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Sepsis Syndrome


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Author: Nazish Ilyas

 

Clinical Vignette:

A 65 year old female admitted with CHF exacerbation complains of dysuria and flank pain on day 3 of hospitalization. She has a temperature of 102.4 and heart rate is 120 bpm. How would you proceed with managing this patient?

Sepsis Syndrome:

Identification of Sepsis: 2 SIRS criteria plus the source of infection

  • Temp ≥ 101 or  ≤ 96.8
  • Pulse ≥ 90
  • RR ≥ 20
  • WBC ≥12,000 or ≤ 4,000 or bands >10%

Identification of Severe Sepsis: Sepsis plus new end organ dysfunction

  • SBP ≤ 90 or MAP ≤ 60
  • New Alerted mental status
  • Acute oliguria Urinary output  ≤ 0.5ml/kg/hr
  • Lactate ≥ 2.2
  • Acute lung injury  PaO₂: FIO₂ < 300
  • Hyperbilirubinemia
  • Acute Kidney Injury Platelet count <100,000
  • Coagulation Abnormalities INR >1.5 or a PTT>60 seconds

Septic Shock: Persistent arterial hypotension despite volume resuscitation

Sepsis Bundle:

To be completed within 3 hours:

  • Administer 30ml/kg crystalloid for hypotension or lactate ≥ 4mmol/L (grade 1C).
  • Measure lactate level – should be resulted within 90 minutes. In patients with elevated lactate levels, targeting resuscitation to normalize lactate (grade 1C).
  • Obtain blood cultures prior to administration of antibiotics (grade 1C).
  • Administer broad-spectrum antibiotics
    • Antibiotics should be reassessed daily for potential de-escalation (grade 1B).
    • Empiric combination therapy should not be administered for more than 3-5 days.
    • De-escalate to most appropriate single therapy as soon as susceptibility profile known (grade 2B).
    • Duration of therapy typically 7-10 days (grade 2C).

To be completed within 6 hours:

  • Apply vasopressors  (for hypotension that does not respond to initial fluid resuscitation) to
  • maintain MAP ≥ 65 mm Hg (grade 1C).
  • Remeasure lactate if initial lactate was elevated.
  • Persistent arterial hypotension despite volume resuscitation or initial lactate ≥ 4 mmol/L:
    • Measure central venous pressure
    • Measure central venous oxygen saturation

Goals during the first 6 hours of Resuscitation:

  • Central venous pressure 8-12 mm Hg
  • Mean arterial pressure ≥ 65 mm Hg
  • Urine Output ≥ 0.5mL/kg/hr
  • Central venous or mixed venous oxygen saturation 70% or 65% respectively

Source Control:

  • Perform imaging studies promptly to confirm a potential source of infection
  • Intervention should be taken within 12 hours after diagnosis is made (grade 1C).
  • When source control in a severely septic patient is required, intervention with the least physiological insult should be used.
  • If intravascular devices are potential sources of infection, they should promptly be removed after other vascular access has been obtained.

Clinical Pearls:

  • Early recognition of sepsis syndromes is critical and allows for earlier implementation of the sepsis bundles, with the goal of reduction of mortality.
  • Fluid resuscitation guided by targeted endpoints for resuscitation – mean arterial pressure, urinary output, lactate, and central venous pressure.
    • Antimicrobial therapy and source control in a timely manner.
    • Triage patient appropriately and consider escalation in the level of care.