Sepsis

Mohan

Sepsis facts
severe

sepsis represent 27% of ICU admissions in UK account for 46% of all ICU bed days Mortality 30% to 50% or 500,000 deaths per year worldwide USA, the average cost per case is $22,100

Pathophysiology
Infection
Host response Neutrophil/macrophage/endothelial activation
Release of mediators

activation of inflammatory cascade

Endothelial damage

Multi organ failure

Pathophysiology CVS Generalised vasodilatation Leaky capillaries Relative hypovolemia Myocardial depression Shock Poor perfusion & organ dysfunction

Pathophysiology
RS

ARDS Abnormal renal function multi factorial Abnormal liver function Abnormal coagulation - DIC

2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference

Sepsis clinical syndrome defined by the presence of both infection and a systemic inflammatory response.

Sepsis Definitions
General variables

T >38 or <36 HR >90 or 2SD above base lines Tachypnoea Altered mental status Significant oedema or Positive fluid balance >20 ml/kg Hyperglycaemia >7.7

Sepsis Definitions Inflammatory variables

WBC >12000 <4000 >10% immature cells Raised CRP Raised Procalcitonin

Definitions
Haemodynamic variables

SBP<90,or <40 below base line MAP<60 CI>3.5 SvO2 >70 %

Tissue perfusion variables

Capillary refill delayed Lactate>1

Definitions

Definitions

Severe sepsis Sepsis +organ dysfunction or hypo perfusion or hypotension

Septic shock Sepsis + hypotension (SBP <90 or MAP<60 or SBP <40 from baseline ) despite fluid resuscitation and evidence of poor perfusion

Management
Surviving sepsis guidelines 2008 Evidence-based recommendations Complete package Improve uniformity/addition of EBM Evidence of Feasibility & benefits beginning to appear

Initial Management
Optimise

perfusion/oxygen delivery to tissues (HB x1.34xSAO2+Pao2 x0.02)

Oxygen delivery= cardiac output X oxygen content

Identify

& eliminate source of infection

Initial Resuscitation((first 6 hrs)

Begin resuscitation immediately in patients with hypotension or elevated serum lactate 4 mmol /L; do not delay pending ICU admission (1C) Resuscitation goals (1C) CVP 812 mm Hg Mean arterial pressure 65 mm Hg Urine output 0.5 mL/kg/hr Central venous (superior vena cava) oxygen saturation 70% or mixed venous 65% Vasopresor to maintain PP If venous oxygen saturation target is not achieved (2C) Consider further fluid Transfuse packed red blood cells if required to hematocrit of 30% and/or Start dobutamine infusion, maximum 20 gkg1min1

Initial resuscitation
Fluid Therapy
No

evidence-based support for one type of fluid over another Fluid challenge based on repeated assessment

Fluid challenge

Base line HR, BP, CVP, Capillary refill 500 ml crystalloids/250 ml colloids over 30 minutes Look at the response

HR
High & Decrease transiently

CVP
Low & Increase transiently

BP
Low & Increase transiently

Action
Further fluid boluses

High but decrease Low but sustained rise

N/Low but sustained rise

Normal

Observe

H/N no change

N/High & marked increase

Possible overload

Management of sepsis
Vassopressor
Either norepinephrine or dopamine

is the first-choice vasopressor agent Low-dose dopamine should not be used for renal protection Vasopressin in refractory shock

Management of sepsis
Inotropic support
In patients with low cardiac output despite adequate fluid resuscitation, dobutamine may be used to increase cardiac output A strategy of increasing cardiac index to achieve an arbitrarily predefined elevated level is not recommended.

Management of sepsis
Diagnosis
Appropriate

cultures >2 blood cultures Each vascular access other appropriate fluids Diagnostic studies

Management of sepsis
Antibiotic therapy
Broad

spectrum IV antibiotics within 1hr Review antibiotic in 48-72 hours

Management of sepsis
Source control
Prompt

Risk benefit ?Percutaneous Line sepsis

Further management
Steroids patients with septic shock Physiological dose(200-300mg/day) Glucose control Normalise ideally 4.4-6.1 at least <8.3 Activated protein C Adults APACHE >25

Other recommendations
Nutritional support Renal support Stress ulcer prophylaxis Maintain Hb 7-9g/dl Thromboprophylaxis Use of bicarbonate no unless PH<7.15 Consideration for Limitation of Support

6 Hour Sepsis Bundle

Presumptive diagnosis Blood& other appropritiate cultures antibiotics administered within 1 hr Immediate fluid 0.5 L/30 min if CVP <8

Vasopressors If MAP < 65 mmHg SVO2 & Lactate Inotropes blood transfusion to target Hb 10 g/dl

24 hour care bundle

R/v homodynamic parameters R/V antibiotics Glucose<8.3 mmol/l Consider steroids Consider APC Nutrition/stress ulcer prophylaxis DVT prophylaxis Ventilatory strategy Renal support Limitation of treatment

Take home
Initiate

fluid resuscitation/oxygen

Appropriate

cultures & Antibiotics&source control assessment &Early referral to seniors / ??ICU

Repeated

Brain Injury
Trauma

CVA
Hypoxic Other

brain injury

Principle of Management

Prevent 2ry Brain injury Optimize PhysiologyCPP >65,PAO2 >12,PACO2 4.5-5 Glucose, electrolytes, Temp EVACUATE Haematoma

General organ support

Some Physiology
CPP=MAP-(ICP+CVP) ICP

PACO2 Montro -Kelly

Management
Initial Management ABCDE Hypoxia/ Hypotention kills
CT

Brain/Evacuate htoma Others C spine Other injury

Management
Later management 300 head up AIM MAP >90 -PaO2 >12 -PaCO2 4.5-5 -BM 4.5-8,T 32-35 Anticonvulsants Stress ulcer ,DVT prophylaxis NO evidence for Steroids, Hypotonic fluids, Glucose (unless hypoglycaemia)

Management
When

to Consider TLC