU
  
 
==External Links==
 
==External Links==
 
*[http://www.mdcalc.com/sirs-sepsis-and-septic-shock-criteria/ MDCalc - SIRS, Sepsis, and Septic Shock Criteria]
 
*[http://www.mdcalc.com/sirs-sepsis-and-septic-shock-criteria/ MDCalc - SIRS, Sepsis, and Septic Shock Criteria]
 
*[http://www.mdcalc.com/qsofa-quick-sofa-score-for-sepsis-identification/ MDCalc - qSOFA Score]
 
*[http://www.mdcalc.com/qsofa-quick-sofa-score-for-sepsis-identification/ MDCalc - qSOFA Score]
 +
*[https://www.mdcalc.com/national-early-warning-score-news-2#evidence MDCalc - NEWS 2]
 
*[http://emcrit.org/podcasts/sepsis-3/ EMCrit Sepsis 3.0]
 
*[http://emcrit.org/podcasts/sepsis-3/ EMCrit Sepsis 3.0]
  

Latest revision as of 20:15, 27 November 2019

Background

  • Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection[1]
  • The infection is most commonly by bacteria, but can also be by fungi, viruses, or parasites[2]
  • Risk of death from sepsis being as high as 30%, severe sepsis as high as 50%, and septic shock as high as 80% [3]
  • The most common primary sources of infection resulting in sepsis are the lungs, the abdomen, and the urinary tract[4]
  • Sepsis carries a 40% in hospital mortality[1]
  • Positive cultures are not obligatory in the diagnosis of sepsis
  • Pneumonia, abdominal abscess and pyelonephritis are common primary causes of sepsis

Definition Changes

In 2016 new definitions were adopted for the evaluation and diagnosis of Sepsis, Severe Sepsis and Septic shock[5]

Old definition New 2016 definition
Sepsis 2 SIRS + suspected infection Life threatening organ dysfunction caused by dysregulated host response to infection. Suspected/documented infection + 2 on the qSOFA:
  • Hypotension with SBP <100 or
  • altered mental status or
  • Tachypnea (RR >/=22) OR
  • Increase in SOFA score by 2 points
Severe sepsis *Sepsis +
  • SBP< 90 or
  • MAP <65 lactate >2 or
  • INR >1.5 or
  • Bili>2 or
  • Urine output <0.5ml/kg/h
  • Creatinine>2.2 or
  • Platelets <100 or
  • SpO@<90%
No longer a category
Septic shock Sepsis + hypotension after adequate fluid resuscitation Sepsis + vasopressors needed to maintain MAP>65 + lactate >2

qSOFA Score

Quick Sequential (Sepsis Related) Organ Failure Assessment Score

  • Respiratory rate of 22/min or greater (+1 Point)
  • Altered mentation (+1 Point)
  • Systolic blood pressure of 100 mm Hg or less (+1 Point)

SOFA Score

  • The SOFA is generally used in the ICU and can stratify the mortality of patients based on the initial score and subsequent changes in score

MEDS score

  • The Mortality in Emergency Department Sepsis (MEDS) prediction rule is a proposed method to risk stratify ED patients with sepsis

NEWS 2 Score

  • National Early Warning Score (NEWS) 2 determines degree of critically ill patient, in non-pregnant patients ≥16 years old[6]
  • Used by the UK NHS to identify acutely ill patients, including those with sepsis
  • Not reliable in spinal cord injury patients due to disturbance of autonomic responses
  • Combination of:
    • Respiratory rate
    • Presence of hypercapnic respiratory failure
    • Presence of supplemental O2
    • Temperature
    • SBP
    • Pulse rate
    • Consciouness
  • See below for MDCalc link

Systemic Inflammatory Response Syndrome (SIRS) Criteria

  • Still acceptable to use in ED depending on local protocol
  • Misses up to 1/8 very septic ICU patients[7]


  • ≥2 of 4 criteria must be present:
  1. Temperature >38°C (100.4F) or <36°C (96.9F)
  2. HR >90 BPM
  3. RR >20 breaths/minute or PaCO2 <32 mmHg
  4. WBC count >12,000/mm3, <4,000/mm3, or >10% bands/immature forms

Clinical Features

Sepsis

Life-threatening organ dysfunction caused by a dysregulated host response to infection. This only needs to include one of the following:[8]

Septic shock

Patients with sepsis and any of the following:[1]

  1. Vasopressor requirement to maintain a mean arterial pressure > 65 mm Hg
  2. Serum lactate level greater than 2 mmol/L (>18mg/dL) in the absence of hypovolemia.

Differential Diagnosis

Shock

Evaluation

Work-Up

Time Specific Management

Time of presentation is defined as the time of triage in the emergency department

3 hour goals[9]

  • Measure lactate level
  • Obtain blood cultures prior to administration of antibiotics
  • Administer broad spectrum antibiotics
  • Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L

6 hour goals[9]

  • Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
  • 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:
    • Option 1: Focused Exam
      • Vital signs
      • Cardiopulmonary Exam
      • Capillary Refill
      • Peripheral Pulse
      • Skin Exam
    • Option 2: Two of the following
      • Measure CVP (IVC ultrasound) with following goals:
        • >8 cmH2O, not intubated
        • >12 cmH2O, intubated
      • Measure ScvO
      • Bedside cardiovascular ultrasound
      • 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[10][11][12]

Circulation Managment

IVF

  • Guidelines recommend initial 30 cc/kg bolus (generally 2L in average adult)
  • Reassess patient's volume status after initial bolus. Auscultate for pulmonary edema. Evaluate peripheral circulation. Consider IVC ultrasound
  • Septic patients can be euvolemic but remain hypotensive due to vasodilation. Consider early vasopressors.
  • Increasing evidence that excessive fluid resuscitation can be harmful.
    • Positive fluid balance on day 3 of hospital admission independently associated with increasing mortality [13]
    • Protocolized fluid administration (e.g. traditional Early Goal Directed Therapy) has no mortality benefit over usual care. [14] [15]
    • High volume (5+ L) resuscitation associated with increased mortality. [16]
  • Consider assessing diastolic dysfunction via echo in CHF patients in whom IVC ultrasound is not reliable


Pressors

  • Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
  • Best if given when the vascular space is filled; ok if it is not

Options:

  • Norepinephrine (5-20mcg/min) - 1st line[17]
  • Epinephrine (1-20 mcg/min) - 2nd line
  • Vasopressin (0.03 units/minute fixed dose) can be added to norepinephrine (NE)
    • as a 2nd line agent may reduce arrhythmia's compared to other pressors with catecholamine properties[18]
  • Dopamine should be used hesitantly and only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia)
    • Do not use Low-dose dopamine for renal protection
    • Dopamine may have increased mortality rates compared to other vasopressors, especially in the pediatric septic patient[19]
  • Phenylephrine should not be used for treating septic shock except if:
    • Norepinephrine is associated with serious arrhythmias
    • Cardiac output is known to be high and blood pressure persistently low
    • As salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target
  • Milrinone
  • Methylene blue consideration for septic shock refractory to catecholaminergic pressors

Inotropes

  • Dobutamine (2-20mcg/kg/min) may be added if:
    • Myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output
    • Ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP

Steroids

  • Controversial and only shown to relieve shock faster in those who have resolution of shock but may increase the risk of infection
    • Consider hydrocortisone 50-100mg in ED (200-300mg QD in 2-4x/d dosing) if pressor/fluid resistant (SBP < 90 persistently)
  • ACTH cosyntropin testing likely unreliable in critically ill patients
  • Do not administer steroids for the treatment of sepsis in the absence of shock

Esmolol

  • One single-center RCT showing ~40% reduction in mortality when esmolol paired with norepinephrine infusion, with goal HR 80 - 95 BPM[20]
  • All patients were fluid resuscitated, intubated, given hydrocortisone 300 mg/day
  • Will require further multi-center RCTs to confirm findings

Infection Control

Source control

Antibiotics

Blood Products

RBCs

Only transfuse RBCs when hemoglobin decreases to <7.0 g/dL (goal is 7.0 –9.0 g/dL in adults)

Erythropoietin

Do not use erythropoietin as a specific treatment of anemia associated with severe sepsis

Platelets

  • In severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding
  • If < 20,000/mm3 (20 x 109/L) and significant risk of bleeding then administer platelets.
  • <50,000/mm3 (50 x 109/L) if there is active bleeding, planned surgery or other procedures.

Disposition

  • Admit, possibly to step-down or ICU

External Links

See Also

References

  1. 1.0 1.1 1.2 Singer, Melvyn et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
  2. Jui, Jonathan (2011). "Ch. 146: Septic Shock". In Tintinalli, Judith E.; Stapczynski, J. Stephan; Ma, O. John; Cline, David M. et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide (7th ed.). New York: McGraw-Hill. pp. 1003–14.
  3. Jawad, I; Lukšić, I; Rafnsson, SB (June 2012). "Assessing available information on the burden of sepsis: Global estimates of incidence, prevalence and mortality". Journal of Global Health 2 (1): 010404. doi:10.7189/jogh.02.010404 (inactive 2015-02-02). PMC 3484761. PMID 23198133 full text
  4. Munford, Robert S.; Suffredini, Anthony F. (2014). "Ch. 75: Sepsis, Severe Sepsis and Septic Shock". In Bennett, John E.; Dolin, Raphael; Blaser, Martin J.. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (8th ed.). Philadelphia: Elsevier Health Sciences. pp. 914–34.
  5. Seymour, C. Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.
  6. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: RCP, 2017.
  7. Kaukonen KM, Bailey M, Bellomo R. Systemic Inflammatory Response Syndrome Criteria for Severe Sepsis. The New England journal of medicine. 373(9):881. 2015.
  8. Seymour, C. Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.
  9. 9.0 9.1 Surviving Sepsis Updated Bundles in Response to New Evidence full text
  10. ProCESS Investigators,Yealy DM, Kellum JA, Juang DT, et al.A randomized trial of protocol-based care for earlyseptic shock. N Engl J Med 2014;370(18):1683-1693 Full Text
  11. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med2014; 371:1496-1506
  12. Mouncey PR, Osborn TM, Power GS, et al for the ProMISe trial investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015:DOI: 10.1056/NEJMoa1500896
  13. Sakr Y et al. Higher Fluid Balance Increases the Risk of Death From Sepsis: Results From a Large International Audit. Critical care medicine. 45(3):386-394, Mar 2017.
  14. Yealy DM, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370:1683-93. DOI: 10.1056/NEJMoa1401602
  15. Mouncey PR, et al. Trial of Early, Goal-Directed Resuscitation for Septic Shock. N Engl J Med 2015;372:1301-11. DOI: 10.1056/NEJMoa1500896
  16. Marik PE, et al. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive Care Med (2017) 43:625–632 DOI 10.1007/s00134-016-4675-y
  17. EBQ:SOAP II Trial
  18. McIntyre, W. F., Um, K. J., Alhazzani, W., Lengyel, A. P., Hajjar, L., Gordon, A. C., … Belley-Côté, E. P. (2018). Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock. JAMA: The Journal of the American Medical Association, 319(18), 1889.
  19. Ventura AM, Shieh HH, Bousso A, Goes PF, Fernandes IC, de Souza DC, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrineas First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015;43:2292-302.
  20. Andrea Morelli et al. Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock: A Randomized Clinical Trial. JAMA. 2013;310(16):1683-1691.