Intern Boot Camp:
Sepsis
Cassie Kovach
PGY-3
Outline/Objectives
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Identification of sepsis
Working up sepsis
Triaging sepsis
Treatment of sepsis
Outline
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Identification of sepsis
Working up sepsis
Triaging sepsis
Treatment of sepsis
Sepsis is a continuum
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SIRS (Systemic Inflammatory Response Syndrome)
Sepsis
Severe sepsis
Septic shock
SIRS Physiology
• Inflammatory state affecting the whole body
• Release of cytokines
 acute phase reaction fever, leukocytosis
 vasodilation/vascular leak hypotension, tachy, edema,
hypoxemia, tissue hypoperfusion
• Non-specific
SIRS Criteria
• Temperature
> 38.0 or < 36.0
• HR
> 90
• Respiratory status
RR >20 or PaCO2 <32
• WBC
>12,000 or <4,000 or >10% bands
**** BP IS NOT A SIRS CRITERIA ****
Sepsis
• 2/4 SIRS criteria + identified or suspected
infection
Severe sepsis
• Sepsis with organ dysfunction
– Cardiovascular
• Sepsis-induced hypotension: SBP <90 or MAP <70 mmHg or SBP decr
>40 or <2 SD below normal for age in absence of other causes
• Elevated lactate
• UOP < 0.5 mg/kg/hr for 2 hrs despite adequate hydration
– Pulmonary
• ALI with PaO2/FiO2<250 in the absence of PNA
• ALI with PaO2/FiO2<200 in the presence of PNA
– Liver
• Bili > 4.0
– Renal
• Cr >2.0 (incr >0.5)
– Hematologic
• Plt < 100,000
• INR > 1.5
Septic shock
• Sepsis + hypotension despite “adequate” fluid
resuscitation
Sick or not sick?
• Severe sepsis/septic shock mortality ~18-46%
• ~10% of all pts in ICU
• Most common cause of death in ICU
Case 1
• 38 yo F just finished running marathon, goes to medical
tent because of LH
– VS: 37.4, 130, 88/60, 24, 97% RA
– Labs not available
• How many SIRS criteria?
2
• Does this patient have sepsis?
No
Case 2
• 65 yo M presents with productive cough, fever, chills.
– VS: 38.0, 92, 120/80, 16, 90% RA
– Labs: WBC 3.8, Hb 9, plt 180
RFP WNL, HFP WNL, lactate WNL, coags WNL
• How many SIRS criteria?
3
• Does this patient have sepsis?
Yes
• Would it make a difference in diagnosis of sepsis if had CXR which showed
LLL infiltrate?
No
• Does this patient have severe sepsis?
No
• Does this patient have septic shock?
No
Case 3
• 89 yo F sent from NH with confusion, diarrhea
– VS: 35.8, 98, 22, 85/45, 97% RA
– Labs: WBC 10,000 with 12% bands, Hb 10, plt 160
bicarb 15, Cr 1.3 (baseline 0.7), lactate 4
ABG: 7.29/25/89
• How many SIRS criteria?
4
• Does this patient have sepsis?
Yes
• Does this patient have severe sepsis?
Yes
• Does this patient have septic shock?
Possibly- will need to see how her BP responds to IVFs
SIRS Criteria
• Temperature
> 38.0 or < 36.0
• HR
> 90
• Respiratory status
RR >20 or PaCO2 <32
• WBC
>12,000 or <4,000 or >10% bands
**** BP IS NOT A SIRS CRITERIA ****
Outline
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Identification of sepsis
Working up sepsis
Triaging sepsis
Treatment of sepsis
History?
• Source
• Severity
History?
• Source
– Lung
• Cough, sore throat, rhinorrhea
• Sick contacts
– Blood
• Fatigue, lines in place, IVDU
– Urine
• Dysuria, hematuria, flank pain
– GI
• Diarrhea, nausea, vomiting, abd pain
• Recent abx or hospitalization, recent travel, sick contacts
– Other: Skin/soft tissue, bone/joint, ascites, CNS, heart
• Skin changes, rash, joint pain, HA, confusion, back pain, neck
stiffness, photophobia
History?
• Severity
– Fevers/chills, appetite, po intake
– Progression
– Onset
Labs?
• Source
• Severity
Labs?
• Source
– Lung
• sputum cx
– Blood
• Bcx: 2 peripheral + 1 from each line the pt has (central lines,
HD lines, art lines, etc)
– Urine
• UA + Ucx
– GI
• C diff, fecal leuks, stool cx
– Other
• culture of any drainage, diagnostic paracentesis, LP, ESR, CRP
**** ALWAYS CULTURE BEFORE STARTING ANTIBIOTICS ****
Labs?
• Severity
– Does patient have evidence of any organ damage?
 Need to evaluate organ systems to determine
• CBC
• RFP
• HFP
• Lactate
• Coagulation screen
• ABG
• ScvO2
Studies?
• Source
• Severity
Studies?
• Source/Severity
– Lung
• CXR, CT chest
– Blood
• TTE
– Urine/GI
• CT abd
– Other
• CT head, MRI (for OM)
Outline
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Identification of sepsis
Working up sepsis
Triaging sepsis
Treatment of sepsis
When to transfer to MICU
• Sepsis
– Usually can treat on the floor
• Severe sepsis
– Floor or MICU depending on how severe the organ
dysfunction is
• Severe lactic acidosis MICU
• Respiratory distress requiring intubation MICU
• Septic shock
– MICU
Outline
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Identification of sepsis
Working up sepsis
Triaging sepsis
Treatment of sepsis
Treatment
• Early Goal Directed Therapy
– Rivers et al 2001
• Surviving Sepsis Campaign
– International guidelines last updated in 2012
Early Goal Directed Therapy
• Single center, 263 enrolled patients
• Purpose: evaluate efficacy of 6 hrs of EGDT prior
to admission to ICU
• Results:
– 30.5% mortality in EGDT group compared to 46.5%
mortality in standard therapy (p=0.009)
– During interval from 7-72 hrs, pts in EGDT had higher
mean ScvO2, lower lactate, higher pH than standard
therapy
• We typically follow the algorithm from this trial in
the ICU
Early Goal Directed Therapy algorithm
EARLY
Initial 6 hrs of
resuscitation in
the ED
GOAL
DIRECTED
CVP > 8
MAP >65
ScvO2 >70%
CVP??
• Approximation of R atrial pressure
• Gives an idea of volume status
• Measured by the nurses off of a central line
(terminates in the SVC… near the R atrium)
• Mechanical ventilation increases CVP (because
of PEEP)
MAP??
• Mean arterial pressure
• Approximates average blood pressure
throughout the cardiac cycle
• MAP = 2/3 DBP + 1/3 SBP
• Automatically calculated in our EMR and on
BP monitor
ScvO2??
• Central venous O2 saturation
• = the oxygen saturation of blood that is
returning to the R atrium (lowest O2sat in the
body before going to lungs)
• Drawn from a central line
• Indication of tissue hypoxia (more tissue
hypoxia  more oxygen extraction at tissue
level  decreased O2 saturation of blood
returning to heart)
Early Goal Directed Therapy algorithm
EARLY
Initial 6 hrs of
resuscitation in
the ED
GOAL
DIRECTED
CVP > 8
MAP >65
ScvO2 >70%
ProCESS Trial
• Published in NEJM May 1, 2014
• Multicenter, 1341 patients enrolled
• Purpose: to determine if EGDT is generalizable and if all
aspects of protocol are necessary
• Results:
– At 60 days: no sig difference between EGDT and either protocolbased standard therapy group or usual-care group
– No sig difference in 90 day mortality, 1 yr mortality, or need for
organ support
• Conclusion: “protocol-based resuscitation of patients in
whom septic shock was diagnosed in the emergency
department did not improve outcomes.”
Surviving Sepsis Campaign
• Takes several studies into account when
developing international guidelines for treating
sepsis
• Has yet to take in to account results of ProCESS
trial, waiting on results of 2 other large trials
• Splits care in to 2 “bundles”: one to be completed
within 3 hrs and the other within 6
– Note: all groups in ProCESS trial essentially followed
the 3 hr bundle
Initial Treatment
• Antibiotics
– If source is known, cater abx to the source
– If source is unknown, use broad spectrum
• Vanc/zosyn
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Fluids
Fluids
Fluids
Remove potential source (line holiday) within 12 hrs
*** WHEN GIVING FLUIDS, KEEP IN MIND PT’S
RENAL FUNCTION AND EF ****
Hypotension
• If not responsive to “adequate” hydration, will
need pressors in the MICU
Pressors
• Need central line
– Aggressive fluid resuscitation
– Administration of pressors
– Measure CVP
• Need arterial line
– More accurate BP monitoring
– Know second-to-second changes in BP
Pressors
• Norepinephrine (Levophed) is 1st pressor used
• Others you can add on if necessary:
– Vasopressin
– Epinephrine
– Phenylephrine
– Dopamine
Goals for treatment
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MAP >65
CVP 8-12 (not intubated), 12-15 (intubated)
ScvO2 >70%
Normal lactate
UOP > 0.5 ml/kg/hr
Tools for treatment
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Fluids
Antibiotics
Pressors
Blood products- if Hb <7, plt <10,000
(Albumin)
Steroids- only if fluids/pressors not adequate
Mechanical ventilation
Central lines/arterial lines
Nutrition- in first 48 hrs
DVT/stress ulcer ppx
Summary
• SIRS criteria: T> 38.0 or < 36.0, HR> 90, RR >20
or PaCO2 <32, WBC >12,000 or <4,000 or
>10% bands
• Sepsis workup should focus on identifying
source and severity
• Initial treatment: cx, abx, fluids
• Patients with septic shock and some with
severe sepsis require MICU