Sepsis resident survival guide
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, M.D. [2]
Definition
- Sepsis = Infection + SIRS
- The presence of systemic inflammatory syndrome (SIRS) is due to many factors. The presence of infection increases the chances of sepsis and increase the SIRS criteria .
- The endothelial dysfunction is the main trigger transforming the localized infection into systemic organ dysfunction
- There is no definitive biomarkers have been associated with the endothelial dysfunction of sepsis.
SIRS is diagnosed by 2 or more of the following:
- Tachycardia > 90 bpm
- Tachypnea > 20 breaths per minute or on blood gas, a PaCO2 < 32 mm Hg
- Temperature < 36 (96.8 °F) or > 38 °C (100.4 °F)
- 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).
Sepsis is diagnosed by at least 1of the following signs of organ failure: [HOME]
- Hypoxemia (arterial oxygen tension [PaO2] < 72 mm Hg at fraction of inspired oxygen [FiO2] 0.21; overt pulmonary disease not the direct cause of hypoxemia)
- Oiguria (urine output < 30 mL or 0.5 mL/kg for at least 1 h)
- Mental status alteration
- Elevated plasma lactate level > 4mg
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 Dysfunction Syndrome (MODS) is the presence of altered organ function in a acutely ill patient whom homeostasis cannot be maintained without intervention.
- The criteria for ALI:[1]
- Oxygenation abnormality with a PaO2/FiO2 ratio < 300
- Bilateral opacities on chest radiograph compatible with pulmonary edema
- Pulmonary artery occlusion pressure < 18 mm Hg or no clinical evidence of left atrial hypertension if PaO2 is not available
ARDS is a more severe form of ALI and is defined similarly but a characteristic PaO2/FiO2 ratio is < 200.
Diagnostic criteria for Sepsis (documented or suspected infection plus one of the following)
- General variables
- Fever (> 38.3°C)
- Hypothermia (core temperature < 36°C)
- Heart rate > 90/min–1 or more than two sd above the normal value for age
- Tachypnea
- Altered mental status
- Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
- Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
- Inflammatory variables
- Leukocytosis (WBC count > 12,000 µL–1)
- Leukopenia (WBC count < 4000 µL–1)
- Normal WBC count with greater than 10% immature forms
- Plasma C-reactive protein more than two sd above the normal value
- Plasma procalcitonin more than two sd above the normal value
- Hemodynamic variables
- Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or less than two sd below normal for age)
- Organ dysfunction variables
- Arterial hypoxemia (Pao2/Fio2 < 300)
- Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
- Creatinine increase > 0.5 mg/dL or 44.2 µmol/L
- Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
- Ileus (absent bowel sounds)
- Thrombocytopenia (platelet count < 100,000 µL–1)
- Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 µmol/L)
- Tissue perfusion variables
- Hyperlactatemia (> 1 mmol/L)
- Decreased capillary refill or mottling
Causes
Life Threatening Causes
Prognosis
- Diabetes and renal disease may explain the higher rates of infection related septic shock.
- Immunosuppression
- Advanced age> 65 year old: a strong correlation exists between the incidence of septic shock in patients older than 50 years.
- Community acquired pneumonia: 48% develop severe sepsis.[7]
- Organ dysfunction is more related to bad prognosis than meeting SIRS criteria. A study found that just meeting SIRS criteria without evidence of organ dysfunction did not predict increased mortality. This concludes the importance of identification of organs dysfunction over the presence of SIRS criteria.[8]
Common Causes
Management
Goals during the first six hours of fluid resuscitation, as suggested by the Surviving Sepsis Campaign Guidelines, include the following:[9]
- CVP 8 to 12 mmHg
- SCV02 (superior vena cava) 70% or SVO2 65%
- MAP ≥65 mmHg
- Urine output ≥0.5 mL/kg/hour
| Sepsis Screening | |||||||||||||||||||||||||||||||
| History of Infection | |||||||||||||||||||||||||||||||
| Yes, History of Infection | No History | ||||||||||||||||||||||||||||||
| Yes,Clinical symptoms >2 clinical signs | No clinical symptoms | ||||||||||||||||||||||||||||||
| Lactate elevation, Evidence of organ dysfunction | No Lactate, Evidence of Organ dysfunction | ||||||||||||||||||||||||||||||
| Tissue hypoperfusion | |||||||||||||||||||||||||||||||
| Yes, tissue hypoperfusion >2 SBO ≤ 90mm Hg >3 MAP ≤ 65 mm Hg >4 Lactate ≥ 4mmol/L | No tissue hypoperfusion | ||||||||||||||||||||||||||||||
| Protocol A and B | Protocol B | ||||||||||||||||||||||||||||||
| Protocol A | |||||||||||||||||||||||||||||||||||
| Sepsis-induced Hypoperfusion Clinical picture plus < 65mm Hg Lactate > 4mmol/L | |||||||||||||||||||||||||||||||||||
| Supplemental O2 (Targeted by O2) Fluid resuscitation at least crystalloid bolus or colloid equivalent 20ml/kg | |||||||||||||||||||||||||||||||||||
| CVP measurement | |||||||||||||||||||||||||||||||||||
| CVP < 8mm Hg | CVP > 8mm Hg | ||||||||||||||||||||||||||||||||||
| Crystalloid bolus or colloid equivalent till CVP > 8 mm Hg | MAP | ||||||||||||||||||||||||||||||||||
| MAP < 65 mmHg | |||||||||||||||||||||||||||||||||||
| Vasopressors till MAP>65 | MAP > 65 mmHg | ||||||||||||||||||||||||||||||||||
| SeVO2 | |||||||||||||||||||||||||||||||||||
| SeVO2 < 70% | SeVO2 > 70% | ||||||||||||||||||||||||||||||||||
| Transfuse if HCT ≤ 30 Dobutamine | |||||||||||||||||||||||||||||||||||
| Goals achieved | Goals achieved | ||||||||||||||||||||||||||||||||||
| Resuscitation completed Reevaluate | Vasopressors still required Stress Dose Steroids | ||||||||||||||||||||||||||||||||||
Do's
- Appropriate antibiotic administration has a significant influence on mortality.
- Initiating broad-spectrum coverage until the specific organism is cultured and antibiotic sensitivities are determined is important.
Don'ts
- Routine use of hemodynamic drugs to raise cardiac output to supranormal levels is not recommended.
- Increasing the cardiac index in order to enhance the oxygen delivery has no improvement on outcome but it has worsened morbidity and mortality.
- Administration of bicarbonate in order to correct the acidosis may worsen the intracellular acidosis. Correction of acidemia with sodium bicarbonate has not been proved to improve hemodynamics in a critically ill patient with increased blood lactate levels.
- Immunosuppressive agents that could suppress the overwhelming inflammatory mediators responsible for MOD, as high-dose corticosteroids, have not shown any benefit in humans. However the encouraging data from animal studies.
- Unfractionated heparin in patients with sepsis did not have any beneficial effect on length of hospital stay, MODS, and mortality compared to placebo.[10]
References
- ↑ Bernard, GR.; Artigas, A.; Brigham, KL.; Carlet, J.; Falke, K.; Hudson, L.; Lamy, M.; Legall, JR.; Morris, A. (1994). "The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination". Am J Respir Crit Care Med. 149 (3 Pt 1): 818–24. doi:10.1164/ajrccm.149.3.7509706. PMID 7509706. Unknown parameter
|month=ignored (help) - ↑ Jones, GR.; Lowes, JA. (1996). "The systemic inflammatory response syndrome as a predictor of bacteraemia and outcome from sepsis". QJM. 89 (7): 515–22. PMID 8759492. Unknown parameter
|month=ignored (help) - ↑ Brun-Buisson, C.; Doyon, F.; Carlet, J.; Dellamonica, P.; Gouin, F.; Lepoutre, A.; Mercier, JC.; Offenstadt, G.; Régnier, B. (1995). "Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis". JAMA. 274 (12): 968–74. PMID 7674528. Unknown parameter
|month=ignored (help) - ↑ Sands, KE.; Bates, DW.; Lanken, PN.; Graman, PS.; Hibberd, PL.; Kahn, KL.; Parsonnet, J.; Panzer, R.; Orav, EJ. (1997). "Epidemiology of sepsis syndrome in 8 academic medical centers". JAMA. 278 (3): 234–40. PMID 9218672. Unknown parameter
|month=ignored (help) - ↑ Kumar, A.; Roberts, D.; Wood, KE.; Light, B.; Parrillo, JE.; Sharma, S.; Suppes, R.; Feinstein, D.; Zanotti, S. (2006). "Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock". Crit Care Med. 34 (6): 1589–96. doi:10.1097/01.CCM.0000217961.75225.E9. PMID 16625125. Unknown parameter
|month=ignored (help) - ↑ Bernard, GR.; Vincent, JL.; Laterre, PF.; LaRosa, SP.; Dhainaut, JF.; Lopez-Rodriguez, A.; Steingrub, JS.; Garber, GE.; Helterbrand, JD. (2001). "Efficacy and safety of recombinant human activated protein C for severe sepsis". N Engl J Med. 344 (10): 699–709. doi:10.1056/NEJM200103083441001. PMID 11236773. Unknown parameter
|month=ignored (help) - ↑ Dremsizov, T.; Clermont, G.; Kellum, JA.; Kalassian, KG.; Fine, MJ.; Angus, DC. (2006). "Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course?". Chest. 129 (4): 968–78. doi:10.1378/chest.129.4.968. PMID 16608946. Unknown parameter
|month=ignored (help) - ↑ Shapiro, N.; Howell, MD.; Bates, DW.; Angus, DC.; Ngo, L.; Talmor, D. (2006). "The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection". Ann Emerg Med. 48 (5): 583–90, 590.e1. doi:10.1016/j.annemergmed.2006.07.007. PMID 17052559. Unknown parameter
|month=ignored (help) - ↑ Dellinger, RP.; Levy, MM.; Rhodes, A.; Annane, D.; Gerlach, H.; Opal, SM.; Sevransky, JE.; Sprung, CL.; Douglas, IS. (2013). "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012". Intensive Care Med. 39 (2): 165–228. doi:10.1007/s00134-012-2769-8. PMID 23361625. Unknown parameter
|month=ignored (help) - ↑ Jaimes, F.; De La Rosa, G.; Morales, C.; Fortich, F.; Arango, C.; Aguirre, D.; Muñoz, A. (2009). "Unfractioned heparin for treatment of sepsis: A randomized clinical trial (The HETRASE Study)". Crit Care Med. 37 (4): 1185–96. doi:10.1097/CCM.0b013e31819c06bc. PMID 19242322. Unknown parameter
|month=ignored (help)