Sepsis and Septic Shock Flashcards
Sepsis-3 Consensus defines sepsis as life threatening __ caused by dysregulated host response to __
Organ dysfunction
Infection
Classification of Sepsis
Sepsis-1 Consensus
1. SIRS
2. Sepsis
3. Severe sepsis
4. Septic shock
5. MODS
Single organ failure - 50-80% mortality
Multiorgan (3 or more) failure - > 90% mortality
SOFA score (sequential organ failure)
- Criteria
- Disadvantages
SOFA
1. PaO2
2. Thrombocytopenia
3. Hyperbilirubinaemia
4. Hypotension and inotrope use
5. GCS
6. Creatinine
Not yet endorsed by all Critical Care organisations and societies
Disadvantages
1. Miss out other cohorts of patients (paeds, elderly) with other signs and symptoms of sepsis
2. Eliminates useful validated clinical tools
qSOFA score proposed by Sepsis-3 modifies and simplifies identification of sepsis with 3 criteria (HAT)
qSOFA
1. Hypotension - SBP ≤ 100
2. Altered mental status - GCS < 15
3. Tachypnoea - RR ≥ 22
Pathogenesis of sepsis and septic shock
A. Alterations of host-pathogen-environment
1. Change in flora and microbiome
2. Change in host factors - age, comorbids, medications
B. Acute inflammatory response
- Large scale activation of leukocyte storm (hyperinflammatory response) and immunosuppression
C. End organ damage
- Dysfunction of epithelial, endothelial, mitochondrium
What organisms are commonly associated with sepsis
A. Gram positive (65%)
- CONS (36%)
- SA (17%)
- Enterococci (10%)
B. Gram negative (25%)
- E. coli, Klebsiella, pseudomonas
- Enterobacter, Serratia, acinetobacter
C. Fungi (9%)
- Candida albicans (54%), glabrata (19%), parapsilosis (11%), topicalis (11%)
What are the commonest organisms of ICU nosocomial acquired infection?
- CONS
- Pseudomonas
- Enterobacter
- Serratia
- Acinetobacter
- MRSA
What are the common primary sources of infection?
- Pneumonia
- Intra-abdominal
- Urinary tract
- Skin and soft tissue
- Haematologic
Pulmonary artery catheter was a classical tool for sepsis (no longer essential)
- Distinguish cardiogenic from non-cardiogenic pulmonary oedema
- Determines shock status (cardiogenic, distributive, hypovolaemia)
- Guide for therapeutic intervention
- Titration of medications in pulmonary hypertension
Surviving Sepsis Campaign Guidelines
- Initial resuscitation
- Cultures and broad spectrum antibiotics
- Haemodynamic support
- Adjunctive therapy within first 24 hours
SSC Guideline on Initial Resuscitation
Studies and Trials
1. Early Goal Directed Therapy (EDGT) - protocolized care
2. ARISE, ProCESS, ProMISE - usual care (non-protocolized care) is equivalent to protocol
Content
1. Resuscitation within 3 hours of identification - IV crystalloids 30mL/kg
(Bolus prior to fluid challenge)
2. Mode of IV access is NOT important (central vz peripheral)
3. Individualised resuscitation goals (non-volume specific dogma)
4. Lactate clearance target recommended - reduction 10%
4A. CVP and oxygen saturations important but not emphasized
5. Target MAP > 65
Fluid Guidance
1. Dynamic: PLR, fluid challenge and FACET protocol
2. Static: SVV and CVP
3. S&S: urine output, CRT
4. Serum lactate reduction 10%
5. Echocardiogram
SSC Guideline on Cultures and Broad Spectrum antibiotics
- Cultures drawn prior to starting antibiotics but NOT delayed for antibiotic initiation
- IV antibiotics within 1 hour (at most 3 hours)
- Adequate dosing, including narrow therapeutic antibiotics
- Broad empiric therapy against all likely pathogens
- MRSA coverage if at risk
- 2 antimicrobial with gram neg coverage if at risk of MDR
- Antifungal if high risk of fungal infection
- Extended infusion duration (after initial bolus) - Emergent source control with LEAST invasive option that PROVIDES adequate source control
- Percutaneous drainage vs open surgery)
- Removal of infected lines
Every hour delay in antibiotics increases risk of death in patients with septic shock
SSC Guidelines on Haemodynamic Support
- Balanced crystalloids as fluid of choice
- HM/RL/Plasmalyte preferred
- NS avoided due to risk of hyperchloraemic acidosis and acute kidney injury
- Starch or gelatin AVOIDED at all cost - Conflicting data on albumin
- Previous old study - IV albumin use may be associated with increased mortality (biased)
- ALBIOS trial: septic shock given IV albumin 20% with aim sAlb > 30 has benefit of reduced mortality
- SAFE trial: albumin reduced mortality compared to crystalloids
- RL vs Albumin in sepsis (RASP): no difference in mortality - Inotropes (peripheral acceptable while awaiting for central line)
- Noradrenaline as vasopressor of choice
- Vasopressin added to limit NA usage when > 0.25-0.5mcg/kg/min
(VASST study showed no survival benefit on limiting NA usage)
- Subsequently: adrenaline for chronotropy
- Cardiac output: dobutamine
(However no benefit in raising CO to supranormal levels)
SSC Guidelines on Adjunctive Therapy
- Bicarbonate infusion
- No data supports such intervention, but remained commonly practised to improve haemodynamics
- Give if pH < 7.15 - Restrictive blood products transfusion
- Aim Hb > 7 or > 8 with IHD - Relaxed glycaemic control
- Aim BGM < 10 (no need for tight 4-6)
- Glocal or focal cerebral injury might benefit from close glucose monitoring
(but no available recommendations) - Mechanical ventilation in ALI or ARDS
- Consider HFNC, CPAP, BiPAP as intubation refrain strategy
- Once intubated, for lung protective strategy
- VV ECMO in critical cases - Corticosteroid use in septic shock
- Limit maximum 400mg/day
- CAPECOD: beneficial in CAP
- Rygard 2018: faster resolution of shock, increases pressor free days
- Serum cortisol testing is NOT recommended
- SE: NM weakness, mortality and morbidity benefits unclear - DVT and stress ulcer prophylaxis
- PPI if >48 hours intubated / coagulopathy present - Setting limitations of support
- Explore extent of care, resuscitation status, wishes and beliefs
Antibiotics coverage for undifferentiated sepsis (without clear defined source)
To cover:
- Resistant gram positive including MRSA
- Resistant gram negative including pseudomonas
- Treatable influenza
Resistant gram positive including MRSA
1. Vancomycin 15mg/kg Q8-12H (up to 20mg/kg loading dose)
2. Alternatives
- IV linezolid 600mg Q12H
- Daptomycin 8-10mg/kg Q24H - ineffective in lung infection
Resistant gram negative choices
1. IV cefepime 2g Q8H
2. IV PipTazo 4.5g Q6H
3. IV meropenem 1g Q8H
4. IV imipenem-cilastatin 500mg Q6H
Penicillin allergy choices
1. IV aztreonam 2g Q8H
2. IV ciprofloxacin 400mg Q8H
3. Aminoglycoside (gentamicin, amikacin, tobramycin)
Treatable influenza
1. Oseltamivir
