3. Sepsis
• Life -threatening
• Organ dysfunction
• Due to dysregulated host response
• To infection.
The third International Consensus 2016 Definition for Sepsis ( Sepsis 3)
4. What differentiates sepsis from infection?
• Dysregulated host response
and
• The presence of organ dysfunction.
5. Sepsis is not merely an infection
• The culprit here is over reaction of our defense mechanism- not the
invader alone
6. • The body normally
releases chemicals
(inflammatory
mediators) into
the bloodstream
to fight an
infection.
• Sepsis occurs
when the body's
response to these
chemicals is out of
balance, triggering
changes that can
damage multiple
organ systems.
7. Epidemiology
• >1.5 million people get sepsis and > 270,000 people die of sepsis
• (Each year in US, that is one person in every 2 minutes.)
• 3rd leading cause of death in the US after heart disease and cancer.
• Respiratory tract and abdominal infections are the most
frequent causes of sepsis, followed by urinary tract and soft tissue
infections.
• Intra-abdominal sepsis is the most common surgical sepsis.
8. Risk factors
• Anyone can get an infection, and almost any infection can lead to
sepsis= everyone is at risk
• People with increased risk
• Adults 65 or older
• People with chronic medical conditions, such as diabetes, lung disease,
cancer, and kidney disease.
• People with weakened immune systems.
• Following major surgery, trauma, or burns.
• The most frequently identified pathogens causing sepsis include
Staph aureus, E. coli, and some types of Streptococcus.
9. When to Screen for Sepsis?
• People with identified source of infection or suspected source of
infection
With
• qSOFA score ≥2.
12. Organ dysfunction
• Assessed with SOFA score.
• A higher SOFA score = an increased probability of mortality.
• SOFA score grades abnormality by organ system and accounts for clinical
interventions.
• Laboratory variables, namely, PaO2, platelet count, creatinine level, and
bilirubin level, are needed for full computation.
• It can be identified as an acute change in total SOFA score 2 points
consequent to the infection.
• The baseline SOFA score should be assumed to be zero unless the patient is
known to have preexisting (acute or chronic) organ dysfunction.
14. Principles of sepsis and septic shock
management
Medical emergencies, and
treatment and
resuscitation should start
immediately.
Includes
Source control
Antibiotics
Resuscitation with iv fluids
Vasopressors
Nutrition and other
supportive measures
16. • It is central to the
implementation of SSC
guideline.
• Goal to begin
resuscitation and
management with
treatment immediately at
the bed side.
• Ideally these
interventions would all
begin in the first hour
from sepsis recognition
but may not necessarily
be completed in the first
hour.
17.
18.
19. Source control
• Infection requiring emergent source control be identified or excluded
as rapidly as possible.
• Any required source control intervention be implemented as soon as
medically and logistically practical. eg
• Radical debridement of necrotizing soft tissue infections
• Incision and drainage of abscess.
20. Antibiotics
• IV antimicrobials be initiated as soon as possible (within 1 h ).
• Empiric combination therapy aimed at the most likely
bacterial pathogen(s) should be used.
• (at least 2 antibiotics of different antimicrobial classes)
• (Weak recommendation; low quality of evidence)
21. Antimicrobial Therapy
Antibiotic Stewardship
• Empiric antimicrobial therapy be narrowed once pathogen
identification and sensitivities are established and/or adequate
clinical improvement is noted.
• Treatment duration of 7-10 days is adequate for most serious
infections .
• Daily assessment should be done for de-escalation of antimicrobial
therapy .
• Procalcitonin levels can be used to support shortening the duration of
antimicrobial therapy.
22. Iv fluid
• Crystalloid is the fluid of choice (initial
resuscitation and subsequent volume
replacement ).
• At least 30 ml/kg of IV crystalloid to be given
within first 3 hours for resuscitation of sepsis
induced hypoperfusion.
• (strong recommendation, low quality of
evidence).
This Photo by Unknown author is licensed under CC BY-SA.
23. Iv fluid
• Additional fluids following initial resuscitation should
be guided by frequent reassessment of
hemodynamic status.
• Remarks: Reassessment should include a
thorough clinical examination and evaluation of
available physiologic variables ( HR,BP, urine
output, and other noninvasive or
invasive monitoring, as available.
• Albumin is used in addition to crystalloids when
patients require substantial amounts of crystalloids.
This Photo by Unknown author is licensed under CC BY-SA.
24. Vasopressor
• Norepinephrine as the first choice vasopressor.
• Vasopressin (up to 0.03 U/min) or epinephrine is added to
norepinephrine with the intent of raising MAP to target
• Vasopressin can be added (up to 0.03 U/min) to decrease
norepinephrine dosage.
• An initial target MAP of 65 mmHg in patients with septic shock
requiring vasopressors.
25. If shock is not resolving quickly....
• Further hemodynamic assessment (such as assessing cardiac
function) should be done to determine the type of shock .
• Dynamic over static variables should be used to predict fluid
responsiveness, where available.
26. Lactate can help guide resuscitation
• Resuscitate till the elevated lactate level(as a marker of tissue
hypoperfusion) normalize.
27. Diagnosis
• Appropriate routine microbiologic cultures (including blood) be
obtained before starting antimicrobial therapy
• (if doing so results in no substantial delay in the start of antimicrobials.) (BPS)
• Remarks: Appropriate routine microbiologic cultures always include at least
two sets of blood cultures (aerobic and anaerobic).
28. Corticosteroids
• Iv hydrocortisone is not suggested to treat septic shock patients if
adequate fluid resuscitation and vasopressor therapy are able to
restore hemodynamic stability.
• If this is not achievable, IV hydrocortisone at a dose of 200 mg per
day.
• (Weak recommendation; low quality of evidence)
29. Mechanical ventilation
• Higher PEEP is recommended in adult patients with sepsis-induced
moderate to severe ARDS.
• Weak recommendation; moderate quality of evidence
• Lower tidal volumes is recommended in adult patients with sepsis-
induced respiratory failure without ARDS.
• (Weak recommendation; low quality of evidence)
• Prone position is recommended in adult patients with sepsis-induced
ARDS and a PaO2/FIO2 ratio <150.
• (Strong recommendation; moderate quality of evidence)
30. Glucose control
• Protocolized approach to blood glucose management is
recommended in ICU patients with sepsis.
• Start insulin dosing when 2 consecutive blood glucose levels are >180
mg/dL.
• Target blood glucose level ≤180 mg/dL
• (Strong recommendation; high quality of evidence)
• Blood glucose values should be monitored every 1 to 2 hrs until
glucose values and insulin infusion rates are stable, then 4hrly.
31. Renal replacement therapy
• Not recommended in patients with sepsis and acute kidney injury for
increase in creatinine or oliguria without other definitive indications
for dialysis.
• (Weak recommendation; low quality of evidence)
32. Nutrition
• Early initiation of enteral feeding is recommended in patients with
sepsis or septic shock who can be fed enterally.
• (Weak recommendation; low quality of evidence)
• Prokinetic agents are recommended in critically ill patients with
feeding intolerance.
• (Weak recommendation; low quality of evidence)
33. Setting goal of care
• Goals of care and prognosis be discussed with patients and
families. (BPS)
• Goals of care should be incorporated into treatment and end-of-life
care planning, utilizing palliative care principles where appropriate.
• (Strong recommendation; moderate quality of evidence)
• Goals of care should be addressed as early as feasible, but no later
than within 72 hours of ICU admission.
• (Weak recommendation; low quality of evidence)
34. Blood transfusion
• If hemoglobin levels fall below 7 g/dL,
• Red blood cell transfusion is recommended to a target hemoglobin range
of 7-9 g/dL.
• Even in the absence of apparent bleeding platelet is transfused if platelet
counts fall below 10,000/µL
• DIC should first be ruled out with fibrinogen split products and peripheral
smears.
• Platelet transfusion may also be considered when bleeding risk is increased
and platelet counts are below 20,000/µl.
• Patients who are to undergo surgery or other invasive procedures may
require higher platelet counts (eg, ≥50,000/µL]).
35. Complications of sepsis
• Once sepsis sets in, if left untreated, it can progress to septic shock
and death.
• Worldwide, one-third of people who develop sepsis die.
• Many who do survive are left with life-changing effects, such as post-
traumatic stress disorder (PTSD), chronic pain and fatigue, organ
dysfunction and/or amputations.
36. Take home message
• Sepsis is the life-threatening organ dysfunction caused by
dysregulated host response to infection.
• Management of sepsis is a complicated clinical challenge requiring
• Early recognition
• Immediate resuscitation with source control, intravenous fluids and
antibiotics.
• Frequent assessment of the patients’ volume status is crucial
throughout the resuscitation period.
37. Cont..
• Appropriate routine microbiologic cultures (including blood) be
obtained before starting antimicrobial therapy.
• Septic shock is a subset of sepsis that results in tissue hypoperfusion,
with
• Vasopressor-requiring hypotension and
• Elevated lactate levels.
• Sepsis kills and disables millions and requires early suspicion and
treatment for survival.
38. Mcq’s
• Which of the following is accurate regarding the treatment of sepsis?
1. Even in the absence of apparent bleeding, patients with sepsis
should receive platelet transfusion if platelet counts < 10,000/µL
2. Routine insertion of a central venous catheter is associated with
improved outcomes and is recommended in all patients with sepsis.
3. Central venous pressure (CVP) should be used to target
resuscitation in patients receiving crystalloid solution.
4. Transfusion is required in patients with sepsis who have
hemoglobin levels of 7-10 g/dL.
39. Mcq’s
• Which of the following is accurate regarding imaging studies used in
patients with sepsis or suspected sepsis?
1. Chest radiography is only indicated in patients with sepsis who have
shown signs of overt respiratory distress.
2. If clinical suspicion of necrotizing fasciitis is high, a surgical consultation
should be obtained immediately, often without imaging.
3. In adult patients with suspected intra-abdominal infection, abdominal
radiography is preferable to CT scanning of the abdomen.
4. MRI or ultrasonography are the imaging modalities of choice for
excluding a retroperitoneal source of infection, especially in obese
patients.
40. Mcq’s
• Which of the following is accurate about the etiology and epidemiology of
sepsis?
1. In the most common form of MODS, the hematologic, cardiovascular, or
renal systems are involved, as opposed to the lungs
2. In most patients with sepsis, the source of infection is rarely identified
3. Soft tissue and urinary tract infections are the most common causes of
sepsis
4. Risk factors for sepsis and septic shock include extremes of age (<10
years, >70 years) and underlying genetic susceptibility
41. References
• Available at:
http://www.survivingsepsis.org/guidelines/Pages/default.aspx. Accessed
June 24, 2016.
• emedicine.com. Accessed February 26, 2019].
• Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign:
International Guidelines for Management of Sepsis and Septic Shock: 2016.
Intensive Care Med. 2017;
• Singer M, Deutschman CS, Seymour CW, et al. The Third International
Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA.
2016;315(8):801-10.
• Howell MD, Davis AM. Management of Sepsis and Septic Shock. JAMA.
2017;
Editor's Notes
The SOFA score involves six organ systems (respiratory, cardiovascular, renal, hepatic, central nervous, coagulation), and the function of each is scored from 0 (normal function) to 4 (most abnormal), giving a possible score of 0 to 24.
