Interactive case on septic shock with discussion on surviving sepsis guidelines Perforation peritonitis

1. Septic shock – Interactive Case
with recommendations
Dr.Vitrag Shah
MD Medicine, FNB Critical Care Medicine, EDIC
Consultant Physician and Chief Intensivist
Kiran Hospital, Surat

2. Clinical Decision Making
In rapidly developing clinical sciences
Concepts change
Procedures change
Technological evolution occurs
Up-to-date knowledge will benefit patients

3. Point to be discussed
1. Sepsis 1 to Sepsis 3 – Definition
2. Sepsis bundles
3. Interactive case
4. SSC 2016 recommendations on
 Antibiotic, PCT
 Fluid
 Vasopressor
 Nutrition
 Others
5. Marik Protocol

5. SEPSIS - 1
1.Temperature >38°C or <36°C;
2.Heart rate >90 beats per minute;
3.Respiratory rate >20 breaths per minute or PaCO2 <32 mmHg;
and
4.White blood cell count >12,000/cu mm, <4,000/cu mm, or >10%
immature (band) forms.
SIRS
Sepsis
Severe sepsis
Septic shock
Two or more of the SIRS criteria plus infection
sepsis associated with organ dysfunction,
hypoperfusion, or hypotension
sepsis-induced hypotension despite adequate fluid resuscitation
along with the presence of perfusion abnormalities causing organ
dysfunction that may include lactic acidosis, oliguria, or an acute
alteration in mental status

6. SEPSIS -2

7. Concerns with the previous sepsis definition…
The Problem with SIRS
Inflammation and related pathways take center stage
Adapted from: Bone RC et al. Chest. 1992;101:1644-55.
Opal SM et al. Crit Care Med. 2000;28:S81-2.

8. SEPSIS -3

9. SEPSIS -3
life-threatening
organ dysfunction caused
by
dysregulated host response
to infection
Sepsis
Severe sepsis
Septic
shock
Suspected or
documented
infection and an
acute increase of
≥2 SOFA points
Subset of sepsis in which
underlying circulatory and
cellular/metabolic
abnormalities are profound
enough to substantially
increase mortality
Despite adequate fluid
resuscitation
vasopressor therapy
needed to elevate MAP
≥65 mmHg and
lactate >2 mmol L−1

10. 1.Altered mental status (GCS
score <15)
2.Systolic blood pressure
<100 mmHg
3.Respiratory rate >22/min
qSOFA
If 2/3 of these 3 criteria are positive, the qSOFA
would be positive!

13. MANAGEMENT OF
SEPSIS

14. CASE HISTORY
• 64 year old female
• H/O Ca tongue (Operated in 2018), completed
Chemotherapy & Radiotherapy (Last RT 1
month back)
• C/O constipation
• C/O Abdominal distension & pain since
yesterday
• C/O fever, low grade & breahing difficulty and
decreased urine output since today morning
• Presented to Our Hospital ER at 2:15PM

15. Physical Examination - 2:15 PM
• GCS 15/15
• T - 98.6 F
• HR - 100/min
• RR - 22/min
• RR - 90/60 mmhg
• SPO2 - 99% on room Air
• P/A - Soft, Distended, Tenderness - Diffuse
• RS, CVS, CNS - Clinically NAD

16. Diagnosis?

17. SSC BUNDLES
(SSC GUIDELINES-2012)

18. REVISED SEPSIS BUNDLES
(SSC 2015 UPDATE)

19. REVISED SEPSIS BUNDLES
(SSC 2015 UPDATE)

20. Surviving Sepsis Campaign : 1 HOUR
BUNDLE (2018)
• Measure lactate level*
• Obtain blood cultures before administering antibiotics.
• Administer broad-spectrum antibiotics.
• Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥
4 ​mmol/L.
• Apply vasopressors if hypotensive during or after fluid resuscitation to maintain
MAP ≥ 65 mm Hg.
• * Remeasure lactate if initial lactate is elevated (> 2 mmol/L).

21. Primary Investigations (2-3PM)
• Chest X-Ray - Gas under diaphragm
• PreopMajor, ABG & one set paired aerobic Blood C/S sent
• RBS - 77mg%
• ABG
– pH 7.16
– PO2 113 on room air
– PCO2 13.5
– HCO3 4.7
– Lactate 18
– Na/K/Cl 134/3.8/107
– Hb/HCT 12.8/39.5

22. Antibiotic
Primary Treatment BY 3:30PM
• Inj.CEFOSULBACTAM 3GM IV STAT
• INJ.METRONIDAZOLE 500MG IV STAT
• INJ 25% D/W IV STAT
• INJ NS 1 LITER OVER ONE HOUR
• Foley's Catheterization
Fluid

23. INITIAL RESUSCITATION

25. PHYSICAL EXAMINATION - 4PM
• GCS 15/15
• HR 120/MIN
• RR 26/MIN
• BP 90/50MMHG ( MAP = 63mmhg)

26. Hemodynamic
assessment
2D ECHO & LUNG USG
• 2D ECHO SCREEN
– EF : GOOD, RA,RV - NORMAL, IVC - 0.9CM
>50% COLLAPSING
• LUNG USG
– NO B-LINES, SLIDING PRESENT

28. EGDT
Reduced the absolute risk of
in-hospital mortality by 16 %
We recommend the protocolized, quantitative
resuscitation of patients with sepsis- induced
tissue hypoperfusion
During the first 6 hrs , the goals of initial
resuscitation
a) CVP 8–12 mm Hg
b) MAP ≥ 65 mm Hg
c) Urine output ≥ 0.5 ml/kg/hr
d) Superior vena cava oxygenation saturation
(Scvo2) or mixed venous oxygen saturation
(SvO2) 70% or 65%, respectively

29. EGDT DRAWBACKS
An arbitrary CVP as surrogate of fluid status
MAP and urine output as surrogate for
organ perfusion
As marker for O2
utilization
Blood transfusions and ionotropes based on Sc

30. Decision to give fluid should be based on :
• Presence of acute circulatory failure
• Presence of preload responsiveness
• Minimal risk of administering fluid

31. Functional Hemodynamic Monitoring
Assessing preload responsiveness
• Variations in arterial pulse pressure, systolic pressure
• Passive leg raising
• End Expiratory Occlusion Test (EEOT)
• Aortic flow variation (TED)
• Echocardiography – IVC and SVC diameter changes
• Mini Fluid Challenge
• End-tidal carbon dioxide
• Non invasive methods - pulse oximeter pleth signal variability
Assess Fluid Tolerance
• Echocardiography – EF, Diastolic function
• Lung Ultrasound - B-Lines

33. 1 Fluid challenge not required if CVP is high
2 Fluid challenge not done in pulmonary edema
• Hypovolemia due to extravasation into lungs
• If shock, fluid challenge will improve blood pressure
3 No fluid challenge since patient has already received 1
litre of fluid in last 1 hour
4 Must continue fluid challenge since CVP is low
Misconceptions in Fluid Challenge

35. RELATIVE EFFECTS OF COMMON VASOACTIVE
MEDICATIONS ON ADRENERGIC RECEPTORS
AGENT (typical dosages) ß-1 ß-2 α-1
Isoproterenol (2-10 ug/min) +++++ +++++ 0
NE (0.01-3 ug/kg/min) +++ ++ +++++
Epinephrine
(Infusion: 0.01 to 0.10 ug/kg/min)
++++ +++ +++++
Phenylephrine
(Infusion: 0.4 to 9.1 ug/kg/min)
0 0 +++++
Dopamine
(2.0 to 20 ug /kg/min, max 50 ug/kg/min )
++++ ++ +++
Dobutamine
(2.0 to 20 ug /kg/min, max 40 ug/kg/min )
+++++ +++ +
- Overgaard CB. Circulation 2008

37. Antibiotics
• We suggest empiric combination therapy
(using at least two antibiotics of different
antimicrobial classes) aimed at the most
likely bacterial pathogen(s) & having good
concentration at suspected site of
infection for the initial management of
septic shock.
– (Weak recommendation; low quality of
evidence)

38. Antibiotics
• We suggest that combination therapy not be
routinely used for on-going treatment of
most other serious infections, including
bacteremia and sepsis without shock.
– (Weak recommendation; low quality of
evidence).
• We recommend against combination therapy
for the routine treatment of neutropenic
sepsis/bacteremia.
– (Strong recommendation; moderate
quality of evidence).

39. Know your local organisms & sensitivity.
Because that determines your antibiotic.

40. Further Treatment (4-5PM)
• RL 500CC + 500CC BOLUS OVER 1 HOUR
• Inj HYDROCORTISONE 200MG IV STAT
• INJ ASCORBIC ACID 1GM IV STAT
• INJ MEROPENAM 2GM IV STAT
(CEFOSULBACTAM STOPPED)
• NORADRENALINE INFUSION
• CENTRAL & ARTERIAL LINE INSERTION

41. A target of no more than 6 to 12 hours after
diagnosis appears to be sufficient for most
cases

42. FURTHER TREATMENT (6PM)
• After primary resuscitation, patient shifted to
OT by 6:15pm
• Sigmoid diverticular perforation and peritonitis
- Exploratory Laprotomy & Hartman Procedure
done, Pus C/S sent intraop.
• Patient shifted to ICU with Nasotracheal &
Nasogastric tube and drains in situ at 9:00 PM

44. Further course in ICU (POD 0-3)
• PATIENT SEDATED
• HR 100/MIN, BP 100/70 WITH NORAD ( 8MG/50ML)
@ 5ML/HR
• ON CONTROLLED MODE OF VENTILATOR
• 2.5 LITRE I/P & 700ML URINE OUTPUT ON ARRIVAL
• 40-50ML/HR URINE AFTER ICU ADMISSION
• Weaning from ventilator started from POD1,
vasopressors tappered
• Decreased urine output on POD1 – 5% Albumin
100ml given in addition to manitainance IV fluid

46. POD-2 to POD-3
• On T-piece for 24 hours on POD2, passing good
urine, vasopressors tappered and stopped.
• Extubated on POD 3
• Pus C/S - E.Coli - Sensitive to BL-BLI,
Quinolones, Aminoglycosides, Carbapenams,
Tigecycline, Fosfomycin, TMP-SMZ,
Chloramphenicol
• Blood C/S - Negative

47. Antimicrobial Therapy
Antibiotic Stewardship
 We recommend that empiric antimicrobial therapy be
narrowed once pathogen identification and sensitivities are
established and/or adequate clinical improvement is noted.
 (BPS)
 We suggest that an antimicrobial treatment duration of 7-10
days is adequate for most serious infections associated with
sepsis and septic shock.
 (Weak recommendation; low quality of evidence)
 We recommend daily assessment for de-escalation of
antimicrobial therapy in patients with sepsis and septic
shock.
 (BPS)
 We recommend that dosing strategies of antimicrobials be
optimized based on accepted pk/pd principles and specific
drug properties in patients with sepsis or septic shock
 (BPS)

48. Role of Procalcitonin

49. POD4 onwards
• Vital stable
• Mobilized
• Maintainance IV fluid as per electrolyte & daily
intake output.
• Shifted to ward
• Meropenam continued for total 8 days
• Stoma started functioning & orally liquid diet
started from POD4.
• Soft diet started from POD5.
• Patient discharged from ward on POD9.

50. Nutrition

54.  www.survivingsepsis.org
 Malbrain, M.L.N.G., Regenmortel, N., Saugel, B. et al. Principles of fluid management and stewardship in
septic shock: it is time to consider the four D’s and the four phases of fluid therapy. Ann. Intensive
Care 8, 66 (2018)
 LIFTL : https://lifeinthefastlane.com/
 UpToDate : www.uptodate.com

55. Questions…….?

56. THANK
YOU