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
- Pulm, skin, GU (account for 80%), abd, CNS
Diagnosis
- SIRS
- 2 or more of the following:
- Temp >38.3 or <36
- HR >90
- Resp rate >20 or CO2 <32
- WBC >12K, <4K, or >10% bands
- 2 or more of the following:
- Sepsis
- SIRS + documented or suspected infection
- Severe sepsis
- Sepsis AND 1 or more of the following signs of organ dysfunction:
- Lactate > upper limit of normal
- Urine output <0.5 mL/kg for >2hr, despite adequate fluid resuscitation
- Cr >2 (presumed to be new)
- Bilirubin >2 (presumed to be new)
- Plt <100K (presumed to be new)
- INR >1.5 (presumed to be new)
- ALI
- PaO2/FIO2 <250 in absence of PNA as infection source
- PaO2/FIO2 <200 in presence of PNA as infection source
- Sepsis AND 1 or more of the following signs of organ dysfunction:
- Septic shock
- SBP <90 after adequate fluid challenge OR
- 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
- 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
- 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:
- Repeat focused exam OR any two of the following:
- Measure CVP
- Measure ScvO
- Bedside cardiovascular ultrasound
- Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
- Repeat focused exam OR any two of the following:
A central line and measurement of ScvO2 is not required and does not impact mortality[2][3]
Circulation
- IVF - Reassess after each bolus
- Average is 5-6L w/in first 6hr
- Careful reassessment of volume status is required in in patients with significantly depressed ejection fraction.
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's not
- Options:
- Norepi (5-20mcg/min) - 1st line
- Dopamine (5-20mcg/kg/min)
Inotropes
- Dobutamine (2-20mcg/kg/min) if perfusion goal not met despite Hb >10
Infection Control
- Source Control
- Remove infected lines, surgery if indicated
Antibiotics
- Administer in 3 hrours
- See Initial Antibiotics in Sepsis (Main)
Coagulation
- Consider FFP if INR >1.5
- Consider plts if <50K
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 (200-300 mg qd in 2-4x/d dosing) if pressor/fluid resistant (SBP < 90 persistently)
- ACTH cosyntropin testing likely unreliable in critically ill patients
External Links
See Also
Source
- ↑ Surviving Sepsis Updated Bundles in Response to New Evidence full text
- ↑ 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
- ↑ 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