MICU Intern's survival guide sepsis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.D. [2]
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Overview
Systemic Inflammatory Response Syndrome [1] [2]
- SIRS can be diagnosed when two or more of the following are present:[3]
- Heart rate > 90 beats per minute
- Temperature < 36 (96.8 °F) or > 38 °C (100.4 °F)
- Tachypnea > 20 breaths per minute or, on blood gas, a PaCO2 < 32 mm Hg
- 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).
- SIRS can be seen in non infectious conditions like pancreatitis and myocardial infarction.
Sepsis
- SIRS + Source of infection
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 dysfunctions (MODS)
- Progressive multiple organ failure secondary to severe sepsis.
Sepsis management
Source control
Source identification
- Depending on the patient's history, sputum, blood, urine or other sources can be cultured. In certain cases in which the source is unclear, a pan-culture should be done.
- Based on the patient's history, appropriate imaging studies should be initiated.
Source management
- Initiation of proper antibiotic within an hour of diagnosis.
- Drainage should be initiated in cases in which an abscess is present.
Resuscitation
Hypotension
- Fluids are the first step in management
- Crystalloids such as normal saline and Ringer's lactate are the first to be used.
- Normal rate of infusion is 40-60 ml/kg.
- If the patient is still hypotensive after fluid administrations, plan to insert a central venous line to guide additional fluid therapy. Internal jugular and subclavian lines are preferred.
- CVP should be checked in Q30 minutes for adequate fluid management.
- Target CVP is:
- 10-12 in non-intubated patients.
- 12-15 in intubated patients.
- If the patient is still hypotensive start vasopressors.
- Norepinephrine is the first line vasopressor agent.
- Dopamine and vasopressin are second line agents.
- A mean arterial pressure of 65 is the goal.
- Continue to check the CVP.
- If the patient is still hypotensive, check ScvO2
- ScvO2 is a marker of cardiac output and tissue perfusion.
- Target ScvO2 is > 70%
- If ScvO2 is < 70% consider transfusing with aim hematocrit of 30
- If hematocrit is already 30% consider starting dobutamine.
- A ScvO2 of 70% indicates that the tissues are adequately extracting oxygen. Therefore, the blood returning to the heart has a low oxygen saturation level.
- A ScvO2 of 80-85%, however, is an ominous sign. It indicates that the tissues are not adequately using oxygen and are currently producing energy anaerobically. In these situations, lactate levels in the blood start increasing.
References
- ↑ Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL (2008). "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008". Critical Care Medicine. 36 (1): 296–327. doi:10.1097/01.CCM.0000298158.12101.41. PMID 18158437. Retrieved 2012-09-16. Unknown parameter
|month=ignored (help) - ↑ Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992 Jun;101(6):1644-55. PMID 1303622.
- ↑ Tslotou AG, Sakorafas GH, Anagnostopoulos G, Bramis J. Septic shock; current pathogenetic concepts from a clinical perspective. Med Sci Monit. 2005 Mar;11(3):RA76-85. PMID 15735579. Full Text.