Management of Sepsis and Septic Shock based on surviving sepsis guidelines.

1. SEPTIC SHOCK
Presentor : Dr. Sudhanshu Goyal,
PGY-1, General Surgery,
Civil Hospital Aizawl
Dated : 28th July 2015, Tuesday

2. What is SEPTIC SHOCK?
Invasion of normally
sterile host tissue
by microorganism
Inflammatory
response to the
presence of
microorganism
Infection
Two or more
of following
Hyothermia or
hyperthermia
Tachycardia
Tachypnoea or
Paco2 <32
mmHg
Leucocytosis or
leucopenia
SIRS
SIRS
Plus
Documented
Infection
Sepsis
Sepsis +
Organ
dysfunction
Plus
Hypotension
Steptic
Shock

3. Pathophysiology of Septic Shock

4. Clinical Presentation
Symptoms
 Fever: insensitive indicator
 Hypothermia: more predictive of severity
and death
 Confusion/Disorientation: metabolic
encephalopathy ?altered a.a.
metabolism
 Hyperventilation: stimulation of
respiratoty centres by inflammatory
mediators
 Organ system localizing symptoms
Signs
 Rectal temperature
 Extremities: Warm vs Cold shock
 Tachycardia and Pulse pressure
 Tachypnoea
 Altered mental status
 Organ system localizing signs

5. Workup
 CBC with DLC
 Coagulation studies :
 PT & aPTT and fibrin split products elevated with fibrin levels decreased in DIC
 Biochemical tests:
 Lactate levels
 Serum Electrolytes
 KFT
 LFT
 Microbiology:
 SSC recommends atleast 2 blood cultures before antibiotics
 One percutaneous
 Other(s) through each vascular access (if >48hrs)
 Urine RME and Culture
 Gram stain and culture of secretions and tissues (at least 1ml/gm)

6. Workup continued…
 Imaging
 Chest radiograph is warranted in every case
 Abdomen
 CT is preferred over radiography
 USG if suspected Gall bladder pathology
 Extremities radiograph if suspected lesion
 Lumbar puncture
 Suspected meningitis or encephalitis

7. SSC Guidelines

8. Management Principles
 Early recognition
 Early and adequate antibiotic therapy
 Source control
 Early hemodynamic resuscitation and continued support
 Proper ventilator management with low tidal volume in patients with acute
respiratory distress syndrome (ARDS)

9. General Management
 2 large bore IV lines for aggressive fluid resuscitation and antibiotics
 Central venous access is useful but not mandatory
 Urinary catheterization to monitor UOP
 All cases of sepsis should be given oxygen
 Intubation in cases of respiratory distress due to DAD and ALI
 Patients who do not respond to initial fluid resuscitation needs ICU admission

10. Specific Management
ProCESS, ARISE and ProMISe trials have concluded that
 Measuring lactate, targeting ScvO2 values and insertion of central venous
catheter, no improved outcomes
 Direct and individualized care
 Culture and early institution of broad spectrum antibiotics
 Restoration of BP
 Reversal of evidence of end organ perfusion

11. Fluid Resuscitation
 Challenge with 1-2 L (30mL/kg) of crystalloids within 30-60 mins
 Continue as long as improvement continues
 End points:
 signs of volume overload
 sustained rise of >5mm Hg in cardiac filling pressure
 Rapid increase of CVP by >2 mm Hg
 Absolute CVP > 8-12 mm Hg
 Crystalloids versus Colloids
 SAFE trial, no significant difference
 Trend towards better outcome with 4% albumin
 NS versus LR
 Randomized double blinded trials
 LR has less chances hyperkalaemia and acidosis
 Mortality was higher in the saline group

12. Vasopressor Therapy
When to start:
 no response with ≥4 L of crystalloid
 if evidence of fluid overload
 persistent hypotension
First line therapy: DOPAMINE vs NORADRENALINE
 Noradrenaline
 Potent α agonist with minimal β agonist activity
 5-20 mcg/min irrespective of weight
 Dopamine
 30% patients fail to reach target MAP
 “No beneficial effect on renal blood flow and function in
setting of circulatory shock of any etiology”
 Useful in cold shock with co-existent bradycardia
 Dose: begin with 5-10 mcg/kg/min upto 20 mcg/kg/min

13. Vasopressor Therapy continued…
Second line agents:
 If poor clinical response to first line agents
 Adrenaline
 Increase Cardiac Index and Stroke Volume as well as HR and SVR
 Increase oxygen delivery and consumption
 Vasopressin
 Reserved for salvage therapy
 VASS Trial, decrease requirement of catecholamines but no significant
effect on mortality
 Dose: 0.03 U/min
 Phenylephrine
 Rarely used
 If tachyarrythmias limit therapy with other agents

14. Ionotrope therapy
 Useful if inadequate:
 Cardia Index
 MAP
 SmvO2
Despite adequate volume resuscitation and vasopressor therapy
 Dobutamine
 β receptor mediated increase in CO
 If myocardial dysfunction or hypoperfusion in presence of adequate fluid resuscitation and
adequate MAP
 Dose: Upto 20 mcg/kg/min

15. Corticosteroids
 CORTICUS study, patients who received hydrocortisone had
 rapid resolution of shock and faster improvement of organ dysfunction
 Higher incidence of recurrent sepsis and super-infections
 Recommendations (ACCCM)
 In patients with septic shock administer
 Hydrocortisone 200mg/day in 4 divided doses or 100mg bolus f/b 10mg/hr for 7 or more days
 In patients with early severe ARDS
 Methylprednisolone 1mg/kg/day continuous infusion for 14 or more days
 Do not use dexamethasone
 Weaning when vasopressor is not needed
 Steroids not to be used in absence of shock

16. Antibiotic therapy
 Broadspectrum empiric antibiotic therapy within 1 hr of recognition
 Use of 1 or more agents active against presumed source of infection plus capable of
penetration in adequate concentrations
 Daily re-evaluation for potential de-escalation
 Combination empiric therapy if:
 Difficult to treat multidrug resistant organism (eg pseudomonas)
 Severe infections associated with respiratory failure and septic shock
 Septic shock and bacteremia from pneumocci
 Combination therapy to be limited to 3-5 days, switch to monotherapy based on
culture and sensitivity results

17. Antibiotic Selection
 Must cover Gram positive, gram negative and anaerobic bacteria
 If antibiotic experienced
 Aminoglycoside over quinolone or cephalosporine for gram negative
 For covering MRSA
 Vancomycin or linezolid to be used
 For ESBL producing organisms
 Cephamycins (eg cefotetan) and carbapenems (eg imipenem, meropenem and ertapenem)
 In immunicompetent adequate coverage is offered by
 Carbapenems (eg imipenem and meropenem)
 3rd and 4th generation cephalosporins (eg cefotaxime, cefoperazone, ceftazidime and cefepime)
 Extended spectrum penecillins (eg ticarcillin and piperacillin)
 No need for Nephrotoxic aminoglycoside

18. Glycemic Control
Based on NICE-SUGAR trials, SSC Guidelines suggest:
 Target blood glucose level is < 180 mg/dL
 Start insulin if 2 consecutive blood glucose levels are >180 mg/dL
 Monitor 1-2 hrly if stable 4 hrly
 Capillary blood to be interpreted catiously

19. Blood Products
 Hemoglobin
 If Hb < 7g/dL transfusion is recommended
 Target Hb 7-9 g/dL
 No role of erythropoietin
 Platelet transfusion if
 < 10,000
 < 20,000 and risk of bleeding
 < 50,000 if surgery or invasive procedures are planned
 FFP
 Not recommended for lab clotting abnormalities
 Only if planned for surgery or invasive procedures

20. Metabolic and Nutritional Support
 K, Mg and PO4 levels should be measured and corrected
 High protein and energy requirement state
 Early nutritional support with preferred oral/enteral route
 Gastroperesis can be treated with motility agents or small bowel feeding tube
 Advantages of enteral route
 Protection of gut mucosa
 Prevention of translocation of organisms from GIT
 Reduced complication
 Low cost

21. Mechanical Ventilation
 Lung protective and pressure-limited ventilation
 TV of 5-8 ml/kg, transpulmonary pressure not more than 30 cm of H2O
 Permissive hypercapnea
 PEEP to prevent alveolar collapse
 Prone position ventilation

22. DVT prophylaxis
 Low dose unfractionated heparin 2-3 times a day
 Low molecular weight heparin in high risk patients (eg severe sepsis and previous
DVT, trauma or orthopedic surgery)
 If creatinine clearance < 30 mL/min use deltaparin
 Use mechanical DVT prevention devices in presence of CI

23. Other measures
 Renal replacement
 Intermittent hemodialysis and continuous venovenous hemofiltration are equivalent
 CVVH is better for hemodynamically unstable patient
 Sedation and NMB
 Use intermittent bolus sedation or continuous infusion sedation
 Daily lightening to produce awakening
 Avoid NMB where possible
 Use of bicarbonate is not recommended
 Stress ulcer prophylaxis
 PPI or H2 blocker
 Prone position ventilation

24. Sepsis at its Inception is
Difficult to Recognize but
Easy to Treat
Left Unattended it becomes
Easy to Recognize but
Difficult to Treat