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sepsis

sepsis / septicaemia

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sepsis updated

  • sepsis now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection
  • organ dysfunction can be determined by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more which reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection
  • the SIRS concept has been removed as it performed poorly
  • septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and having a serum serum lactate and lactic acidosis level >2 mmol/L (18 mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%.

quick SOFA (qSOFA)

  • positive if:
    • RR > 22/min
    • altered mentation, and,
    • systolic BP < = 100mmHg
  • can quickly identify patients with infection who are likely to have a prolonged ICU stay or to die in the hospital

SOFA score

system 0 1 2 3 4
respiration: PaO2/FiO2 mmHg >= 400 < 400 < 300 < 200 with resp. support < 100 with resp. support
coag: platelet count >= 150 < 150 < 100 < 50 < 20
liver: bilirubin in umol/L < 20 20-32 33-101 102-204 > 204
cardiac: (inotropes in ug/kg/min for > 1hr) MAP >= 70mmHg MAP < 70mmHg dopamine < 5 dopamine 5.1-15 or adrenaline or NA dopamine > 15 or adrenaline > 0.1 or NA > 0.1
CNS: GCS 15 13-14 10-12 6-9 < 6
renal: CRN in in umol/L < 110 110-170 171-299 300-440 > 440
urine output < 500 mL/d < 200 mL/day

recognise or suspect sepsis EARLY

does the patient need immediate resuscitation?

  • purpuric rash consistent with meningococcal septicaemia
  • immunocompromised with either fever, hypothermia or history of chills (these patients need iv antibiotics within 30 minutes)
  • adult patients with two or more of the following are also at risk of rapid deterioration and should be considered for immediate activation of resuscitation as per sepsis pathway:
    • systolic BP < 100mmHg
    • recent change in mental status
    • lactate > 2 mmol/L

possible exclusions to aggressive sepsis Mx regime

  • these conditions may cause a SIRS-like state and the patient may not be septic nor have SIRS despite fevers:
  • NFR status

does the patient have one of the following high risk factors?:

  • immunocompromised
  • indwelling medical devices
  • recent surgery or invasive procedure
  • history of fever, muscle pains, or rigors
  • bone or joint pain or swelling
  • skin - cellulitis or wound discharge
  • possible UTI - dysuria, frequency, odour
  • abdominal pain or peritonism
  • chest infection - cough, SOB
  • neuro: decreased mental state, delirium, neck stiffness, headache

do they have at least 2 criteria for SIRS (Systemic Inflammatory Response Syndrome)

criteria

  • in adults, at least two of:
    • temp > 38.3deg. C
    • temp < 36deg. C
    • heart rate > 90/min
    • respiratory rate > 20/min
    • WCC > 12
    • WCC < 4
    • acutely altered mental state
    • blood glucose > 6.6 in the absence of known diabetes

suspect infective causes

exclude sepsis mimics - non-infective causes of SIRS

if SIRS, do they have severe sepsis?

criteria

  • SIRS plus:
    • infection suspected, plus either:
    • systolic BP < 90, MAP < 65, lactate > 2 or other evidence of new organ dysfunction suggested by either:
      • creatinine > 177
      • bilirubin > 34
      • platelets < 100
      • INR > 1.5
      • APTT > 60sec
      • new or increased oxygen needs to keep SaO2 > 90%
      • urine output < 0.5ml/kg/hr for 2hours

if SIRS criteria met and infection is likely but not "severe sepsis"

  • if petechial rash or purpura, Mx as for meningococcal septicaemia
  • if meningism, Mx as for meningitis
  • otherwise:
    • iv access - at least 18G
    • oxygen to maintain sats > 95% (or to 88-92% if COPD or chronic type II resp. failure)
    • FBE, U&E, CRP, LFT, amylase, lipase, glucose, lactate and clotting + Xmatch
    • blood cultures x 2 sets from separate sites (or 1 set from each lumen of a intravascular device or port plus 1 peripheral set)
    • search for infective causes
      • CXR, urine culture, wound culture
      • consider CT chest/abdo/pelvis where indicated
    • iv antibiotics preferably within 1hr (30 minutes if immunocompromised) (see below under severe sepsis for antibiotic choice)
    • 500mL normal saline or Hartmanns bolus stat if BP < 100mmHg or if lactate > 2 mmol/L
      • if no response, repeat once
      • look for signs of fluid overload / pulm. oedema especially if known cardiac failure or elderly
      • if still hypotensive may need early inotropes
    • hourly obs
    • control source of infection where possible:
      • eg. drainage of abscess, surgery where indicated

if severe sepsis criteria met

initial Mx of severe sepsis in the 1st hour

  • iv access
  • FBE, U&E, LFT, amylase, lipase, glucose, lactate and clotting + Xmatch
  • 30 minutely obs
  • monitor fluid balance
  • iv NSaline (aiming for a CVP of 8-12mmHg, MAP >= 65mmHg):
    • if systolic BP < 90 or lactate > 4 then
      • give 20ml/kg stat then boluses of 200-500ml NSaline if systolic BP falls below 90 again.
    • otherwise, give 500-1000ml NSaline over 30-60min
  • urgent senior medical consultation
    • take 2 sets but do not delay administration of antibiotics
  • iv antibiotics within 60 minutes according to most likely aetiology
    • if petechial/purpuric rash
    • if febrile neutropenia or immunocompromised then:1)
      • cefepime 2 g (child: 50 mg/kg up to 2 g) IV, 8-hourly, OR,
      • ceftazidime 2 g (child: 50 mg/kg up to 2 g) IV, 8-hourly, OR,
      • Tazocin (piperacillin + tazobactam) 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, 8-hourly
      • add vancomycin if either:
        • is in shock
        • known to have MRSA
        • has clinical evidence of a catheter-related infection in a unit with a high incidence of MRSA infection
        • not responding by 48hrs
    • empiric antibiotics in adults if Pseudomonas is unlikely:
    • empiric antibiotics in adults if Pseudomonas IS likely:
  • urinary catheter and sent CSU m/c/s, monitor fluid balance
  • CXR
  • blood transfusion if Hb < 7
  • repeat lactate after 1hr Rx

now, is the patient in septic shock?

criteria

  • severe sepsis, plus, either:
    • systolic BP < 90, MAP < 65 or repeat lactate > 4 after initial iv bolus. or,
    • initial lactate > 4 and repeat lactate after initial iv bolus still > 2

Mx in next 4 hours of the septic shock patient

  • decide if patient will be suitable for ICU care, and if so, then proceed with critical care Mx as below.
  • discuss with critical care team early and seek ICU/HDU bed
  • this assumes initial Mx in 1st hours as for severe sepsis has been completed
  • Rx targets:
    • CVP 8-12mmHg
    • mean arterial pressure ≥ 65mmHg
    • urine output ≥ 0.5 mL/kg/hr
    • central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively
    • normalisation of serum lactate levels
    • source of infection controlled
  • consider inserting central venous line if not already placed, and no C/I
    • no benefit of routine CVC insertion 2)
  • insert arterial line if not already placed
  • control source of infection
    • remove any infected catheter or device
    • if no source of infection is evident then urgent CT scans of chest, abdo, and pelvis should be strongly considered ASAP, without contrast if administration of contrast will either delay CT or cause issues with nephrotoxicity. The risk of radiation from having to perform repeat scans with contrast at a later time is far outweighed by the risk of occult surgical sepsis or bowel ischaemia not being detected early.
    • if abscess or pus is detected, arrange for drainage
      • when infected peripancreatic necrosis is identified as a potential source of infection, definitive intervention is best delayed until adequate demarcation of viable and nonviable tissues has occurred3)
      • the effective intervention associated with the least physiologic insult should be used (eg, percutaneous rather than surgical drainage of an abscess)
  • iv crystalloid boluses of 500-1000ml to maintain CVP 8-12mmHg
  • if CVP adequate but MAP < 65mmHg, and patient suitable for ICU, then:
      • NB. adrenaline is not used as initial single agent as it has a higher likelihood of impairing splanchnic blood flow and tissue perfusion
      • NB. dopamine may have some benefits over noradrenaline for those with hypoperfusion of the extremities (“cold sepsis”) but as it has more adverse effects and it is more likely to fail as a single agent, noradrenaline is still a reasonable choice4)
      • NB. vasopressin may be a useful 2nd line agent
      • NB. phenylephrine may be useful when tachycardias and arrhythmias preclude use of agents with beta-adrenergic activity such as noradrenaline
    • if central venous oxygen saturation < 70% despite Hb > 7, and adequate CVP and MAP, then:
  • iv dexamethasone 0.15mg/kg to max 10mg qid or hydrocortisone 50mg iv qid for 5-7 days
    • starting within 8hrs of onset of shock if severe septic shock (defined as a systolic blood pressure <90 mmHg for more than one hour despite both adequate fluid resuscitation and vasopressor administration)5)
    • NB. appears to be no added benefit of also using fludrocortisone
sepsis.txt · Last modified: 2020/02/03 07:22 (external edit)