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