Sepsis

Sepsis – Kaele Leonard

Background

  • Sepsis-3: organ dysfunction from dysregulated host response to infection
  • Acute change in baseline SOFA score ≥2
  • Sequential Organ Failure Assessment (SOFA) score: P/F ratio, Plts, Tbili, SBP, GCS, Cr
  • "Quick" SOFA (qSOFA): ≥2 of AMS (GCS≤13), SBP≤100 mmHg, RR≥22/min
  • Septic shock = sepsis + vasopressors + lactate >2 meq/dL

 

Evaluation

  • Cultures prior to antibiotics if possible (but don’t delay antibiotics just to get cultures): obtain blood Cx x2 (peripheral vein via venipuncture preferred), urine Cx, etc.
  • Consider sputum Cx, paracentesis, thoracentesis, wound Cx, LP, joint aspiration
  • Lactate (even if not hypotensive)
  • Imaging: x-ray or CT of potential source

 

Management

  • Source control: Remove old lines, Chest tube for empyema, Drain abscesses  
  • Early antibiotics: START EARLY—each hour of delay of antibiotics mortality by ~7%
    • Target organisms most likely to cause infection in suspected organ; if source unknown, start empiric broad-spectrum
    • MRSA coverage vancomycin/daptomycin/linezolid/ceftaroline
    • Pseudomonas coverage zosyn/cefepime/meropenem /cipro/gentamicin
    • Pneumonia: add atypical coverage (azithromycin/levaquin; 2nd line doxycyline)
    • Fungal coverage for Candida: if neutropenic, TPN, abdominal surgery, prior antibiotics, >1 site colonized fluconazole, micafungin for Candida glabrata ( or resistant strains)

 

  • Resuscitation
    • IV fluid: give 1-3 L (≥30 mL/kg of body weight) of IV balanced crystalloid
    • Only give blood if Hb < 7, unless evidence of bleeding, severe hypoxemia, or myocardial ischemia
    • Monitor HR, BP, mental status, urine output – do NOT give beta-blockers to slow HR in the setting of sepsis unless dangerously high and limiting diastolic filling (discuss with fellow), this is an appropriate stress response
    • Assess fluid responsiveness by US IVC (mixed data), pulse pressure, leg raise
  • Vasopressors
    • Start if MAP not responsive to fluid resuscitation
    • Target MAP > 65mmHg, also monitor mental status, serum lactate, and urine output; may need higher goal with pts with chronic HTN
    • Start with norepinephrine -- via central line, PICC, port; can run through peripheral IV up to 15 mcg/min for up to 48 hours
        • SOAP II trial -- norepinephrine > dopamine (less arrhythmias)
        • No upper limit of NE but can cause peripheral ischemia with prolonged use
    • Add vasopressin at fixed dose of 0.04 units/min when NE dose >= 50 mcg/min
        • VASST trial: possible benefit for pts on 5-15 of NE; however, this was opposite of hypothesis and vasopressin is expensive
    • Add epinephrine or dobutamine when low cardiac output
    • Add phenylephrine for pts with tachyarrhythmias
    • Rarely use dopamine
    • Consider Angiotensin II (discuss with fellow, needs MICU leadership approval) contraindicated with CHF and DVT/PE/clots/hypercoagulability
    • Consider steroids if vasopressors failing or on steroids chronically hydrocortisone 100mg IV q8hr or 50mg IV q6hr (see Endocrine Section)