Sepsis (main)
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 caries a 40% in hospital mortality[1]
Definition Changes
In 2016 new definitions were adopted for the evaluation and diagnosis of Sepsis, Sever Sepsis and Septic shock
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:
|
Severe sepsis | *Sepsis +
|
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.
Clinical Presentation
Sepsis
Life-threatening organ dysfunction caused by a dysregulated host response to infection. This only needs to include one of the following:[5]
- Hypotension with SBP <100 or
- AMS or
- Tachypnea (RR >/=22) OR
- Increase in SOFA score by 2 points
Septic shock
Patients with sepsis and any of the following:[1]
- Vasopressor requirement to maintain a mean arterial pressure > 65 mm Hg
- Serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.
Differential Diagnosis
- Adrenal Insufficiency
- Salicylate Toxicity
- Anticholinergic Toxicity
- Neuroleptic Malignant Syndrome
- Malignant Hyperthermia
- Thyrotoxicosis
Shock
- Cardiogenic
- Acute valvular Regurgitation/VSD
- CHF
- Dysrhythmia
- ACS
- Myocardial Contusion
- Myocarditis
- Drug toxicity (e.g. beta blocker, CCB, or bupropion OD)
- Obstructive
- Distributive
- Hypovolemic
- Severe dehydration
- Hemorrhagic shock (traumatic and non-traumatic)
Altered mental status and fever
- Infectious
- Sepsis
- Meningitis
- Encephalitis
- Cerebral malaria
- Brain abscess
- Other
Diagnosis
Work-Up
- CBC
- UA/Urine culture
- Blood culture
- CXR
- Chem
- LFT
- Lipase
- VBG
- Lactate
- Procalcitonin
- Coags
- DIC panel (fibrinogen, D-dimer, FDP)
- T&S
- ?CT head/LP
- ?TSH (thyroid storm)
- ?Cosyntropin stim vs. random cortisol (adrenal insufficiency)
Time Specific Management
Time of presentation is defined as the time of triage in the emergency department
3 hour goals[6]
- 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[6]
- 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[7][8][9]
Circulation Managment
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:
- Norepinephrine (5-20mcg/min) - 1st line
- Epinephrine (1-20 mcg/min) - 2nd line
- Vasopressin (0.03 units/minute fixed dose) can be added to norepinephrine (NE)
- 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[10]
- 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
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 (200-300 mg 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
Infection Control
- Source Control
- Remove infected lines, surgery if indicated
Antibiotics
- Administer within 3 hours
- See Initial Antibiotics in Sepsis (Main)
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.
External Links
See Also
References
- ↑ 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
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 6.0 6.1 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
- ↑ 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
- ↑ 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.