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Sepsis

Terms in this set (49)

Define Sepsis
AKA: blood poisoning
The body's often deadly response to infection or injury.
What bacteria is associated with sepsis today?
usually caused by gram positive bacteria today
Staph Aureus
Strep pneumoniae
Define SIRS.
Systemic Inflammatory Response Syndrome
Must have two or more of the following:
Temperature >38 (100.4) or <36 (96.8)
Heart Rate >90 BPM
Respiratory Rate >20 or PCO2 <32mm Hg
Abnormal WBC (>12K or <4K or >10% Bands)
Define Sepsis.
A suspected or proven infection PLUS SIRS
Neurologic dysfunction associated with Sepsis.
New altered mental status
Hematologic dysfunction associated with sepsis.
Platelet count <100,000
Coagulapathies - INR >1.5 PTT >60
Renal dysfunction associated with sepsis.
Creatinine >2.0 without prior disease or an
increase of 0.5mg/dL from baseline
Acute oliguria output <0.5mL/kg/hr for at least 2 hours despite fluid resuscitation.
Pulmonary dysfunction associated with sepsis.
RR >20
SaO2 <90% or <94% with supplemental O2
Mechanical ventilation
PaO2/FIO2 <300:arterial hypoxemia
GI dysfunction associated with sepsis.
Ileus; absent bowel sounds
Hyperbilirubinemia
Plasma total bilirubinemia >4mg/dL
CV dysfunction associated with sepsis.
Hypotension
Which type of bacteria are associated with higher mortality rates in sepsis?
Gram negative
Septic Shock
State of acute circulatory failure persistent hypotension unexplained by other causes
SBP <90
MAP <60
Reduction in SBP more than 40 from baseline
After adequate fluid resuscitation (20-30cc/kg of crystalloid)
Explain the Resuscitation Bundle for Sepsis.
Measure serum lactate levels (increased = decreased oxygen availability leading to breakdown of CHO for oxygen and byproduct of acid)
Blood cultures prior to abx treatment
Broad spectrum abx within 3 hours if ED and within 1 hour if non-ED admit
Fluid resuscitation
Vasopressors if BP unresponsive to fluid
CVP >8
ScVO2 >70%
What is the management bundle of sepsis?
Low dose steroid administered for septic shock
Drotrecogin alfa (activated) if appropriate
Glucose control
Inspiratory plateau pressures maintained <30 in vented patients
What causes multi system organ failure in sepsis?
Platelet clumping leads to emboli in organs preventing adequate oxygenation to vital organs.
What are the Golden Hours of Sepsis?
The first 6 hours after sepsis is diagnosed; should have aggressive treatment during these hours.
CVP Goals in the treatment of sepsis?
500cc fluid bolus given every 30 minutes until CVP 8-12
Sepsis guidelines recommend 1000cc crystalloid or 500cc colloids over 30 minutes
What is the affect on intravascular space when administering crystalloid?
1000cc LR = 250cc in intravascular space
Widely distributed in the body leaving only 250cc in the intravascular space
What is the affect on intravascular space when administering colloid?
500cc HES = 800cc intravascular space
Will volume expand up to 800cc in the space vs extracellular leaking
Two first line drugs in MAP management in the treatment of sepsis?
Dopamine can be used to increase the MAP and cardiac output
Increase stroke volume and HR
More useful in patients with systolic dysfunction
More arrhythmogenic
Norepinephrine can be used (more potent than dopamine)
Vasoconstictive effects with little effect on HR
Less increase in stroke volume compared to dopamine
Both are 1st line drugs for the treatment of hypotensive septic patient.
Explain Epinephrine in the treatment of hypotension in sepsis.
High potential for tachycardia
May decrease splanchnic circulation
May cause hyperlactemia
Explain the use of Phenylephrine of hypotension in sepsis.
Least likely to produce tachycardia
Pure vasopressor causing decreased stroke volume
Explain the use of vasopressin in the treatment of hypotensive patient with sepsis.
Consider if physiologic depletion suspected
Caution - high doses may be associated with cardiac, digital and splanchnic ischemia
Definition of SvO2 .
SvO2 = oxygen delivered - oxygen consumed
What does high SvO2 indicate and when does it occur?
Increased oxygen delivery
Low oxygen demand
Seen in Increaesd FIO2, Hyperoxia, Hypothermia, Anesthesia, Pharmacologic paralysis, Sepsis
What does low SvO2 indicate and when does it occur?
Decreased oxygen delivery
Decreased Hgb
Decreased SaO2
Decreased CO
Increased Oxygen demand
Caused by anemia, hypoxia, suctioning, hypovolemia, shock, arrhythmias, hyperthermia, pain, shivering, seizures
What is the difference between SvO2 and ScVO2?
Mixed venous oxygen saturation (SVO2) runs 5-7% lower than central venous oxygen saturation (ScvO2)
When are SVO2 or ScVO2 levels too low?
SVO2 less than 65% or ScVO2 less than 70%
Should transfuse with PRBCs until HCT >30%
Dobutamine gtt to increase CO/CI
How should a septic patient be managed in the ICU?
Intravascular fluid resuscitation
Antibiotics
Vasopressors and inotropes
Source control
Xigris
Corticosteroids
Blood Products
Mechanical Ventilation
Sedation/analgesia/neuromuscular blockade
Glycemic control
Renal replacement therapy
Bicarbonate therapy
DVT prophylaxis
Stress Ulcer prophylaxis
When should abx be administered in sepsis?
After blood cultures are drawn
Should be received within the first hour = 78.9% survival
Each delay in abx administration associated with 7.6% increase in mortality.
Common gram positive pathogens.
Staphylococcus (MRSA, MSSA, CoNS)
Enterococcus Species (E. Faecalis, E. Faecium, VRE)
Streptococcus Species (Group A, Group B, Strep Pneumoniae)
Common gram negative pathogens.
E. Coli
Klebsiella species
Proteus Species
Enterobacter
What is important in source control r/t infection site in sepsis?
Early identification and removal of source if possible
Exception to this is Peripancreatic necrosis in which waiting is indicated to get a line of demarkation prior to removal.
What is the pathophysiology of Activated Protein C (Xigris)?
Endogenous protein
Decreased level in sepsis
Inhibition of conversion of Protein C to activated Protein C
What is the MOA of Xigris?
Administering Xigris inhibits thrombosis and inflammation, promoting fibrinolysis
Modulates coagulation and inflammation
What is the indication for Xigris therapy?
APACHE II score >/= 25 with organ failure and no contraindication
Corticosteroid therapy in sepsis?
Use steroids when pt unresponsive to fluids and pressers
No need for ACTH stimulation
Avoid dexamethasone if hydrocortisone can be used
Wean from steroids when pressers are no longer needed
OK to use steroids in patients that were previously on steroids
Blood product administration in sepsis?
Want the HCT to be greater than 30%
Goal Hgb 7-9
Increases oxygen delivery but does not increase oxygen consumption
Platelet transfusion - transfuse when <5K, plt count 5-30K if at risk for bleeding
Platelet count <50K if surgery or invasive procedures
Do you give erythropoetin in sepsis?
Not indicated; can continue to use if renal failure patient
Do you give FFP in sepsis?
Not unless actively bleeding or surgical intervention is planned
Should antithrombins be administered in septic patients?
No beneficial effect on 28 day mortality
Ventilator management in septic patients.
Adopt a low threshold for intubation
Tidal volume 6mL/kg in patients with ALI
No mode is better than another
Plateau pressure <30, allowing permissive hypercapnea if necessary to minimize plateau pressure
Use PEEP to avoid lung collapse at end expiration
Positioning of patients who are septic.
Prone positioning 17 hours per day is recommended.
Elevate HOB 30-45 degrees
Evaluate for extubation (daily SBT, sedation holiday)
Invasive monitoring in sepsis?
Avoid routine use of PA catheters
Conservative fluid strategy for patients WITHOUT evidence of tissue hypoperfusion
Sedation, analgesia, neuromuscular blockade in sepsis.
Sedation Protocols recommended (RAMSEY, RASS)
Intermittent bolus vs. continuous infusion - Continuous infusion can lead to longer ventilator times, should have a daily sedation holiday
NMB - Avoid if possible, intermittent vs. continuous infusion, NMB and steroids (increased risk of long term myopathy)
Monitoring depth of NMB with TOF, BIS monitoring
Glucose control in sepsis.
Keep glucose <150mg/dL
Use validated protocol
Renal replacement therapy in sepsis.
CRRT and conventional HD are equivalent
CRRT is recommended for hemodynamically unstable patients
Bicarbonate therapy in sepsis.
Avoid in hypoperfusion-induced lactic acidemia with pH >7.15 according to guidelines
Can increase fluid overload, increased sodium levels
DVT Prophylaxis in sepsis.
Heparin 2-3x/day SQ (preferred in decreased renal function)
LMWH
SCDs
High risk patients should use both SCDs and heparin therapy (LMWH preferred in high risk)
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