This document provides an overview of treating sepsis in 8 steps: 1) Rapidly assess for critical instability and signs of organ dysfunction 2) Administer empiric fluids and perform ultrasound exams to identify potential infection sources 3) Administer early, broad-spectrum antibiotics within 1 hour 4) Identify and control infection sources 5) Understand appropriate vasoactive medications 6) Recognize patients that deteriorate rapidly 7) Use lactate levels to guide resuscitation but recognize limitations 8) Optimize hemodynamics prior to intubation for shock patients Two case studies are then presented and managed using the stepwise approach.

1. Faheem Guirgis MD, FACEP
Assistant Professor of Emergency Medicine
Division of Research
Department of Emergency Medicine
UF Health Jacksonville
8 Tips for Treating Sepsis

2. Financial Disclosures
 K23 from NIGMS
 NIH Loan Repayment Program

3. Objectives
 Learn rapid stepwise assessment of possible
sepsis patients
 Learn how to evaluate patients for organ
dysfunction
 Review evidence-based early sepsis management
 Discuss common pitfalls and how to avoid them
 Review and discuss recent literature and
implications for sepsis management

4. Fundamental Question
What is the diagnostic approach
to evaluate a patient with an
infection for sepsis?

5. Stepwise Assessment for sepsis
in patients with infection
Assess and Address:
 1. Critical instability
 2. Clinical signs of organ dysfunction (qSOFA)
 3. Subtle signs of organ dysfunction

6. 1. Critical Instability
 Always start with ABCs
 Immediate interventions
 Hypoxia, respiratory distress, hypotension,
hypoperfusion, hypothermia/hyperthermia, or
hypoglycemia

7. +
2. Bedside assessment
Infection?

8. UF JAX QSOFA

9. qSOFA
“rule-in for high risk sepsis”
NOT
a screening tool

10. 3. Subtle Signs of Organ
Dysfunction
 Lactate > 2 mmol/L
 PaO2/FiO2 < 400, SpO2/FiO2 < 302
 Platelets < 150k
 Tbili > 1.2 (clinical indication)
 MAP < 70
 GCS < 15
 Cr > 1.2

12. Case 1
A 60-year-old man w/ PMH prostate CA (in remission)
presents with burning with urination and fever for the 3
days.
HR 110, BP 130/90, RR 20, SpO2 98%,Temp 102 F.
Exam – Mild suprapubic tenderness, B CVA tenderness
WBC 18k with 5% bands, Cr 1.5, Platelets 130k, UA 80
WBCs, + Nit/LE; Lactate 1.2
AfterTylenol and Fluids, the patient wants to leave…

13. Case 2
A 70 yof with PMH DM, HTN, CVA arrives via EMS from a local
NH for fever and right leg pain.
NH Staff say she’s “not acting right”
EMSVitals: BP 85/50, HR 105, RR 20, 99.5 F, O2 96%, glucose
270 mg/dL.
Exam – AOx1; tender, warm and erythematous right leg;
Crepitus to foot
What next?

14. Ready for the 8 tips?
Stay Tuned…

15. 1. Follow the 4 F’s.
Figure it out early
Fill the tank
Fight the bugs
Fix perfusion

16. 2. Empiric Fluids Plus Ultrasound
(fill the tank)

17. Empiric Fluids
 Currently CMS requires 30 ml/kg fluids to be
given to patients with septic shock in the first
3 hours
 CMS definition of shock =
 Lactate > 4
 Hypotension not responsive to fluids

18.  11k patients, multi-center study
 Improved outcomes for early fluids
compared to delayed fluids (> 120
min)
 Mortality OR increased 1.09 per hr

19.  49k patients, multicenter study
 Higher risk-adjusted mortality
 > 3 hr to bundle completion (1.04 per
hour)
 longer time to antibiotics (1.04 per hour)
 Longer time to fluids was not associated
with increased risk of mortality (1.01)

20. Beyond Empiric Fluids - US
Learn from the experts

21. Cardiac Ultrasound
Quick estimation of EF – Good squeeze

22. Bad Squeeze

23. IVC Ultrasound

24. 3 cm
Spontaneously breathing patient - 40-50% collapse

26. IVC Collapse - Intubated
Neurocrit Care. 2010;13:3 (Intensive Care Med. 2004 Sep;30(9):1834-7)

27. 3. Antibiotics
TIMING IS EVERYTHING

28. Use a full loading dose of
early, broad-spectrum
antibiotics

29. Antibiotics
Antibiotics in the 1st hour (all sepsis)
Studies
49k - 1.04 per hour mortality (Seymour, et al)
35k - increased odds of death (1.09) (Liu et al)
Kumar study – 8% mortality increase/hr
Post-shock = OR 2.4 mortality (Puskarich et al)

30. 4. Source ID and Control

31. “Sepsis is a compulsive search
for a source of infection”
1. Treat the patient like a trauma – fully expose
2. The less the patient can tell you the more
compulsive the search

32. Source Severity should be
proportional to severity of
illness
 Don’t blame the UA!
 Source control ASAP
 Remove infected lines
 IR/Surgery

33. 5. Know your vasoactive meds
2016 Guidelines
 Norepinephrine 1st agent
 Vaso or Epi as 2nd agent
 Dopamine – increased risk of
mortality in septic shock and
cardiogenic shock

34.  Adult patients on norepinephrine of 0.2
mcg/kg/min
 Improved MAP ≥ 75 mm Hg (p< 0.001)
 Improved CV SOFA at 48 hours (p = 0.01)
 No difference in mortality
 FDA warning – increased thrombosis?

36.  Shock, mechanical ventilation, + pressors ≥ 4 hrs
 3800 patients (HC 200 mg/day vs placebo)
 No 90 day mortality difference (27.9% HC,
28.8%P)
 HC patients, shorter time to:
 Shock resolution (3 vs. 4 days, p < 0.001)
 ICU discharge (10 vs. 12 days, p < 0.001)
 Cessation of initial mechanical ventilation (6 vs. 7 days)

37. 6. Recognize “Talk and Die”
Sepsis Patients
 Asplenic Pneumonia
 NSTIs
 CdiffToxic Megacolon/Dead gut
 Meningococcal meningitis
 Post-flu MRSA Pneumonia

38. Watch out for POOP

39. 7. Understand lactate-guided
resuscitation
Strength: High lactate is associated with poor
outcomes.

40. Failure to normalize lactate
Repeat Lactate ≥ 5 has 90% specificity for early death

41. Lactate Limitations
 Lactate can come from many different sources
 Anaerobic metabolism
 Reduced clearance (liver/kidney)
 B1 adrenergic stimulation (Na+/K+ ATPase)
 Altered mitochondrial function or “cytopathic
hypoxia”
 Lactate can be normal in septic shock

42.  26% of High shock index patients became
hypotensive post induction
 Low shock index patients became
hypertensive
8. Optimize Hemodynamics prior
to Intubation

43.  Fluid load
 Push-dose vasopressors or norepinephrine drip
initiated prior to intubation
 Half dose induction meds for RSI, Max dose
paralytics
Intubation for Shock

44. Back to our Cases

45. Case 1 - Stepwise Assessment
60 yom with Fever, Back pain, + UA
 1. Critical Instability? No
 2. Bedside assessment?
 qSOFA negative
 3. Subtle organ dysfunction?
 Yes
 Cr of 1.5 mg/dL
 Platelet count of 130 x 103/mm3

46. Case 1 – 60 yom w/ UTI
 SOFA of 2
 Treated with sepsis bundle
 After his vital signs remained stable, the
patient was admitted to a monitored hospital
bed and was discharged to continue oral
antibiotics 2 days later.

47. Case 2 – Stepwise Assessment
70 yof with AMS and leg pain
 1. Critical Instability?
 Yes - Address hypotension with Fluid bolus
 2. Bedside assessment?
 qSOFA positive (hypotension + AMS)

48. Management
 Resus bay – Sepsis bundle, large bore IVs, 30
ml/kg fluid bolus
 Required norepinephrine (initiated at 10
mcg/min) to maintain a MAP > 65 mm Hg
 XRAY?

49. OR then SICU – discharged back to NH after 10
day hospital admission

50. The End!
 Thank you!
 Email with questions:
Faheem.Guirgis@jax.ufl.edu