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

Early Goal Directed Therapy

1. Goals
   1. Preload Goal: CVP >8 (>12 if intubated)
   2. Afterload Goal: MAP >65
   3. Perfusion goal: ScvO2 >70% OR lactate clearance >10%
   4. Hb >10 (if ScvO2 target not otherwise met)
   5. Lactate clearance of at least 10%
   6. Urine output >0.5 mL/kg/hr
2. Airway
   1. Careful - sedatives for intubation may worsen hypotension
   2. Careful - PPV reduces preload and CO
3. Breathing
   1. Maintain O2 sat >93%
   2. Maintain PaCO2 at 35-40
   3. Consider early mechanical ventilation
      1. Rationale:
         1. Ensures efficient oxygenation
         2. Decreases O2 demand by respiratory muscles
      2. Settings
         1. Tidal volume 6mL/kg ideal wt
         2. Plateau pressure <30
4. Circulation
   1. IVF - Reassess after each bolus
      1. Average is 5-6L w/in first 6hr
      2. IVF can be harmful in cardiogenic shock or in pts w/ pulm edema
   2. 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)
   3. Inotropes
      1. Dobutamine (2-20mcg/kg/min) if perfusion goal not met despite Hb >10
5. Infection Control
   1. Source Control
      1. Remove infected lines, surgery if indicated
   2. Abx
      1. Give ASAP
      2. See Initial Antibiotics in Sepsis (Main)
6. Coagulation
   1. Consider FFP if INR >1.5
   2. Consider plts if <50K
7. Steroids
   1. Controversial
   2. Consider hydrocortisone 200-300 mg qd if pressor/fluid resistant (SBP < 90 persistently)
   3. ACTH cosyntropin testing likely unreliable in critically ill pts

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