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Definition

Sepsis is a systemic inflammatory response syndrome (SIRS) following an infection, and it is manifested by multi-system organ dysfunction in addition to hypotension that is not readily reversible with fluid resuscitation.

Diagnostic Criteria For Sepsis

(Documented/Suspected Infection Plus Inflammatory variables Plus One of The Organ Dysfunction)

General variables

• Fever > 38.3°C
• Hypothermia (core temperature < 36°C)
• Heart rate > 90/min–1 or > 2 Standard deviation (SD) above the normal value for age
• Tachypnea
• Altered mental status
• Edema
• 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)
• Immature WBCs forms are > 10% with normal count
• Plasma C-reactive protein > 2 SD above the normal value
• Plasma procalcitonin > 2 SD above the normal value

Hemodynamic variables

• Arterial hypotension after 30 ml/kg fluid bolus (Systolic blood pressure (SBP) < 90 mm Hg, mean arterial pressure (MAP) < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or < 2 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 Sec)
• 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

Diagnostic Criteria for Severe Sepsis (sepsis induced hypoperfusion or organ dysfunction)

Includes any one of the following caused due to the infection:

• Sepsis-induced hypotension
• Lactate above upper limits laboratory normal
• Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
• Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
• Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
• Creatinine > 2.0 mg/dL (176.8 μmol/L)
• Bilirubin > 2 mg/dL (34.2 μmol/L)
• Platelet count < 100,000 μL
• Coagulopathy (international normalized ratio > 1.5)

Management

Characterize the symptoms: ❑ Fever ❑ Hypothermia ❑ Altered mental status ❑ Mottling ❑ Ileus ❑ Oliguria

Examine the patient: ❑ Tachycardia ❑ Tachypnea ❑ Edema ❑ Hyperglycemia ❑ Hypotension after an initial 30 ml/Kg bolus ❑ Decreased capillary refill

Order labs: ❑ Random blood sugar (RBS) ❑ Complete blood count (CBC) ❑ Plasma C reactive protein (CRP) ❑ Plasma procalcitonin ❑ Pulse oximetry ❑ Urinalysis/Renal function tests ❑ PT/INR ❑ Liver function tests ❑ Serum lactate ❑ Central venous pressure (CVP)

Consider alternative diagnosis: ❑ Infections ❑ Acute pancreatitis ❑ Diabetic ketoacidosis Lower gastrointestinal bleeding Myocardial infarction

Initial resuscitation: Goals to achieve in first 6 hours ❑ Central venous pressure (CVP) 8-12 mm Hg ❑ Mean arterial pressure (MAP) ≥ 65 mm Hg ❑ Urine output ≥ 0/5 mL/Kg/hr ❑ Central venous O2 sat. 70% ❑ If lactate levels elevated, target is normalization

Diagnosis: ❑ Perform 2 sets of blood cultures (aerobic and anaerobic) atleast, before starting antibiotics Drawn percutaneously Drawn through each vascular access device present for > 48 hours ❑ Perform 1,3 beta-D-glucan assay, mannan, anti-mannan antibody assay if available ❑ Perform imaging studies as appropriate to locate a source

Antimicrobial therapy: ❑ Initiate within 1st hour of diagnosis Reassess regimen daily ❑ Use low procalitonin levels for prognosis ❑ Usual duration of therapy 10 days ❑ Longer in neutropenics, slow responders, undrainable foci, immunologically compromised

Choice of antibiotics

Unknown organism ❑ Empiric therapy with broad spectrum antbiotic with good tissue penetrance

Neutropenic pt with severe sepsis (goal is to cover Acinetobacter & Pseudomonas spp) ❑ Use combination empirical therapy

Severe infections + resp failure + septic shock ❑ Extended spectrum beta lactam and aminoglycoside/fluoroquinolone

Streptococcus pneumoniae ❑ beta lactam + macrolide

Culture specific organism ❑ Shift to appropriate anti-bacterial, antiviral or antifungal

Remove source/foci of infection: ❑ Use minimally invasive process ❑ Source removal best done in first 12 hours ❑ Remove intravascular access devices if they are a possible source ❑ Oral chlorhexidine gluconate to reduce oral contamination as a risk factor for ventilator associated pneumonia

Hemodynamic support Fluid therapy: ❑ Administer crystalloids, use albumin when demand for fluids is too high ❑ Use dynamic variables (change in pulse pressure, stroke volume) and static variables (arterial pressure,heart rate) to assess status Vasopressors (to achieve target MAP ≥ 65 mm Hg): ❑ Place arterial line as soon as feasible ❑ Administer norepinephrine as 1st choice drug ❑ Use epinephrine - when additional agent needed ❑ Use vasopressin 0.03 units/minute to raise MAP or decrease norepinephrine usage ❑ Selective dopamine (absolute or relative bradycardia) and phenylephrine usage Inotropic therapy: ❑ Trial of dobutamine infusion 20 μg/Kg if cardiac output low with elevated cardiac filling pressure

Corticosteroids: ❑ Use continuous flow IV hydrocortisone 200 mg/day if shock doesn’t improve with fluids & vasopressor ❑ Taper when vasopressors no longer required

Blood products: ❑ Transfuse blood when hemoglobin < 7.0 g/dL ❑ Transfuse platelets if < 10,000/mm3 or < 20,000/mm3 in those with high risk

Mechanical ventilation for sepsis induced ARDS': ❑ Target tidal volume of 6 mL/Kg ❑ Target plateau pressure ≤ 30 mm Hg ❑ Use PEEP (positive end expiratory pressure) to avoid alveolar collapse ❑ Raise patients bed to 30-45° ❑ Attempt weaning when all foll. criteria are met: ❑ Pt arousable ❑ Hemodynamics stable ❑ No new complications ❑ Low ventilatory/fiO2 requirements ❑ Extubate when weaning successful

Other supportive therapy Sedation & neuromuscular blockade: ❑ Use minimal sedation/neuromuscular blockade in mechanically ventilated patients Glucose control: ❑ Blood glucose target value should be ≤ 180 mg/dL ❑ Use insulin infusion and 1-2 hourly monitoring to achieve target Renal replaement therapy: ❑ May be used for management of fluid balance in hemodynamically unstable patients ❑ Use for septic patients with acute renal failure DVT prophylaxis: ❑ Do pharmacoprophylaxis with low molecular weight heparin (LMWH), if no contraindications present ❑ Use pneumatic compression devices whenever possible Stress ulcer prophylaxis ❑ Consider prophylaxis if risk factors are present Feeding: ❑ Enteral & oral feeding preferred over total parenteral feeding (TPN) ❑ Adjust calorie requirement in subsequent days, as tolerated Goals of care: ❑ Discuss goals or care, patient aspirations and future directives with family with 72 hours of admission

Do's

• Patients who are suspected of being severely infected, should be routinely screened for sepsis.

• Administer antimicrobial therapy within 1 hour of diagnosis of sepsis.

• Delay intervention, if source/foci of infection is peri-pancreatic necrosis.

Dont's

• Antimicrobial Therapy:

Do not use empiric combination therapy for more than 3-5 days.

Do not use antimicrobial agents in severely inflamed patients, from a non-infectious cause.

• Fluid therapy:

Do not use hydroxyethyl starch for resuscitation of severe sepsis and septic shock.

• Vasopressors:

Do not use low dose vasopressin/dopamine/phenylephrine as monotherapy.

Do not use low dose dopamine for renal protection.

• Corticosteroids:

Do not use corticosteroids in absence of shock.

• Blood products:

Do not use erythropoietin as a specific treatment of anemia associated with sepsis.

Do not use antithrombin.

Do not use fresh frozen plasma to correct clotting abnormalities in the absence of bleeding or planned invasive procedure.

• Other supportive therapy:

Do not use following therapies as their role is not clear:

IV immunoglobulins

IV selenium

Do not use pulmonary artery catheters routinely.

Do not use bicarbonate therapy as prophylaxis of hypoperfusion induced lactic acidosis if pH > 7.15.