MICU Intern's survival guide sepsis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Systemic Inflammatory Response Syndrome [1] [2]
- SIRS can be diagnosed when two or more of the following are present:[3]
- Heart rate > 90 beats per minute
- Temperature < 36 (96.8 °F) or > 38 °C (100.4 °F)
- Tachypnea > 20 breaths per minute or, on blood gas, a PaCO2 < 32 mm Hg
- White blood cell count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 109 or > 12 x 109 cells/L), or > 10% band forms (immature white blood cells / bandemia).
- SIRS can be seen in non infectious conditions like pancreatitis and myocardial infarction.
Sepsis
- SIRS + Source of infection
Severe sepsis
- Sepsis + organ dysfunction
- Organ damage can present as decreased urine output, acute kidney injury, and elevated liver function tests.
Septic shock
- Severe sepsis + persistent hypotension after adequate fluid challenge.
Multiple organ dysfunctions (MODS)
- Progressive multiple organ failure secondary to severe sepsis.
Sepsis management
Source control
Source identification
- Depending on the patient's history sputum, blood, urine or other sources can be cultured. In case of unclear source, pan-culture should be done.
- Based on the patient's history proper imaging should be initiated.
Source management
- Initiation of proper antibiotic within an hour of diagnosis.
- Drainage in cases of an abscess should be done.
Resuscitation
Hypotension
- Fluids are the first line management
- Crystalloids like normal saline, ringer lactate are the first to be used.
- Normal rate of infusion is 40-60ml/kg.
- If patient still hypotensive after fluid challenge plan to insert a central venous line to guide additional fluid therapy. An internal jugular and subclavian lines are preferred.
- CVP should be checked in Q30 minutes for adequate fluid management.
- Target CVP are:
- 10-12 in non-intubated patients.
- 12-15 in intubated patients.
- If patient still hypotensive start vasopressors.
- Nor-epinephrine is the first line vasopressor agent.
- Dopamine and vasopressin are second line agents
- Goal mean arterial pressure should be 65.
- Continue to bolus for CVP.
- If patient still hypotensive check ScvO2
- ScvO2 is a marker of cardiac output and tissue perfusion.
- ScvO2 is a marker of cardiac output and tissue perfusion.
- Target ScvO2 is > 70%
- If ScvO2 is < 70% consider transfusing with aim hematocrit of 30
- If hematocrit already 30% consider starting dobutamine
- A ScvO2 of 70% indicates that the tissue are adequately extracting oxygen thus the blood returing to heart have low oxygen saturation.
- A Scvo2 of 80-85% however is an ominous sign. It indicates that the tissues are not adequately using oxygen and instead of aerobic are doing anaerobic metabolism. In these situations lactate levels in the blood starts increasing.
Resuscitation
References
- ↑ Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL (2008). "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008". Critical Care Medicine. 36 (1): 296–327. doi:10.1097/01.CCM.0000298158.12101.41. PMID 18158437. Retrieved 2012-09-16. Unknown parameter
|month=ignored (help) - ↑ Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992 Jun;101(6):1644-55. PMID 1303622.
- ↑ Tslotou AG, Sakorafas GH, Anagnostopoulos G, Bramis J. Septic shock; current pathogenetic concepts from a clinical perspective. Med Sci Monit. 2005 Mar;11(3):RA76-85. PMID 15735579. Full Text.