SEPSIS
BODY’S RESPONSE TO INFECTION IN PRESENCE OF SIRS.
SIRS
DISSEMINATED INFLAMMATORY RESPONSE THAT MAY ARISE AS
A RESULT OF NUMBER OF INSULTS SUCH AS INFECTION,
ISCHEMIA ETC.
TWO OF :
HYPERTHERMIA(>38°C) OR HYPOTHERMIA (<36°)
TACHYCARDIA(>90/MIN,NO Β BLOCKERS) OR TACHYPNOEA
(20/MIN)
WBC COUNT >12 x10⁹/L OR < 4 x10⁹
SEVERE SEPSIS
SEPSIS WITH EVIDENCE OF END ORGAN
DYSFUNTION OR HYPOPERFUSION.
• ACUTE RESPIRATORY DISTRESS SYNDROME
• ACUTE KIDNEY INJURY
• CARDIOVASCULAR DYSFUNTION
• CENTRILOBULAR NECROSIS OF LIVER
SEPTIC SHOCK
SEPTIC SHOCK DEFINED AS PERSISTING HYPOTENSION
REQUIRING VASOPRESSORS TO MAINTAIN MAP [MEAN ARTERIAL
PRESSURE] >65 MMHG AND HAVING A SERUM LACTATE LEVEL
>2 MMOL/L (18 MG/DL) DESPITE ADEQUATE VOLUME
RESUSCITATION.
• RECOGNIZING SEPTIC SHOCK BEGINS WITH DEFINING THE PATIENT AT
RISK.
• THE CLINICAL MANIFESTATIONS OF SEPTIC SHOCK WILL USUALLY BECOME
EVIDENT AND PROMPT THE INITIATION OF TREATMENT BEFORE
BACTERIOLOGIC CONFIRMATION OF AN ORGANISM OR THE SOURCE OF
AN ORGANISM IS IDENTIFIED.
– FLUSHING, WARM PERIPHERIES, RAPID CAPILLARY REFILL TIME, LOW
CVP AN DROWSY MENTAL STATE.
• AN AGGRESSIVE SEARCH FOR INFECTION, INCLUDING A THOROUGH
PHYSICAL EXAMINATION, INSPECTION OF ALL WOUNDS, EVALUATION OF
INTRAVASCULAR CATHETERS OR OTHER FOREIGN BODIES, OBTAINING
APPROPRIATE CULTURES, AND ADJUNCTIVE IMAGING STUDIES, AS
NEEDED.
• DISTRIBUTIVE SHOCK CHARATERISED BY INADEQUATE ORGAN PERFUSION
ACCOMPANIED BY VASCULAR DILATATION (NO2) WITH HYPOTENSION,
LOW SYSTEMIC VASCULAR RESISTANCE, INADEQUATE AFTERLOAD AND A
RESULTING ABNORMALLY HIGH CARDIAC OUTPUT.
• HYPERGLYCEMIA
• HIGH BASE DEFICIT (> 6mmol/L)
• INCREASED MIXED VENOUS OXYGEN SATURATION
– ACCURATE MEASUREMENT VIA ANALYSIS OF BLOOD DRAWN FROM
LONG CENTRAL LINE PLACED IN THE RIGHT ATRIUM.
– NORMAL LEVEL IS 50% TO 70%.
– IN SEPSIS, >70%, DUE TO DISORDERED UTILIZATION OF OXYGEN AT THE
CELLULAR LEVEL AND ARETERIO VENOUS SHUNTING OF BLOOD AT THE
MICROVASCULAR LEVEL.
– IF NOT ABOVE 70% IN A SEPTIC PATIENT , SUSPECT OTHER CAUSES OF
SHOCK.
MANAGEMENT OF SEPSIS INDUCED SHOCK
ESSENTIALLY COMPRISES OF
IDENTIFYING AND TREATING THE CAUSE.
SUPPORTING ORGAN FUNCTION.
THE SURVIVING SEPSIS CAMPAIGN
BUNDLE: 2018 UPDATE HOUR-1 BUNDLE
• MEASURE LACTATE LEVEL. REMEASURE IF INITIAL LACTATE >
2MMOL/L
• OBTAIN BLOOD CULTURES PRIOR TO ADMINISTRATION OF
ANTIBIOTICS
• ADMINISTER BROAD-SPECTRUM ANTIBIOTIC
• BEGIN RAPID ADMINISTRATION OF 30 ML/KG CRYSTALLOID FOR
HYPOTENSION OR LACTATE > 4 MMOL/L
• APPLY VASOPRESSORS IF PATIENT IS HYPOTENSION DURING OR
AFTER FLUID RESUSCITATION TO MAINTAIN MAP > 65 MM HG.
AIRWAY AND VENTILATION
FLUID THERAPY
• AT LEAST 30 ML/KG OF IV CRYSTALLOID FLUID WITHIN FIRST 3 HOURS
• AFTER INITIAL RESUSCITATION, ADDITIONAL FLUIDS GUIDED BY FREQUENT
REASSESSMENT
• END POINTS OF FLUID RESUCITATION
– MAP >65 MM HG
– RESUSCITATION TO NORMALIZE LACTATE IN PATIENTS WITH ELEVATED LACTATE
LEVELS AS A MARKER OF TISSUE HYPOPERFUSION.
– FLUID CHALLENGE TECHNIQUE WITH CONTINUED FLUID ADMINISTRATION AS
LONG AS HEMODYNAMICS FACTORS CONTINUE TO IMPROVE.
• RESCUE
– RECOMMENDED GOAL OF 30 ML/KG OF IV CRYSTALLOI
• OPTIMIZATION PHASE
– ISCHEMIA AND REPERFUSION PHASE
– REPEATED ASSESSMENTS OF INTRAVASCULAR FLUID STATUS AND
DETERMINATION FOR FURTHER FLUID ADMINISTRATION
• STABILIZATION
– MAINTAIN INTRAVASCULAR VOLUME, REPLACE ONGOING FLUID
LOSSES, SUPPORT ORGANS DYSFUNCTION, AVOID IATROGENIC HARM
WITH UNNECESSARY FLUID ADMINISTRATION
• DE-ESCALATION
ANTIBIOTICS
• EMPIRIC, BROAD-SPECTRUM INTRAVENOUS ANTIMICROBIALS SHOULD
BE INITIATED AS SOON AS POSSIBLE AFTER RECOGNITION, IDEALLY AFTER
COLLECTION OF BLOOD CULTURES AND OTHER CULTURES, AND WITHIN 1
HOUR FOR BOTH SEPSIS AND SEPTIC SHOCK ACCORDING TO THE
CURRENT GUIDELINES WITH MODERATE EVIDENCE.
• COMBINATION THERAPY FOR INITIAL MANAGEMENT OF SEPTIC SHOCK
• PROCALCITONIN LEVELS TO SUPPORT SHORTENING DURATION OF
THERAPY.
• SOURCE CONTROL AND PERCUTANEOUS DRAINAGE AND OPERATIVE
MANAGEMENT TO TARGET A FOCUS OF INFECTION.
VASOPRESSORS
• AFTER FIRST-LINE THERAPY OF THE SEPTIC PATIENT WITH ANTIBIOTICS, IV FLUIDS, AND
INTUBATION IF NECESSARY, VASOPRESSORS MAY BE NECESSARY TO TREAT PATIENTS WITH SEPTIC
SHOCK.
• CATECHOLAMINES ARE THE VASOPRESSORS USED MOST OFTEN, WITH NOREPINEPHRINE BEING
THE FIRST-LINE AGENT FOLLOWED BY EPINEPHRINE.
• OCCASIONALLY, PATIENTS WITH SEPTIC SHOCK WILL DEVELOP ARTERIAL RESISTANCE TO
CATECHOLAMINES.
• ARGININE VASOPRESSIN, A POTENT VASOCONSTRICTOR, IS OFTEN EFFICACIOUS IN THIS SETTING
AND IS OFTEN ADDED TO NOREPINEPHRINE.
• DOBUTAMINE THERAPY IS RECOMMENDED FOR PATIENTS WITH CARDIAC DYSFUNCTION AS
EVIDENCED BY HIGH FILLING PRESSURES AND LOW CARDIAC OUTPUT OR CLINICAL SIGNS OF
HYPOPERFUSION AFTER ACHIEVEMENT OF RESTORATION OF BLOOD PRESSURE FOLLOWING
FLUID RESUSCITATION.
HYPERGLYCEMIA
• HYPERGLYCEMIA AND INSULIN RESISTANCE ARE TYPICAL IN CRITICALLY ILL
AND SEPTIC PATIENTS, INCLUDING PATIENTS WITHOUT UNDERLYING
DIABETES MELLITUS.
• INTENSIVE INSULIN THERAPY WITH TIGHT BLOOD SUGAR LEVEL
MAINTENANCE BETWEEN 80 TO 110 MG/DL HAS SHOWN BETTER
OUTCOMES.
• SEPSIS GUIDELINES - <180 mg/dl
STEROIDS
• THE OBSERVATION THAT SEVERE SEPSIS OFTEN IS ASSOCIATED WITH
ADRENAL INSUFFICIENCY OR GLUCOCORTICOID RECEPTOR RESISTANCE
HAS GENERATED RENEWED INTEREST IN THERAPY FOR SEPTIC SHOCK
WITH CORTICOSTEROIDS.
• SEVERAL STUDIES SUGGEST THAT HYDROCORTISONE THERAPY CANNOT
BE RECOMMENDED AS ROUTINE ADJUVANT THERAPY FOR SEPTIC SHOCK.
• HOWEVER, IF SBP REMAINS LESS THAN 90 MMHG DESPITE APPROPRIATE
FLUID AND VASOPRESSOR THERAPY, HYDROCORTISONE AT 200 mg/day
FOR 7 DAYS IN FOUR DIVIDED DOSES OR BY CONTINUOUS INFUSION
SHOULD BE CONSIDERED.
• TRANSFUSION
PACKED RED CELLS IF HB IS LEASS THAN 7g/dl.
• LMWH
• H2 RECEPTOR BLOCKER
• NUTRITION
COMPLICATIONS
• METABOLIC ACIDOSIS
• DIC
• MODS
• HYPERCATABOLIC STATE
• STRESS ULCERS
• PULMONARY HYPERTENSION
SEQUENTIAL [SEPSIS-RELATED] ORGAN
FAILURE ASSESSMENT (SOFA) SCORE
• PATIENTS SHOULD HAVE A SUSPECTED OR DOCUMENTED INFECTION AND
AN ACUTE INCREASE OF AT LEAST 2 SOFA POINTS FROM BASELINE.
• IF PATIENTS MEET THE CRITERIA AND REQUIRE VASOPRESSOR THERAPY
TO MEET THE MEAN ARTERIAL PRESSURE (MAP) OF AT LEAST 65 MM HG
AND THEIR LACTATE CONCENTRATION IS GREATER THAN 2 MMOL/L (18
MG/DL) DESPITE ADEQUATE FLUID RESUSCITATION, THEIR CONDITION IS
CLASSIFIED AS SEPTIC SHOCK
• THE SEQUENTIAL ORGAN FAILURE ASSESSMENT (SOFA) IS A
MORTALITY PREDICTION SCORE THAT IS BASED ON THE DEGREE OF
DYSFUNCTION OF 6 ORGAN SYSTEMS.
• THE SCORE IS CALCULATED AT ADMISSION AND EVERY 24 HOURS
UNTIL DISCHARGE, USING THE WORST PARAMETERS MEASURED
DURING THE PRIOR 24 HOURS.
• THE SCORES CAN BE USED IN SEVERAL WAYS, INCLUDING:
» AS INDIVIDUAL SCORES FOR EACH ORGAN TO DETERMINE THE PROGRESSION
OF ORGAN DYSFUNCTION.
» AS A SUM OF SCORES ON A SINGLE INTENSIVE CARE UNIT (ICU) DAY.
» AS A SUM OF THE WORST SCORES DURING THE ICU STAY.
• THE SOFA SCORE STRATIFIES MORTALITY RISK IN ICU PATIENTS
WITHOUT RESTRICTING THE DATA USED TO ADMISSION VALUES
qSOFA
• QSOFA IS SUGGESTED TO IDENTIFY PATIENTS WITH
SUSPECTED INFECTION WHO ARE LIKELY TO DEVELOP SEPSIS
OR SEPTIC SHOCK.
• THIS TOOL CAN BE USED OUTSIDE THE ICU, AND EVEN
OUTSIDE THE HOSPITAL, BECAUSE IT IS EASY TO PERFORM BY
CLINICAL EXAMINATION.
• ONCE PATIENTS MEET AT LEAST TWO QSOFA CRITERIA, ORGAN
DYSFUNCTION SHOULD BE ASSESSED USING THE SOFA SCORE.
