Sepsis Management

Runal Shah1st year Resident MEM,

KDAH,Mumbai.

What is Infection ?• Infection is the invasion of a host organism's

body tissues by disease-causing agents, their multiplication, and the reaction of host tissues to these organisms and the toxins they produce.

• A suspected or proven (by positive culture, tissue stain, or PCR test) infection caused by any pathogen or a clinical syndrome associated with a high probability of infection.

• Evidence of infection includes positive findings on clinical examination, imaging, or laboratory tests– WBC in a normally sterile body fluid

– perforated viscus,

– CXR consistent with pneumonia

– Petechial or purpuric rash or purpura fulminans

DefinitionsSIRS :

• At least 2 of the following

1)Temp : > 100.9°F / < 96.8°F

2)Tachycardia : HR > 90/min

3)Respiratory rate : >20 breaths/min or PaCO2 <32 mm Hg

4)Leukocyte Counts >12,000 or <4000; or >10% immature (band) forms.

Cause can be Infective or Inflammatory !

Sepsis:• Systemic response to Infection, fulfilling >=2 criteria of SIRS

Severe Sepsis:• Sepsis + CVS dysfunction / ARDS / >=2 other organs

dysfunction

Septic Shock:• Acute circulatory failure – Persistent arterial hypotension

despite adequate fluid resuscitation.

• Hypotension = SBP < 90 mm Hg / MAP <60 mm Hg / fall of SBP >40 mm Hg

Sepsis SixSepsis Six to be delivered within 6 hours -

1) Deliver high-flow Oxygen

2) Take a blood culture

3) Administer empiric IV Antibiotics

4) Measure serum lactate and send full blood count

5) Start IV fluid resuscitation

6) Commence accurate urine output measurement

Surviving Sepsis Campaign

Early Goal Directed Therapy• Goals: Optimization of

oxygenation, ventilation, circulation

Initiation of antibiotics Control of the source of

Sepsis

Airway(A) & Breathing(B) Maintain SpO2 > 90% in sepsis patient Endotracheal Intubation

• If airway is not secured

• If respirations are inadequate

• Hypotension unresponsive to fluid resuscitation, to avoid respi. muscles fatigue from Hypoperfusion

Goal for ventilation is 6ml/Kg of Ideal body weight

Limiting Tidal volume• Decreases mortality 40%31%• Reduce organ dysfunction• Lower cytokines level

Circulation(C) Immediate 1 or more large bore IV access is recommended. Give NS at rate of 0.5L every 5-10 min, this can exceed up to

4-6L in total. (30ml/kg) Crystalloids preferred over Colloids. According to EGDT guidelines, early Invasive monitoring with

Central Venous Catheter & Arterial Line placement should be done.

Current recommendations: To maintain.. Central venous pressure 8-12 mm Hg MAP >65 mm Hg Venous Oxygen Saturation >70%

Circulation(C)Clinical Indicators of Hemodynamics:

• Pulse rate• Blood pressure• Respiration• Mental status• Central venous pressure• Urine output (>0.5ml/kg/hour)

New parameter: Bedside Ultrasound assessment of Inferior Vena Cava

Inotropes for Circulation(C) Indication of Inotropes:

• No hemodynamic response even after 3-4L of fluid

• Signs of fluid overload – Pulm edema / Raised CVP

• Nor-epinephrine = 2.5-20 mcg/kg/min (of choice)• Dopamine = 5-20 mcg/kg/min

If still unresponsive Epinephrine infusion

Dobutamine can be initiated when Low cardiac output with High filling pressure !! (mostly ICU set-up)

Identify the source & Early Antibiotics If focal source of sepsis is found, remove the nidus of

infection, e.g.• Indwelling IV catheters• Blocked urinary catheters• Intra-abdominal / sinus / soft tissue abscesses

Empirical antibiotics within 30 min of Hypotension if given, yield the survival rate of >80%.

Timing of antibiotics administration is critical to survival.• Provide empiric IV therapy against gram-positive organisms

(Streptococcus and Staphylococcus species) and gram-negative bacteria.

• Administer the maximum antibiotic doses allowed.

Empirical Antibiotics Adult without an obvious source of Infection:

Gram Negative Bacilli / S. Aureus / Streptococci

Imipenem / Ertapenem / Doripenem / Meropenem

+ Vancomycin

Suspected Billiary source: Aerobic Gram Negative bacilli, enterococci

• Ampicillin+Sulbactam / Piperacillin+Tazobactam / Ticarcillin+Clavunate

Suspected LRTI: S.Pneumonia, Methicillin Resistant S.Aureus, Legionella

• Ceftriaxone + Azithromycin + Levoflox/Moxiflox + Vancomycin

Suspected UTI (Urosepsis): Enterobacteriacae, Ps.Aeruginosa, Enterococci, Rarely S.aureus

• Piperacillin+Tazobactam / Imipenem / Meropenem / Doripenem / Ampicillin+Gentamycin

Glycemic controlHyperglycemia adverse effects:

• Promotes inflammation• Impaires immune function• Affects fluid balance• Hyperglycemia adversely affects granulocyte

adherence, chemotaxis, phagocytosis and intracellular killing.

Judicious glycemic control of <150mg/dl to achieve

SteroidsHydrocortisone <=300mg/dl per day.

Hypotension refractory to Fluids and inotropes !!

Anemia to treatHb >9 gm/L : no packed RBC required

Hb 7-9 gm/L : Transfuse in patient in which suspected on going hemorrhage !!

<7 gm/L : Blood transfusion required

Thank You…• Ref :

– Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th Edition