23. Sepsis 6h Bundle

Question 1

Define SIRS

Answer 1

Temp <36C or >38C

HR > 90

RR >20

WCC <4>3 x 10^9 cell/L

Question 2

old Sepsis defn

Old Severe sepsis defn

Septic Shock

Answer 2

SIRS + Systemic manifestation infection

Sepsis + end organ dysfunction

Sepsis induced hypotension despite fluid resus

Question 3

New Sepsis defn

sepsis 3

Answer 3

life-threatening organ dysfunction caused by a dysregulated host response to infection

Question 4

Septic shock new defn sepsis 3

Answer 4

sepsis that has circulatory, cellular, and metabolic abnormalities that are associated with a greater risk of mortality than sepsis alone

these abnormalities can be clinically identified as all of the following:

• Patients who fulfill the criteria for sepsis (above)
• Patients who, despite adequate fluid resuscitation, require vasopressors to maintain a mean arterial pressure (MAP) ≥65 mmHg
• Patients who have a lactate >2 mmol/L (>18 mg/dL).

Question 5

MODS

Answer 5

Multiple organ dysfunction syndrome (MODS) refers to progressive organ dysfunction in an acutely ill patient, such that homeostasis cannot be maintained without intervention. It is at the severe end of the severity of illness spectrum of both infectious (sepsis, septic shock) and noninfectious conditions (eg, SIRS from pancreatitis). MODS can be classified as primary or secondary:

Question 6

SIRS

Answer 6

The use of systemic inflammatory response syndrome (SIRS) criteria to identify those with sepsis has fallen out of favor since it is considered by many experts that SIRS criteria are present in many hospitalized patients who do not develop infection, and their ability to predict death is poor when compared with other scores such as the SOFA score

Question 7

Sepsis Management

Initial priorities

Investigations

Answer 7

For patients with sepsis and septic shock,
therapeutic priorities
include securing the airway,
correcting hypoxemia,
and establishing appropriate vascular access
for the early
administration of fluids and antibiotics.

Simultaneously obtaining the following is preferable (within 45 minutes) but should not delay the administration of fluids and antibiotics

Routine laboratory studies

• Serum lactate
• Arterial blood gases
• Blood cultures (aerobic and anaerobic) from two distinct venipuncture sites and from all indwelling vascular access devices; it is preferable that blood cultures be drawn before the initiation of antibiotics
• Cultures from easily accessible sites (eg, sputum, urine)
• Imaging of suspected sources

Question 8

Sepsis Management

Resus

Answer 8

For patients with sepsis and septic shock, we suggest the infusion of intravenous fluids (30 mL/kg), commencing within the first hour and completed within the first three hours of presentation,

rather than vasopressors, inotropes, or red blood cell transfusions#

Fluid boluses are the preferred method of administration and should be repeated until blood pressure and tissue perfusion are acceptable, pulmonary edema ensues, or there is no further response

Balanced crystalloid
Hyperoncotic starch should not be administered

Question 9

Micro & ABx

Answer 9

Blood bcx

PCR assay

For patients with sepsis, we recommend that optimal doses of empiric broad spectrum intravenous therapy with one or more antimicrobials be administered in a prompt fashion (eg, within one hour) of presentation (Grade 1B). Broad spectrum is defined as therapeutic agent(s) with sufficient activity to cover a broad range of gram-negative and positive organisms, and, if suspected, against fungi and viruses.

Drain collections surgically / rad asap

Removed possibly infected vascular access devices

Reassess daily
rationalise as results become available in conjunction with Microbiology

For patients with septic shock associated with likely gram-negative sepsis, we suggest consideration of the use of two antibiotics from different classes to ensure effective treatment of resistant organisms.

Agent selection depends upon patient’s history, comorbidities, immune defects, clinical context, suspected site of infection, presence of invasive devices, Gram stain data, and local prevalence and resistance patterns. The routine administration of antifungal therapy is not warranted in nonneutropenic patients.

Question 10

Monitoring

Answer 10

For most patients with sepsis and septic shock, we recommend that fluid management be guided using clinical targets including mean arterial pressure 60 to 70 mmHg (calculator 1) and urine output ≥0.5 mL/kg/hour

HD dynamic measures ppv
cvp / cv sat easily availab

Follow serum lactate

Source control

Question 11

Patients who fail initial therapy

Answer 11

– For patients with sepsis who remain hypotensive despite adequate fluid resuscitation
(eg, 3L in first three hours),
we recommend vasopressors (Grade 1B);

the preferred initial agent is norepinephrine

For patients who are refractory to intravenous fluid and vasopressor therapy, additional therapies, such as glucocorticoids, inotropic therapy, and blood transfusions, can be administered on an individual basis. We typically reserve red blood cell transfusion for patients with a hemoglobin level <7 g/dL.

inotropes for septic cardiomyopathy pre existing failure / low output states

Question 12

Patients who respond to therapy

Answer 12

For patients with sepsis who have demonstrated a response to therapy, we suggest that the rate of fluid administration should be reduced or stopped, vasopressor support weaned, and, if necessary, diuretics administered.

We also recommend that antimicrobial therapy be narrowed once pathogen identification and susceptibility data return.

Antimicrobial therapy should be pathogen and susceptibility directed for a total duration of 7 to 10 days, although shorter or longer courses are appropriate for select patients.