Sepsis, Basic guidelines of sepsis management in ED, initial approach, sepsis bundle, sepsis survival concept..

1. Sepsis Management
Runal Shah
1st
year Resident MEM,
KDAH,
Mumbai.

2. What is Infection ?
• Infection is the invasion of a host organism's
body tissues by disease-causing agents, their multiplication, and
the reaction of host tissues to these organisms and
the toxins they produce.
• A suspected or proven (by positive culture, tissue stain, or PCR
test) infection caused by any pathogen or a clinical syndrome
associated with a high probability of infection.
• Evidence of infection includes positive findings on clinical
examination, imaging, or laboratory tests
– WBC in a normally sterile body fluid
– perforated viscus,
– CXR consistent with pneumonia
– Petechial or purpuric rash or purpura fulminans

3. Definitions
SIRS :
• At least 2 of the following
1)Temp : > 100.9°F / < 96.8°F
2)Tachycardia : HR > 90/min
3)Respiratory rate : >20 breaths/min or PaCO2 <32 mm Hg
4)Leukocyte Counts >12,000 or <4000; or >10% immature
(band) forms.
 Cause can be Infective or Inflammatory !

4. Sepsis:
• Systemic response to Infection, fulfilling >=2 criteria of SIRS
Severe Sepsis:
• Sepsis + CVS dysfunction / ARDS / >=2 other organs
dysfunction
Septic Shock:
• Acute circulatory failure – Persistent arterial hypotension
despite adequate fluid resuscitation.
• Hypotension = SBP < 90 mm Hg / MAP <60 mm Hg / fall of
SBP >40 mm Hg

5. Sepsis Six
Sepsis Six to be delivered within 6 hours -
1) Deliver high-flow Oxygen
2) Take a blood culture
3) Administer empiric IV Antibiotics
4) Measure serum lactate and send full blood count
5) Start IV fluid resuscitation
6) Commence accurate urine output measurement

6. Surviving Sepsis Campaign

7. Early Goal Directed Therapy
• Goals:
 Optimization of
oxygenation, ventilation,
circulation
 Initiation of antibiotics
 Control of the source of
Sepsis

8. Airway(A) & Breathing(B)
 Maintain SpO2 > 90% in sepsis patient
 Endotracheal Intubation
• If airway is not secured
• If respirations are inadequate
• Hypotension unresponsive to fluid resuscitation, to avoid
respi. muscles fatigue from Hypoperfusion
Goal for ventilation is 6ml/Kg of Ideal body weight
Limiting Tidal volume
• Decreases mortality 40%31%
• Reduce organ dysfunction
• Lower cytokines level

9. Circulation(C)
 Immediate 1 or more large bore IV access is recommended.
 Give NS at rate of 0.5L every 5-10 min, this can exceed up to 4-
6L in total. (30ml/kg)
 Crystalloids preferred over Colloids.
 According to EGDT guidelines, early Invasive monitoring with
Central Venous Catheter & Arterial Line placement should be
done.
 Current recommendations: To maintain..
 Central venous pressure 8-12 mm Hg
 MAP >65 mm Hg
 Venous Oxygen Saturation >70%

10. Circulation(C)
Clinical Indicators of Hemodynamics:
• Pulse rate
• Blood pressure
• Respiration
• Mental status
• Central venous pressure
• Urine output (>0.5ml/kg/hour)
New parameter: Bedside Ultrasound assessment
of Inferior Vena Cava

11. Inotropes for Circulation(C)
Indication of Inotropes:
• No hemodynamic response even after 3-4L of fluid
• Signs of fluid overload – Pulm edema / Raised CVP
• Nor-epinephrine = 2.5-20 mcg/kg/min (of choice)
• Dopamine = 5-20 mcg/kg/min
If still unresponsive  Epinephrine infusion
 Dobutamine can be initiated when Low cardiac output with
High filling pressure !! (mostly ICU set-up)

12. Identify the source & Early Antibiotics
 If focal source of sepsis is found, remove the nidus of
infection, e.g.
• Indwelling IV catheters
• Blocked urinary catheters
• Intra-abdominal / sinus / soft tissue abscesses
 Empirical antibiotics within 30 min of Hypotension if given,
yield the survival rate of >80%.
 Timing of antibiotics administration is critical to survival.
• Provide empiric IV therapy against gram-positive organisms
(Streptococcus and Staphylococcus species) and gram-negative
bacteria.
• Administer the maximum antibiotic doses allowed.

13. Empirical Antibiotics
 Adult without an obvious source of Infection:
 Gram Negative Bacilli / S. Aureus / Streptococci
 Imipenem / Ertapenem / Doripenem / Meropenem
+ Vancomycin
 Suspected Billiary source:
 Aerobic Gram Negative bacilli, enterococci
• Ampicillin+Sulbactam / Piperacillin+Tazobactam /
Ticarcillin+Clavunate

14.  Suspected LRTI:
 S.Pneumonia, Methicillin Resistant S.Aureus, Legionella
• Ceftriaxone + Azithromycin + Levoflox/Moxiflox + Vancomycin
 Suspected UTI (Urosepsis):
 Enterobacteriacae, Ps.Aeruginosa, Enterococci, Rarely S.aureus
• Piperacillin+Tazobactam / Imipenem / Meropenem / Doripenem /
Ampicillin+Gentamycin

15. Glycemic control
Hyperglycemia adverse effects:
• Promotes inflammation
• Impaires immune function
• Affects fluid balance
• Hyperglycemia adversely affects granulocyte
adherence, chemotaxis, phagocytosis and
intracellular killing.
Judicious glycemic control of <150mg/dl to
achieve

16. Steroids
Hydrocortisone <=300mg/dl per day.
Hypotension refractory to Fluids and inotropes !!

17. Anemia to treat
Hb >9 gm/L : no packed RBC required
Hb 7-9 gm/L : Transfuse in patient in which
suspected on going hemorrhage !!
<7 gm/L : Blood transfusion required

18. Thank You…
• Ref :
– Tintinalli’s Emergency Medicine A Comprehensive Study Guide,
7th Edition