Emergency lectures - Sepsis
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Emergency lectures - Sepsis

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    Emergency lectures - Sepsis Emergency lectures - Sepsis Presentation Transcript

    • SEPSISHugh Hemsley MDFebruary 2011
    • Goals of this lecture Review how sepsis and severe sepsis affects patients Recognize the signs and symptoms of sepsis Discuss the current management strategies
    • 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
    • How does sepsis kill? Sepsis  Circulatory Dysfunction intravascular volume depletion peripheral vasodilatation myocardial depression microcapillary injury Hypoperfusion/End Organ Damage and Death
    • 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
    • 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.
    • 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
    • The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
    • 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
    • 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
    • Who is most likely to get severesepsis? Immunocompromised Elderly Chronically Ill Newborns
    • The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
    • Early Goal Directed Therapy:AKA- The Sepsis Protocol
    • 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
    • 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.
    • The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
    • Labs to Order: The Essentials CBC CMP Amylase/Lipase PT/PTT/INR (evaluate for potential DIC) Cortisol Lactate* Urinalysis Cultures: Blood, Urine, Wound, CSF
    • 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
    • The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
    • 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
    • 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
    • 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
    • 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
    • The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
    • 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!
    • 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
    • The Septic PatientEarly Goal Directed Disposition Therapy Recognition Labs and ResuscitationDiagnositics Antibiotics
    • 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
    • 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?
    • 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.
    • 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
    • Thank you Questions?