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

Clinical Presentation

SIRS

• 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

Sepsis

• SIRS + documented or suspected infection

Severe sepsis

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. Acute Lung Injury
   • PaO2/FIO2 <250 in absence of PNA as infection source
   • PaO2/FIO2 <200 in presence of PNA as infection source

Septic shock

• SBP <90 after adequate fluid challenge OR
• Lactate >4

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
  • Air embolism
  • Aortic Stenosis
  • Cardiac Tamponade
  • PE
  • Tension pneumothorax
• Distributive
  • Adrenal crisis
  • Anaphylaxis
  • Neurogenic shock
  • Sepsis
  • Toxicologic
• Hypovolemic
  • Severe dehydration
  • Hemorrhagic shock (traumatic and non-traumatic)

Diagnosis

Work-Up

• CBC
• UA/Urine culture
• Blood culture
• CXR
• Chem
• LFT
• Lipase
• VBG
• Lactate
• Coags
• DIC panel (fibrinogen, D-dimer, FDP)
• T&S
• ?CT head/LP

Management

Time Related Goals

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

3 hour goals

• 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

A central line and measurement of ScvO₂ is not required and does not impact mortality

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:
  • 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)

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

• MDCalc - SIRS, Sepsis, and Septic Shock Criteria

See Also

• Initial Antibiotics in Sepsis (Main)
• Sepsis (Peds)
• EBQ:ProCESS Trial