Sepsis (main)

Background

• Pancreatitis may appear identical to sepsis
• Infection sources:
  • CNS, pulm, abd, GU, skin
    • Childbearing age woman: septic abortion, postpartum endometritis
    • No obvious source: consider bacteremia, endocarditis

Diagnosis

1. Sepsis
   1. Documented or suspected infection AND 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. 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
3. Septic shock
   1. SBP <90 after adequate fluid challenge OR
   2. Lactate >4

DDx

• Adrenal Insufficiency
• Salicylate Toxicity
• Anticholinergic Toxidrome
• Neuroleptic Malignant Syndrome
• Malignant Hyperthermia
• Thyrotoxicosis
• Other shock
  • Cardiogenic
  • Hypovolemic
  • Anaphylactic
  • 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
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) OR 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 Sepsis (Initial Abx)
6. Coagulation
   1. Consider FFP if INR >1.5
   2. Consider plts if <50K
7. Steroids
   1. Controversial
   2. Consider hydrocortisone 100 mg if pressor resistant

See Also

Sepsis (Initial Abx)

Source

• Tintinalli
• Surviving Sepsis Guidelines 2008