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Sepsis

Charlie Oertli

Background

Most recent definition (Sepsis-3): organ dysfunction from dysregulated host response to infection

  • 2021 Surviving Sepsis Guidelines: SIRS, MEWS, NEWS superior to qSOFA for screening sepsis
  • SIRS ≥2 of any of: 1) RR>20, 2) T \<36 or >38, 3) HR >90, 4) WBC \<4 or >12 or >10% bands
  • Septic Shock = sepsis + vasopressors + lactate >2 meq/dL (Sepsis 3 definition)
  • Alternate screening systems you may see which are more specific and better at prognosis of in hospital mortality than SIRS:
    • Acute change in baseline SOFA score ≥2: P/F ratio, Plts, Tbili, SBP, GCS, Cr
    • "Quick" SOFA (qSOFA): ≥2 of AMS (GCS≤13), SBP≤100 mmHg, RR≥22/min

Evaluation

  • Cultures prior to antibiotics if possible (but don’t delay antibiotics just to get cultures)
  • Consider sputum Cx, paracentesis, thoracentesis, wound Cx, LP, joint aspiration
  • Lactate (even if not hypotensive)
  • Imaging: x-ray, CT, or US of potential source

Management

Source control: Remove old lines, chest tube for empyema, drain abscesses, etc

Antibiotics

  • Early antibiotics: within 1 hour if septic shock, within 3 hours if sepsis
  • Target organisms most likely to cause infection in suspected organ; if source unknown, start empiric broad-spectrum
  • MRSA coverage - vancomycin/daptomycin/linezolid/ceftaroline
  • Pseudomonas coverage - zosyn/cefepime/meropenem /cipro/gentamicin
  • Pneumonia: add atypical coverage (azithromycin/levaquin; 2nd line doxycycline if prolonged QTC or elderly) if severe or being admitted to the ICU
  • Fungal coverage for Candida: if neutropenic, TPN, abdominal surgery, prior antibiotics
  • De-escalation: Once source is controlled, if abx duration is unknown use procalcitonin, culture susceptibilities, and clinical evaluation to help guide de-escalation

Resuscitation

  • Give 1-3 L (≥30 mL/kg of body weight) of IV balanced crystalloid within first 3 hours
  • Only give blood if Hb \< 7, unless evidence of bleeding or myocardial ischemia
  • Monitor HR, BP, mental status, urine output – do NOT give beta-blockers to slow HR in the setting of sepsis unless dangerously high and limiting diastolic filling (discuss with fellow), this is an appropriate stress response
  • Assess fluid responsiveness by leg raise (if BP improves with leg raise, give more fluids). Other options US IVC (mixed data), pulse pressure

Vasopressors

  • Start if MAP not responsive to fluid resuscitation
  • Target MAP > 65mmHg, also monitor mental status, serum lactate, and urine output; may need higher goal for pts with chronic HTN
  • Start with norepinephrine -- via central line, PICC, or port. Can run through peripheral IV (at least 18g, proximal to wrist) up to 15 mcg/min for up to 48 hours if no central access
    • SOAP II trial: norepinephrine > dopamine (less arrhythmias)
    • No upper limit of NE but can cause peripheral ischemia with prolonged use
  • Add vasopressin at fixed dose of 0.04 units/min when NE dose >= 50 mcg/min
    • VASST trial: possible benefit for pts on 5-15 of NE; however, this was opposite of hypothesis and vasopressin is expensive
  • Add epinephrine or dobutamine if low cardiac output
  • Add phenylephrine for pts with tachyarrhythmias (reflex bradycardia)
  • Consider Angiotensin II (discuss with fellow, needs MICU leadership approval) contraindicated with CHF and DVT/PE/clots/hypercoagulability
  • Consider steroids if vasopressors failing or on steroids chronically hydrocortisone 100mg IV q8hr or 50mg IV q6hr for 5 to 7 days
Last update: 2022-06-02 13:28:55