Sepsis

1. SEPSIS
ACOMMON BUT MAJOR MORTALITYCAUSE IN CRITICALCARE
Dr Atta Ur Rehman

2. • DEFINITION
• OBJECTIVE
• SCREENING
• INFECTION CONTROL MEASURES
• MANAGEMENT
Initial Resuscitation
Area to admit
Fluid Management
BP Management
Hemodynamics monitoring
Infection Management and Control
Ventilation
Metabolic acidosis AKI
Blood glucose management
DVT / GI prophylaxis
GOALS OF CARE

3. DEFINITION
• Sepsis is life-threatening organ dysfunction caused by a
dysregulated host response to infection (1
).
• Septic shock is defined by persistent hypotension despite
fluid resuscitation requiring vasopressors to maintain
mean a arterial pressure of 65 mm Hg or higher.

4. Mortality
• Major healthcare issue, impacting millions of people
around the world each year and killing between one in
three and one in six of those it affects (2–4
).
• It affects people worldwide, particularly high burden in
low- and middle-income countries
• Estimates from 2017 suggest 48.9 million cases of
sepsis occur each year, with 11 million deaths.
• Many patients who survive sepsis suffer long-term
complications as a result.1

5. CONSEQUENCES OF SEPSIS

6. MULTI-ORGAN DYSFUNCTION

8. Objective
• The recommendations for the clinician caring for adult
patients with sepsis or septic shock in the hospital setting.
• Recommendations from these guidelines cannot replace
the clinician’s decision-making capability when presented
with a unique patient’s clinical variables.

9. Key factor
•Early identification and
•Appropriate Management
in the initial hours after the
development of sepsis improve
outcomes.

10. SCREENING OF SEPSIS
• Q SOFA
• SOFA
• SIRS
• NEWS

13. Interpretation
• 0 being considered normal
• 4 indicating a high degree of dysfunction.
• fewer than 9 points on the SOFA score are considered to
have a less than 33% risk of mortality.
• Patients with 9 to 11 points are considered to have a risk
of mortality between 40 and 50%.
• While for patients with more than 11 points, the risk of
mortality is considered to be greater than 95%.

14. NEWS

17. MANAGEMENT

18. INITIAL RESUSCITATION
•TIME ZERO ?

19. SEPSIS BUNDLE

21. Sepsis Bundle / Management
Time 0 Zero Definition
When patient land in E.r
When patient land in ICU
Assessment :
Qsofa
GCS<15
Tachypnea >22
Hypotension <100 SBP
Score : 0-1 Low risk
2-3 High risk
If score is 2 or more, then follow sepsis bundle
Immediate Measures: (After ABC)
Yes / No Doctor’s name Time
Immediately start I/v fluids (N/S or R/L)
Send serum Lactate level
Obtain blood culture(Aerobic & Anaerobic)
Administer broad spectrum ABx
(after taking Blood cultures)
1 Hour bundle Fluid management protocol (30cc/kg)
0 min to 10min  250cc N/S 0.9%
11min to 30min  500cc N/S 0.9%
31min to 60min  1000cc N/S 0.9%
After 1 Hour bundle if SBP <100, start vasopressor (Nor Epinephrine 0.01-3mcg/kg/min)
meanwhile follow 2 hour bundle.
2 Hour bundle 10ml/kg Every 30min till 2 hours
After 3 hours of fluid resuscitation, repeat serum lactate level and plan further/seek expert/consultant
advice

22. AREA TO ADMIT
• For adults with sepsis or septic shock who require ICU
admission, we suggest admitting the patients to the ICU
within 3-6 hr.

23. TEAM WORK IS MANDATORY

24. DIAGNOSIS

25. • There is no “gold standard” test to diagnose sepsis, the
bedside provider cannot have a differential diagnosis of
sepsis alone in a patient with organ dysfunction.
• Diagnose the cause of sepsis.

26. FLUID RESUSCITATION
• Sepsis and septic shock are medical emergencies, and
we recommend that treatment and resuscitation begin
immediately. (Best practice statement)
• For patients with sepsis induced hypoperfusion or septic
shock we suggest that at least 30 mL/ kg of IV crystalloid
fluid should be given within the first 3 hr of resuscitation.

27. CHOICE OF fLUIDS
• For adults with sepsis or septic shock, we recommend
using crystalloids as first-line fluid for resuscitation.
• For adults with sepsis or septic shock, we suggest using
balanced crystalloids instead of normal saline for
resuscitation.

28. • For adults with sepsis or septic shock, we suggest using
albumin in patients who received large volumes of
crystalloids.
• For adults with sepsis or septic shock, we recommend
against using starches and gelatins for resuscitation.

29. HOW TO CHECK FLUID RESPONSE

30. • MAP
• LACTATE
• URINE OUTPUT
• SCVO2
• IVC
• CVP
• LUNG ULTRASOUND… FALLS PROTOCOL
• PULSE PRESSURE VARIATION
• CAPILLARY REFILL TIME
• PCWP
• OTHER ADVANCE METHODS

31. BP MANAGEMENT
• MEAN ARTERIAL PRESSURE
• For adults with septic shock on vasopressors, we
recommend an initial target mean arterial pressure (MAP)
of 65 mm Hg over higher MAP targets.

32. Vasopressors
• For adults with septic shock, we recommend using
norepinephrine as the first-line agent over other
vasopressors.
• For adults with septic shock on norepinephrine with
inadequate mean arterial pressure levels, we suggest
adding vasopressin instead of escalating the dose of
norepinephrine.

33. • For adults with septic shock and inadequate mean arterial
pressure levels despite norepinephrine and vasopressin,
we suggest adding epinephrine.
• For adults with septic shock, we suggest against using
terlipressin.
• For adults with septic shock and cardiac dysfunction with
persistent hypoperfusion despite adequate volume status
and arterial blood pressure, we suggest either adding
dobutamine to norepinephrine or using epinephrine alone.

34. Strong for nor epinephrine
Dopamine. High-quality evidence
Vasopressin. Moderate-quality evidence
Epinephrine. Low quality of evidence

35. Corticosteroids
• For adults with septic shock and an ongoing requirement
for vasopressor therapy we suggest using IV
corticosteroids.
• Remarks:
• IV hydrocortisone at a dose of 200 mg/d given as 50
mg intravenously every 6 hours or as a continuous
infusion.
• It is suggested that this is commenced at a dose of
norepinephrine or epinephrine ≥ 0.25 mcg/kg/min at least
4 hours after initiation.

36. HEMODYNAMICS MONITORING

37. • For adults with septic shock, we suggest invasive
monitoring of arterial blood pressure over noninvasive
monitoring, as soon as practical and if resources are
available.
• For adults with septic shock, we suggest starting
vasopressors peripherally to restore mean arterial
pressure rather than delaying initiation until a central
venous access is secured.

38. Biomarkers to Start Antibiotics
• LACTATE
• TLC
• CRP
• PROCALCITONIN
• For adults with suspected sepsis or septic shock, we
suggest against using procalcitonin plus clinical
evaluation to decide when to start antimicrobials, as
compared to clinical evaluation alone.

39. INFECTION MANAGEMENT

40. Time to Antibiotics
• For adults with possible septic shock or a high likelihood
for sepsis, we recommend administering antimicrobials
immediately, ideally within one hour of recognition.
• Strong recommendation, low quality of evidence (septic
shock)
• Strong recommendation, very low quality of evidence
(sepsis without shock)

42. EMPIRICALAPPROACH..
• Gram positive
• Gram negative
• Fungal
• Anaerobes
• Miscellaneous coverage…

43. Antimicrobial Choice
• For adults with sepsis or septic shock at high risk of
methicillin-resistant Staphylococcus aureus (MRSA),
• we recommend using empiric antimicrobials with MRSA
coverage over using antimicrobials without MRSA
coverage.
Best practice statement.
• For adults with sepsis or septic shock at low risk of
MRSA, we suggest against using empiric antimicrobials
with MRSA coverage, as compared with using
antimicrobials without MRSA coverage.
Weak recommendation, low quality of evidence.

44. • For adults with sepsis or septic shock and high risk for
multidrug resistant (MDR) organisms, we suggest using
two antimicrobials with gram-negative coverage for
empiric treatment over one gram-negative agent.
• Weak recommendation, very low quality of evidence.

45. • For adults with sepsis or septic shock and low risk for
MDR organisms, we suggest against using two gram-
negative agents for empiric treatment, compared with one
gram-negative agent.
• Weak recommendation, very low quality of evidence.

46. • For adults with sepsis or septic shock, we suggest
against using double gram-negative coverage once the
causative pathogen and the susceptibilities are known.
• Weak recommendation, very low quality of evidence.

47. Antifungal Therapy
• For adults with sepsis or septic shock at high risk of fungal
infection, we suggest using empiric antifungal therapy
over no antifungal therapy.
• Weak recommendation, low quality of evidence.
• For adults with sepsis or septic shock at low risk of fungal
infection, we suggest against empiric use of antifungal
therapy.
• Weak recommendation, low quality of evidence.

48. Examples of Risk Factors for Fungal
Infection

49. Risk Factors for Candida Sepsis
• Candida Colonization at Multiple Sites
• Surrogate Markers Such as Serum Beta-D-Glucan Assay
• Neutropenia
• Immunosuppression
• Severity of Illness (High APACHE score)
• Longer ICU Length of Stay
• Central Venous Catheters and Other Intravascular Devices
• Persons Who Inject Drugs
• Total Parenteral Nutrition
• Broad Spectrum Antibiotics
• Gastrointestinal Tract Perforations and Anastomotic Leaks
• Emergency Gastrointestinal or Hepatobiliary Surgery
• Acute Renal Failure and Hemodialysis
• Severe Thermal Injury
• Prior Surgery

50. Risk Factors for Endemic Yeast (Cryptococcus,
Histoplasma, Blastomyces, Coccidioidomycosis)
• Antigen Markers Such as Cryptococcal, Histoplasma or
• Blastomyces assays
• HIV Infection
• Solid Organ Transplantation
• High Dose Corticosteroid Therapy
• Hematopoietic Stem Cell Transplantation
• Certain Biologic Response Modifiers
• Diabetes Mellitus

51. Source control of infectious foci
• For adults with sepsis or septic shock, we recommend
prompt removal of intravascular access devices that are a
possible source of sepsis or septic shock after other
vascular access has been established.
• Best practice statement.

52. De-escalation of Antibiotics
• For adults with sepsis or septic shock, we suggest daily
assessment for de-escalation of antimicrobials over using
fixed durations of therapy without daily reassessment for
de-escalation.
• Weak recommendation, very low quality of evidence.

53. Duration of Antibiotics
• For adults with an initial diagnosis of sepsis or septic
shock and adequate source control, we suggest using
shorter over longer duration of antimicrobial therapy.
• Weak recommendation, very low quality of evidence.

54. Biomarkers to Discontinue Antibiotics
• For adults with an initial diagnosis of sepsis or septic
shock and adequate source control where optimal
duration of therapy is unclear, we suggest using
• Procalcitonin and clinical evaluation
• to decide when to discontinue antimicrobials over clinical
evaluation alone.
• Weak recommendation, low quality of evidence.

56. INFECTON CONTROL MEASURES
• HAND HYGIENE
• VAP BUNDLE
• CLABSI BUNDLE
• PROCEDURE PROTOCOL
• STANDARD MEASURES
• RESPIRATORY CAUTION
• ID MONITORS
• ID CONSULTANT

57. VENTILATION
• Oxygen Targets
• NIV
• HFNC
• For adults with sepsis-induced hypoxemic respiratory
failure, we suggest the use of high flow nasal oxygen
over noninvasive ventilation.
• MECHANICAL VENTILATOR

58. ADDITIONAL THERAPIES
• BLOOD TRANSFUSION
• IMMUNOGLOBULINS
• STRESS ULCER PROPHYLAXIS
• DVT PROPHYLAXIS
• RRT / HDX
• GLUCOSE CONTROL
• BIACRB THERAPY
• NUTRITION THERAPY

59. GOALS OF CARE

60. • Recommendations
• For adults with sepsis or septic shock, we recommend
discussing goals of care and prognosis with patients and
families over no such discussion.
• Best practice statement.
• For adults with sepsis or septic shock, we suggest
addressing goals of care early (within 72 hours) over late
(72 hours or later).
• Weak recommendation, low-quality evidence.

61. Goals of Care
• Palliative Care
• Peer Support Groups
• Transitions of Care
• Screening for Economic or Social Support
• Sepsis Education for Patients and Families
• Shared Decision Making
• Cognitive Therapy
• Post-Discharge Follow-Up

62. TIMEISKEYINMANAGINGSEPSIS
TIMEZEROISSTARTOFACCELARATORYEFFORTTOSALVAGEPATIENTSLIFE
THANKS

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