Sepsis
Defintion
Sepsis: systemic, deleterious host response to infection, leading to severe sepsis
Severe sepsis/ SIRS: Sepsis (SIRS) associated with organ dysfunction, hypoperfusion, or hypotension. Hypoperfusion and perfusion abnormalities may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status.
The systemic inflammatory response to a wide variety of severe clinical insults, manifested by two or more of the following conditions:
Septic shock: Severe sepsis +
Refractory sepsis: Large amounts of vasopressors
MODS: Bad end of SIRS spectrum, progressive organ dysfunction requiring interventions to attain haemostasis
Epidemiology
Clinical Features
As "Definition"
Investigations
Management
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics (refer to therapeutic guidelines: for now, ceftriaxone + azithromycin)
4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg
6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)*
- Measure central venous oxygen saturation (ScvO2)* - not done in Aus
7) Remeasure lactate if initial lactate was elevated*
*Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg; ScvO2 of ≥70%, and normalization of lactate.
Summary
NOTE: Don't five more when sedation onset very slow after injection (blood circulation going slowly)
NOTE: If inc Na too fast, can cause demyelination --> paraplegia
Complications
Source
Dr Matt Brain 2014
http://www.survivingsepsis.org/Bundles/Pages/default.aspx
Sepsis: systemic, deleterious host response to infection, leading to severe sepsis
Severe sepsis/ SIRS: Sepsis (SIRS) associated with organ dysfunction, hypoperfusion, or hypotension. Hypoperfusion and perfusion abnormalities may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status.
The systemic inflammatory response to a wide variety of severe clinical insults, manifested by two or more of the following conditions:
- Temperature > 38.3°C or < 36°C
- Heart rate > 90 beats/min
- Respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg
- WBC count > 12,000/mm3 , < 4000/mm3 , or > 10% immature (band) forms
Septic shock: Severe sepsis +
- MAP <60mmHg, or
- MAP > 60 requires vasopressor agents despite adequate fluid resuscitation
Refractory sepsis: Large amounts of vasopressors
MODS: Bad end of SIRS spectrum, progressive organ dysfunction requiring interventions to attain haemostasis
Epidemiology
- ICU admission: 0.77 (Aus) - 3 / 1000
- Pumonary 50%, abdo 19%
- ~26% 1 month mortality
Clinical Features
As "Definition"
Investigations
- Bloods: FBC, ABG (Lactate - ? hypoperfusion), VBG (venous sat - <70% as blood circulation slow, more O2 extracted), blood culture
- Imaging: CXR (pneumonia, APO, pul effusion), US (?empyema, ventricular ejection)
- Others: Urine output
Management
- DRSABCD
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics (refer to therapeutic guidelines: for now, ceftriaxone + azithromycin)
4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg
6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)*
- Measure central venous oxygen saturation (ScvO2)* - not done in Aus
7) Remeasure lactate if initial lactate was elevated*
*Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg; ScvO2 of ≥70%, and normalization of lactate.
Summary
- Abx early
- Refer early
- Maintain organ perfusion
NOTE: Don't five more when sedation onset very slow after injection (blood circulation going slowly)
NOTE: If inc Na too fast, can cause demyelination --> paraplegia
Complications
- Stroke
Source
Dr Matt Brain 2014
http://www.survivingsepsis.org/Bundles/Pages/default.aspx