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Sepsis & septic shock an updated management
1. Sepsis and Septic Shock
DR. MD. AHAD HOSSAIN
MD(phase A)
Dept. of Anesthesiology, BSMMU
2. Sepsis and Septic Shock
• Definitions
• Epidemiology
• Pathogenesis
• Principles of management
3. Definitions
• SIRS: systemic response to infection manifested by ≥ 2 of:
– Temp > 38oC or < 36oC
– HR > 90 b/m
– RR > 20 /m or PaCO2 < 32 mmHg
– WBC > 12 x 109/L, < 4 x 109/L or >10% band form
SEPSIS: SIRS plus documented infection
• Septic shock: sepsis with hypotension despite adequate
fluid resuscitation, with perfusion abnormalities that
could include, but are not limited to, lactic acidosis,
oliguria, and/or acute mental status.
ACCP/SCCM Consensus Conference: Bone et al, Chest 1992 101:1644
4. SIRS
• SIRS – systemic inflammatory response syndrome
• Must have at least 2 of the following:
– Temperature >38.5ºC or <36ºC
– Heart rate >90 beats/min
– Respiratory rate >20 breaths/min or PaCO2 <32
mmHg
– WBC >12,000 cells/mm3, <4000 cells/mm3, or
>10 % immature (band) forms
• SIRS is the body’s response to infection,
inflammation, stress.
5. Severe sepsis
• Severe sepsis is defined as sepsis plus organ
dysfunction
• Hypo perfusion or hypotension
• A major cause of organ failure in ICU
• Severe sepsis is directly or indirectly
responsible for 75% of all ICU death
9. Severe sepsis incidence and mortality
increase with age
0
5
10
15
20
25
30
<1
1-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
>85
Incidenceper100,000
0
5
10
15
20
25
30
35
40
45
Mortality%
Angus Crit Care Med 29:1301, 2001
Mortality
Incidence
10. Organ dysfunction at time of severe
sepsis recognition
0
10
20
30
40
50
60
70
80
PercentofPatients
Shock
Respiratory
Renal
Metabolic
Coag
DIC
Bernard NEJM 344:699, 2001
18. Diagnostic Criteria for Sepsis
General variables
• Fever (> 38.3°C)
• Hypothermia (core temperature < 36°C)
• Heart rate > 90/min–1 or more than two sd above the
normal value for age
• Tachypnea
• Altered mental status
• Significant edema or positive fluid balance (> 20 mL/kg
over 24 hr)
• Hyperglycemia (plasma glucose > 140 mg/dL or 7.7
mmol/L) in the absence of diabetes
19. Inflammatory variable
• Leukocytosis (WBC count > 12,000 μL–1)
• Leukopenia (WBC count < 4000 μL–1)
• Normal WBC count with greater than 10% immature forms
• Plasma C-reactive protein more than two sd above the normal value
• Plasma procalcitonin more than two sd above the normal value
Hemodynamic variables
• Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an
SBP decrease > 40 mm Hg in adults
20. Organ dysfunction variables
• Arterial hypoxemia (Pao2/Fio2 < 300)
• Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2
hrs despite adequate fluid resuscitation)
• Creatinine increase > 0.5 mg/dL or 44.2 μmol/L
• Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
• Ileus (absent bowel sounds)
• Thrombocytopenia (platelet count < 100,000 μL–1)
• Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or
70 μmol/L)
Tissue perfusion variables
• Hyperlactatemia (> 1 mmol/L)
• Decreased capillary refill or mottling
21. Severe Sepsis
• Sepsis-induced hypotension
• Lactate above upper limits laboratory normal
• Urine output < 0.5 mL/kg/hr for more than 2 hrs despite
adequate fluid resuscitation
• Acute lung injury with Pao2/Fio2 < 250 in the absence of
pneumonia as infection source
• Acute lung injury with Pao2/Fio2 < 200 in the presence of
pneumonia as infection source normal >400
• Creatinine > 2.0 mg/dL (176.8 μmol/L)
• Bilirubin > 2 mg/dL (34.2 μmol/L)
• Platelet count < 100,000 μL
• Coagulopathy (international normalized ratio > 1.5)
22. Initial resuscitation of sepsis:
therapeutic goals
• Central venous pressure: 8 – 12 mmHg
• Mean arterial pressure: ≥ 65 mmHg
• Urine output: 0.5 mL/kg/h
• Central venous (SVC) or mixed venous
oxygen saturation: ≥ 70%
23. Immediate management of
severe sepsis
• Give high-concentration oxygen
•Take blood cultures
• Give intravenous antibiotics
(appropriate to likely organism)
• Volume-resuscitate
• Measure Hb and lactate
• Measure urine output
• Control source of infection
24. SURVIVING SEPSIS CAMPAIGN BUNDLES
TO BE COMPLETED WITHIN 3 HOURS:
• 1) Measure lactate level
• 2) Obtain blood cultures prior to
administration of antibiotics
• 3) Administer broad spectrum antibiotics
• 4) Administer 30 mL/kg crystalloid for
hypotension or lactate 4mmol/L
25. TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not
respond to initial fluid resuscitation)
to maintain a mean arterial pressure (MAP) 65 mm Hg
In the event of persistent arterial hypotension despite
volume resuscitation (septic shock) or initial lactate 4
mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)*
- Measure central venous oxygen saturation (ScvO2)*
Remeasure lactate if initial lactate was elevated*
*Targets for quantitative resuscitation included in the
guidelines are CVP of 8 mm water.
ScvO2 of 70%, and normalization of lactate
26. Hemodynamic Support and Adjunctive Therapy
Fluid Therapy of Severe Sepsis
1. initial fluid of choice in the resuscitation of severe
sepsis and septic shock.
2. albumin -patients require substantial amounts of
crystalloids.
3.(SSC) recommend against the use of hydroxyethyl
starches(HES) for fluid resuscitation of severe sepsis
and septic shock.
27. Vasopressors
1. (MAP) of 65 mm Hg.
2. Norepinephrine - first choice
3. Epinephrine -added to and potentially
substituted for norepinephrine.
4. Low dose vasopressin is not recommended
5. Dopamine as an alternative vasopressor agent to
norepinephrine.
6. Low-dose dopamine should not be used for renal
protection.
7. All patients requiring vasopressors have an arterial
catheter placed as soon as practical if resources are
available (UG).
28. Corticosteroids
1. Not using intravenous hydrocortisone to treat adult
septic shock patients if adequate fluid resuscitation and
vasopressor
therapy are able to restore hemodynamic stability.
In case this is not achievable, we suggest
intravenous hydrocortisone alone at a dose of 200 mg
per day.
2. Corticosteroids not be administered for the treatment
of sepsis in the absence of shock.
29. Sites of infection in critically ill patients
Sites of infection Investigations and comments
Major
Intravenous lines (particularly
If the patient develops sepsis, replace
any lines that have not been changed
for > 4 days
Lungs High risk of nosocomial pneumonia in
intubated patients. After ICU stay > 3–
4 days, particularly if
antibiotics are given, the nasopharynx
becomes colonised with Gram-
negative bacteria, which
migrate to the lower respiratory tract.
Prophylaxis with parenteral and
enteral antibiotics (selective
decontamination of the digestive tract)
reduces the incidence of nosocomial
pneumonia
Urinary tract Urine culture (but this is a relatively
unusual source in unexplained sepsis)
30. Abdomen Consider intra-abdominal abscess or necrotic gut in
patients who have had abdominal surgery
Pancreatitis, acute cholecystitis or perforated peptic
ulcer may develop as a complication of critical
illness. Ultrasound, CT, aspiration of collections of
fluid/pus and laparotomy may be required
Other
Heart valves
Transthoracic or transoesophageal echocardiogram
Meningitis Lumbar puncture after checking coagulation and
platelet count
Joints &bones X-ray, gallium or technetium white cell scan
Nasal sinuses, ears,
retropharyngeal space
Clinical examination, plain X-ray, CT
Genitourinary tract (particularly
post-partum)
PV examination, ultrasound
Gastrointestinal tract PR examination, stool culture, Clostridium difficile
toxin, sigmoidoscopy
31. Issues in the rational choice of antibiotics
EFFICACY
• Spectrum of activity
• Pharmacokinetics & pharmacodynamics
• Patterns of resistance
TOXICITY
COST
32. Choosing antibiotics in sepsis
• There is no, single, “best” regimen
• Consider the site of the infection
• Consider which organisms most often cause
infection at that site
• Choose antibiotic(s) with the appropriate
spectrum
• After obtaining cultures, give antibiotics
quickly and empirically at appropriate dose
33. Inadequate treatment of bloodstream infections
increases ICU mortality
Ibrahim et al, Chest 2000 118:146
34. “Non-antibiotic” therapy for sepsis
• Low dose steroids
• Intensive insulin therapy
– tight glycaemic control
• Activated protein C
• Goal directed therapy
35. Other Supportive Therapy of Severe Sepsis
• Glucose control
• Renal replacement therapy
• Bicarbonate therapy
• Deep vein thrombosis prophylaxis
• Stress ulcer prophylaxis
• Nutrition
