SEPSIS

Hugh Hemsley MDFebruary 2011

Goals of this lecture

Review how sepsis and severe sepsis affects patients

Recognize the signs and symptoms of sepsis

Discuss the current management strategies

What is Sepsis? The Invasion

Infection occurs in the body Urine Pneumonia Skin Abdominal/Pelvic

Bacteria enters the blood stream

The body has an immune response fever, vasodilation

Microvascular instability ensues

Septic Shock

How does sepsis kill?

Sepsis Circulatory Dysfunction

intravascular volume depletion

peripheral vasodilatation

myocardial depression

microcapillary injury

Hypoperfusion/End Organ Damage and Death

Why is sepsis recognition important?

Most common admission diagnosis to ICU In the US, approximately 750,000 cases

yearly with 225,000 fatalities Rate of death despite antibiotics and

advanced life support remains between 30-50%

Why? Advanced Age, Invasive Procedures, Antibiotic

Resistance, Immunosuppressive Therapy

Facts—that we can't ignore

†National Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association.

2000. ‡Angus DC et al. Crit Care Med. 2001 ;29(7):1303-1310.

AIDS* Colon BreastCancer§

CHF† Severe Sepsis‡

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What are the components of sepsis treatment?

Requires a team effort of recognition and treatment

Requires an understanding of the appropriate resuscitation goals and medical treatments

Requires an interdepartmental approach to patient management

Requires continual review to ensure patient treatment goals are being met

The Septic Patient

Labs and Diagnositics

Antibiotics

Resuscitation

Disposition

Recognition

Early Goal Directed Therapy

Recognizing Sepsis

SIRS (Systemic Inflammatory Response Syndrome) Temp >100.4 or <96.8 Heart Rate >90 beats/min Respiration Rate >20 breaths/min WBC >12,000 or <4,000 or >10% bands

Sepsis– 2 or more SIRS criteria and suspected infection

Severe Sepsis: presence of sepsis plus organ dysfunction

Septic Shock: sepsis plus refractory hypotension

What does a septic patient look like?

Non-Specific: malaise, change in mental status, decreased urine output, hypo/hyperglycemia

Localized Symptoms: Cough, Urinary Symptoms, Abscess/Cellulitis, Flank pain

SIRS Criteria: Fever, Tachycardia, Tachypnea

Immune compromised patients, Nursing Home Resident, Diabetics, Dialysis Patients

Who is most likely to get severe sepsis?

ElderlyImmunocompromised

Chronically Ill

Newborns

The Septic Patient

Labs and Diagnositics

Antibiotics

Resuscitation

Disposition

Recognition

Early Goal Directed Therapy

Early Goal Directed Therapy:AKA- The Sepsis Protocol

I have a potentially septic patient, now what?

Assess the patient’s respiratory status Place the patient on a cardiac monitor Draw a “rainbow” of labs Draw a set of blood cultures and urine

cultures Obtain a Chest XR for suspected pneumonia Plan for broad-spectrum antibiotics Prepare to Initiate the Severe Sepsis Protocol

Sepsis Resuscitation Bundle

6 - hour Severe Sepsis/Septic Shock Bundle

• Early Detection:– Obtain serum lactate level.

• Early Blood Cx/Antibiotics:– within 3 hours of

presentation.

• Early EGDT: • Hypotension (SBP < 90, MAP

< 65) or lactate > 4 mmol/L:– initial fluid bolus 20-40 ml of

crystalloid (or colloid equivalent) per kg of body weight.

• Vasopressors:– Hypotension not

responding to fluid– Titrate to MAP > 65

mmHg.

• Septic shock or lactate > 4 mmol/L:– CVP and ScvO2 measured.– CVP maintained >8 mmHg.– MAP maintain > 65 mmHg.

• ScvO2<70%with CVP > 8 mmHg, MAP > 65 mmHg:– PRBCs if hematocrit < 30%. – Inotropes.

The Septic Patient

Labs and Diagnositics

Antibiotics

Resuscitation

Disposition

Recognition

Early Goal Directed Therapy

Labs to Order: The Essentials CBC CMP Amylase/Lipase PT/PTT/INR (evaluate for potential DIC) Cortisol Lactate* Urinalysis Cultures: Blood, Urine, Wound, CSF

Why is Lactate Important?

Measures adequate perfusion on a cellular level

“Cryptic Shock” – Some patients have hypoperfusion of tissues with normal blood pressures.

Lactate clearance (drawing lactates separated by 6 hours) has prognostic indications

Elevated lactates at 24 hours has an 89% mortality

The Septic Patient

Labs and Diagnositics

Antibiotics

Resuscitation

Disposition

Recognition

Early Goal Directed Therapy

Antibiotic Strategies

Rapid administration of appropriate antibiotics Obtain blood and urine cultures prior to

antibiotic administration Broad-Spectrum antibiotics are preferred

initially. Use 2 or More Antibiotics—prevents

selection of resistance, provides synergy against single pathogen

Single antibiotics may not cover spectrum of possible pathogens

An Example of a Recommended Antibiogram

Type of Infection Example of Initial Antibiotics Penicillin allergic patients

Community Acquired Pneumonia

Ceftriaxone 2 grams IV Plus eitherAzithromycin 500 mg IV or Levaquin 750 mg IV  

Levaquin 750 mg IV

Nosocomial / Health-Care Associated Pneumonia

Zosyn 4.5 g IV +Tobramycin IV +Vancomycin IV  

Amikacin IV Tobramycin IV +Vancomycin IV

Community Acquired Intraabdominal infection

Zosyn 3.375 g IV Ciprofloxacin 400 mg IV +Metronidazole 500 mg IV  

Nosocomial Intraabdominal Infection

Zosyn 4.5 g IV +Tobramycin IV + Vancomycin IV

Ciprofloxacin 400 mg IV +Metronidazole 500 mg IV +Tobramycin IV + Vancomycin IV  Sepsis from a Urinary Source Zosyn 3.375 g IV+

Tobramycin IV Ciprofloxacin 400 mg IV +Tobramycin IV  

Intravascular Catheter-Related Sepsis

Zosyn 3.375 g +Vancomycin IV

Amikacin IV +Vancomycin IV  

Febrile Neutropenia Ceftazidime 2 g IV +Tobramycin IV +/-Vancomycin IV

Amikacin IV +Tobramycin IV +Vancomycin IV  

Unknown Source Zosyn 4.5 g IV +Tobramycin IV + Vancomycin IV

Amikacin IV +Tobramycin IV +Vancomycin IV  

More Antibiotic Strategies…

Consider: Age Allergies Renal clearance Recent hospitalizations or procedures

Don't let obtaining cultures delay administration—i.e. Meningitis

Consider hospital specific empiric antibiotic guidelines

Factors in Multi-Drug Resistant

•Antibiotics in preceding 90 days

•Current hospitalization of 5 days or more

•High frequency of antibiotic resistance in community or specific hospital unit

•Immunosuppressive disease and/or therapy

•Presence of risk factors for HCAP (Health Care Associated Pneumonia)

-Hospitalized for ≥ 2 days in the preceding 90 days

-Residence in Nursing Home/Extended Care facility

-Home Infusion Therapy (including antibiotics)

-Chronic Dialysis within 30 days

-Home Wound Care

-Family Member with Multi-Drug Resistant Pathogen

(Amer J Resp Crit Care Med)

The Septic Patient

Labs and Diagnositics

Antibiotics

Resuscitation

Disposition

Recognition

Early Goal Directed Therapy

Resuscitation Guidelines

Normo-tensive patients, may have hypoperfusion or “cryptic-shock”. Check a lactate. Hypotension—often reversed with aggressive fluid replacement Initial boluses of 1000ml with goals of:

MAP >65mmHgUrine Output >0.5 ml/kg/hrCVP 8-12mmHg

Initiate 20cc/kg fluid bolus or 1 Liter—over 30 min Do not withhold fluid resuscitation EVEN IF the patient has renal failure or CHF. Studies show that intubation is better than under-resuscitating!

Resuscitation Guidelines: Central Venous Lines

Central Venous Line Uses Place if the patient continues

to remain hypotensive and requires pressors

Can be used in an ICU setting to monitor Central Venous Pressures

Allows for fluid, pressors and antibiotic administration simultaneously

Central Venous Line Principles Does not include a PICC Line,

Power Port or Porta-Cath Place under sterile technique

The Septic Patient

Labs and Diagnositics

Antibiotics

Resuscitation

Disposition

Recognition

Early Goal Directed Therapy

Resuscitation: The First Line PressorsNorepinephrine and Dopamine

Norepinephrine (First Line) Increases BP & vascular resistance without changing

cardiac output Produces a reflex bradycardia in response to the

increase in MAP Decrease in Cardiac O2 consumption

Dopamine (First Line) Positive inotropic and chronotropic effects Increases cardiac output with minimal effect on

vascular resistance Increases cardiac oxygen requirements can

potentiate dysrhythmias Second Line Therapy: Vasopressin

Disposition: Floor, Telemetry or ICU

Does the patient have potential for respiratory compromise?

Has the patient been stabilized? Does the patient require pressors or

repetitive fluid boluses?

A Quick Review of the Protocol1. Lactate Levels: If you suspect sepsis order the levels.2. Blood Cultures/Urine Cultures- Always order 2 blood cultures

and a urine culture prior to antibiotics.3. Antibiotics- Rapid administration of appropriate antibiotics4. Resuscitation- Every patient (regardless of CHF, renal status,

respiratory status) should receive a 20cc/kg NS bolus or 1000 cc NS initial bolus for hypotension (MAP less than 65).

5. Pressors- If the patient continues to be hypotensive after 2L of NS boluses, pressors should be started with Neosynephrine and/or Dopamine as first-line.

6. Central Line Therapy- If a patient continues to be hypotensive after fluid boluses and pressors are necessary, a central line must be started. If you are uncomfortable with starting  a central line, please consult surgery early.

Goals of Therapy

Resuscitation Goals NS Bolus: At least 1000cc or 20cc/kg

initially for hypotension Start pressors for refractory hypotension Central Line

Obtain appropriate cultures Antibiotics Lactate Levels for ALL septic patients Improve patient survival

Thank you

Questions?