2. Goals of this lecture Review how sepsis and severe sepsis affects patients Recognize the signs and symptoms of sepsis Discuss the current management strategies
3. What is Sepsis? The Invasion  Infection occurs in the body  Urine  Pneumonia  Skin  Abdominal/Pelvic  Bacteria enters the blood stream  The body has an immune response  fever, vasodilation  Microvascular instability ensues  Septic Shock
4. How does sepsis kill? Sepsis  Circulatory Dysfunction intravascular volume depletion peripheral vasodilatation myocardial depression microcapillary injury Hypoperfusion/End Organ Damage and Death
5. Why is sepsis recognitionimportant? Most common admission diagnosis to ICU In the US, approximately 750,000 cases yearly with 225,000 fatalities Rate of death despite antibiotics and advanced life support remains between 30-50% Why? Advanced Age, Invasive Procedures, Antibiotic Resistance, Immunosuppressive Therapy
6. Facts—that we cant ignore Incidence of Severe Sepsis Mortality of Severe Sepsis 300 250,000 250 200,000Cases/100,000 Deaths/Year 200 150,000 150 100,000 100 50,000 50 0 0 AIDS* Colon Breast CHF† Severe AIDS* Breast AMI† Severe Cancer§ Sepsis‡ Cancer§ Sepsis‡†National Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association.2000. ‡Angus DC et al. Crit Care Med. 2001 ;29(7):1303-1310.
7. What are the components of sepsistreatment? Requires a team effort of recognition and treatment Requires an understanding of the appropriate resuscitation goals and medical treatments Requires an interdepartmental approach to patient management Requires continual review to ensure patient treatment goals are being met
8. The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
9. Recognizing Sepsis SIRS (Systemic Inflammatory Response Syndrome)  Temp >100.4 or <96.8  Heart Rate >90 beats/min  Respiration Rate >20 breaths/min  WBC >12,000 or <4,000 or >10% bands Sepsis– 2 or more SIRS criteria and suspected infection Severe Sepsis: presence of sepsis plus organ dysfunction Septic Shock: sepsis plus refractory hypotension
10. What does a septic patient looklike? Non-Specific: malaise, change in mental status, decreased urine output, hypo/hyperglycemia Localized Symptoms: Cough, Urinary Symptoms, Abscess/Cellulitis, Flank pain SIRS Criteria: Fever, Tachycardia, Tachypnea Immune compromised patients, Nursing Home Resident, Diabetics, Dialysis Patients
11. Who is most likely to get severesepsis? Immunocompromised Elderly Chronically Ill Newborns
12. The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
13. Early Goal Directed Therapy:AKA- The Sepsis Protocol
14. I have a potentially septic patient,now what? Assess the patient’s respiratory status Place the patient on a cardiac monitor Draw a ―rainbow‖ of labs Draw a set of blood cultures and urine cultures Obtain a Chest XR for suspected pneumonia Plan for broad-spectrum antibiotics Prepare to Initiate the Severe Sepsis Protocol
15. Sepsis Resuscitation Bundle 6 - hour Severe Sepsis/ Septic Shock Bundle • Vasopressors: • Early Detection: – Hypotension not – Obtain serum lactate level. responding to fluid – Titrate to MAP > 65 • Early Blood Cx/Antibiotics: mmHg. – within 3 hours of presentation. • Septic shock or lactate > 4 mmol/L: – CVP and ScvO2 measured. • Early EGDT: – CVP maintained >8 mmHg. • Hypotension (SBP < 90, MAP – MAP maintain > 65 mmHg. < 65) or lactate > 4 mmol/L: – initial fluid bolus 20-40 ml of • ScvO2<70%with CVP > 8 crystalloid (or colloid equivalent) mmHg, MAP > 65 mmHg: per kg of body weight. – PRBCs if hematocrit < 30%. – Inotropes.
16. The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
17. Labs to Order: The Essentials CBC CMP Amylase/Lipase PT/PTT/INR (evaluate for potential DIC) Cortisol Lactate* Urinalysis Cultures: Blood, Urine, Wound, CSF
18. Why is Lactate Important? Measures adequate perfusion on a cellular level ―Cryptic Shock‖ – Some patients have hypoperfusion of tissues with normal blood pressures. Lactate clearance (drawing lactates separated by 6 hours) has prognostic indications Elevated lactates at 24 hours has an 89% mortality
19. The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
20. Antibiotic Strategies Rapid administration of appropriate antibiotics Obtain blood and urine cultures prior to antibiotic administration Broad-Spectrum antibiotics are preferred initially. Use 2 or More Antibiotics—prevents selection of resistance, provides synergy against single pathogen Single antibiotics may not cover spectrum of possible pathogens
21. An Example of a RecommendedAntibiogramType of Infection Example of Initial Antibiotics Penicillin allergic patientsCommunity Acquired Pneumonia Ceftriaxone 2 grams IV Levaquin 750 mg IV Plus either Azithromycin 500 mg IV or Levaquin 750 mg IVNosocomial / Health-Care Zosyn 4.5 g IV + Amikacin IVAssociated Pneumonia Tobramycin IV + Tobramycin IV + Vancomycin IV Vancomycin IVCommunity Acquired Zosyn 3.375 g IV Ciprofloxacin 400 mg IV +Intraabdominal infection Metronidazole 500 mg IVNosocomial Intraabdominal Zosyn 4.5 g IV + Ciprofloxacin 400 mg IV +Infection Tobramycin IV + Metronidazole 500 mg IV + Vancomycin IV Tobramycin IV + Vancomycin IVSepsis from a Urinary Source Zosyn 3.375 g IV+ Ciprofloxacin 400 mg IV + Tobramycin IV Tobramycin IVIntravascular Catheter-Related Zosyn 3.375 g + Amikacin IV +Sepsis Vancomycin IV Vancomycin IVFebrile Neutropenia Ceftazidime 2 g IV + Amikacin IV + Tobramycin IV +/- Tobramycin IV + Vancomycin IV Vancomycin IVUnknown Source Zosyn 4.5 g IV + Amikacin IV + Tobramycin IV + Tobramycin IV + Vancomycin IV Vancomycin IV
22. More Antibiotic Strategies… Consider:  Age  Allergies  Renalclearance  Recent hospitalizations or procedures Dont let obtaining cultures delay administration—i.e. Meningitis Consider hospital specific empiric antibiotic guidelines
23. Factors in Multi-Drug Resistant•Antibiotics in preceding 90 days•Current hospitalization of 5 days or more•High frequency of antibiotic resistance in community or specific hospital unit•Immunosuppressive disease and/or therapy•Presence of risk factors for HCAP (Health Care AssociatedPneumonia) -Hospitalized for ≥ 2 days in the preceding 90 days -Residence in Nursing Home/Extended Care facility -Home Infusion Therapy (including antibiotics) -Chronic Dialysis within 30 days -Home Wound Care -Family Member with Multi-Drug Resistant Pathogen (Amer J Resp Crit Care
24. The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
25. Resuscitation Guidelines Normo-tensive patients, may have hypoperfusion or ―cryptic-shock‖. Check a lactate. Hypotension—often reversed with aggressive fluid replacement Initial boluses of 1000ml with goals of: MAP >65mmHg Urine Output >0.5 ml/kg/hr CVP 8-12mmHg Initiate 20cc/kg fluid bolus or 1 Liter—over 30 min Do not withhold fluid resuscitation EVEN IF the patient has renalfailure or CHF. Studies show that intubation is better than under-resuscitating!
26. Resuscitation Guidelines:Central Venous Lines Central Venous Line Uses  Place if the patient continues to remain hypotensive and requires pressors  Can be used in an ICU setting to monitor Central Venous Pressures  Allows for fluid, pressors and antibiotic administration simultaneously Central Venous Line Principles  Does not include a PICC Line, Power Port or Porta-Cath  Place under sterile technique
27. The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
28. Resuscitation: The First LinePressorsNorepinephrine and Dopamine Norepinephrine (First Line)  Increases BP & vascular resistance without changing cardiac output  Produces a reflex bradycardia in response to the increase in MAP  Decrease in Cardiac O2 consumption Dopamine (First Line)  Positive inotropic and chronotropic effects  Increases cardiac output with minimal effect on vascular resistance  Increases cardiac oxygen requirements  can potentiate dysrhythmias Second Line Therapy: Vasopressin
29. Disposition: Floor, Telemetry orICU Does the patient have potential for respiratory compromise? Has the patient been stabilized? Does the patient require pressors or repetitive fluid boluses?
30. A Quick Review of the Protocol1. Lactate Levels: If you suspect sepsis order the levels.2. Blood Cultures/Urine Cultures- Always order 2 blood cultures and a urine culture prior to antibiotics.3. Antibiotics- Rapid administration of appropriate antibiotics4. Resuscitation- Every patient (regardless of CHF, renal status, respiratory status) should receive a 20cc/kg NS bolus or 1000 cc NS initial bolus for hypotension (MAP less than 65).5. Pressors- If the patient continues to be hypotensive after 2L of NS boluses, pressors should be started with Neosynephrine and/or Dopamine as first-line.6. Central Line Therapy- If a patient continues to be hypotensive after fluid boluses and pressors are necessary, a central line must be started. If you are uncomfortable with starting a central line, please consult surgery early.
31. Goals of Therapy Resuscitation Goals  NS Bolus: At least 1000cc or 20cc/kg initially for hypotension  Start pressors for refractory hypotension  Central Line Obtain appropriate cultures Antibiotics Lactate Levels for ALL septic patients Improve patient survival