|
|
| (24 intermediate revisions by 2 users not shown) |
| Line 1: |
Line 1: |
| ==Definition==
| |
|
| |
|
| Sepsis is a systemic, deleterious host response to infection, manifested as multi system organ dysfunction plus hypotension, that is not readily reversible with fluid resuscitation.
| |
|
| |
| ==Diagnostic Criteria For Sepsis (Documented/Suspected Infection Plus Inflammatory variables Plus One of The Organ Dysfunction)==
| |
|
| |
| :'''General variables'''
| |
| :*Fever > 38.3°C
| |
| :*Hypothermia ( core temperature < 36°C )
| |
| :*Heart rate > 90/min–1 or > 2 SD above the normal value for age
| |
| :*Tachypnea
| |
| :*Altered mental status
| |
| :*Edema
| |
| :*Positive fluid balance ( > 20 mL/kg over 24 hr)
| |
| :*Hyperglycemia ( plasma glucose > 140 mg/dL or 7.7 mmol/L ) in the absence of diabetes
| |
|
| |
| :'''Inflammatory variables'''
| |
| :*Leukocytosis ( WBC count > 12,000 µL–1 )
| |
| :*Leukopenia ( WBC count < 4000 µL–1 )
| |
| :*Immature WBCs forms are > 10% with normal count
| |
| :*Plasma C-reactive protein > 2 SD above the normal value
| |
| :*Plasma procalcitonin > 2 SD above the normal value
| |
|
| |
| :'''Hemodynamic variables'''
| |
| :*Arterial hypotension after 30 ml/kg fluid bolus ( SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or < 2 SD below normal for age )
| |
|
| |
| :'''Organ dysfunction variables'''
| |
| :*Arterial hypoxemia ( Pao2/Fio2 < 300 )
| |
| :*Acute oliguria ( urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation )
| |
| :*Creatinine increase > 0.5 mg/dL or 44.2 µmol/L
| |
| :*Coagulation abnormalities ( INR > 1.5 or aPTT > 60 Sec )
| |
| :*Ileus ( absent bowel sounds )
| |
| :*Thrombocytopenia ( platelet count < 100,000 µL–1 )
| |
| :*Hyperbilirubinemia ( plasma total bilirubin > 4 mg/dL or 70 µmol/L )
| |
|
| |
| :'''Tissue perfusion variables'''
| |
| :*Hyperlactatemia > 1 mmol/L
| |
| :*Decreased capillary refill or mottling
| |
|
| |
| ==Diagnostic Criteria for Severe Sepsis (sepsis induced hypoperfusion or organ dysfunction)==
| |
| Includes any one of the following caused due to the infection:
| |
| :* Sepsis-induced hypotension
| |
| :* Lactate above upper limits laboratory normal
| |
| :* Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
| |
| :* Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
| |
| :* Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
| |
| :* Creatinine > 2.0 mg/dL (176.8 μmol/L)
| |
| :* Bilirubin > 2 mg/dL (34.2 μmol/L)
| |
| :* Platelet count < 100,000 μL
| |
| :* Coagulopathy (international normalized ratio > 1.5)
| |
|
| |
| ==Management==
| |
|
| |
| {{familytree/start}}
| |
| {{familytree | | | | | | | | | A01 | | | | | | | | | | |A01=<div style="float: left; text-align: left "> ''' Characterize the symptoms:''' <br> ❑ Fever <br> ❑ Hypothermia <br> ❑ Altered mental status <br> ❑ Mottling <br> ❑ Ileus <br> ❑ Oliguria </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | B01 | | | | | | | | | | |B01=<div style="float: left; text-align: left "> '''Examine the patient:''' <br> ❑ Tachycardia <br> ❑ Tachypnea <br> ❑ Edema <br> ❑ Hyperglycemia <br> ❑ Hypotension after an initial 30 ml/Kg bolus <br> ❑ Decreased capillary refill </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | C01 | | | | | | | | | | |C01=<div style="float: left; text-align: left "> '''Order labs:''' <br> ❑ Random blood sugar (RBS) <br> ❑ Complete blood count (CBC) <br> ❑ Plasma C reactive protein (CRP) <br> ❑ Plasma procalcitonin <br> ❑ Pulse oximetry <br> ❑ Urinalysis/Renal function tests <br> ❑ PT/INR <br> ❑ Liver function tests <br> ❑ Serum lactate <br> ❑ Central venous pressure (CVP) </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | D01 | | | | | | | | | | |D01=<div style="float: left; text-align: left "> '''Consider alternative diagnosis:''' <br> ❑ Infections <br> ❑ Acute pancreatitis <br> ❑ Diabetic ketoacidosis <br> Lower gastrointestinal bleeding <br> Myocardial infarction </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | E01 | | | | | | | | | | |E01=<div style="float: left; text-align: left "> '''Initial resuscitation: Goals to achieve in first 6 hours''' <br> ❑ CVP 8-12 mm Hg <br> ❑ Mean arterial pressure (MAP) ≥ 65 mm Hg <br> ❑ Urine output ≥ 0/5 mL/Kg/hr <br> ❑ Central venous O<sub>2</sub> sat. 70% <br> ❑ If lactate levels elevated, target is normalization </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | F01 | | | | | | | | | | |F01=<div style="float: left; text-align: left "> '''Diagnosis:''' <br> ❑ Perform 2 sets of blood cultures (aerobic and anaerobic) atleast, before starting antibiotics <br>
| |
| :# Drawn percutaneously <br>
| |
| :# Drawn through each vascular access device present for > 48 hours <br>
| |
| ❑ Perform 1,3 beta-D_glucan assay, mannan, anti-mannan antibody assay if available <br> ❑ Perform imaging studies as appropriate to locate a source </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | G01 | | | | | | | | | | |G01=<div style="float: left; text-align: left "> '''Antimicrobial therapy:''' <br> ❑ Initiate within 1st hour of diagnosis <br> Reassess regimen daily <br> ❑ Use low procalitonin levels for prognosis <br> ❑ Usual duration of therapy 10 days <br> ❑ Longer in neutropenics, slow responders, undrainable foci, immunologically compromised </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | H01 | | | | | | | | | | |H01=Choice of antibiotics }}
| |
|
| |
| {{familytree | | | | | | | | | | | | | | | | | | | | | }}
| |
| {{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | }}
| |
| {{familytree | I01 | | I02 | | I03 | | I04 | | I05 | | |I01='''Unknown organism''' <br> ❑ Empiric therapy with broad spectrum antbiotic with good tissue penetrance |I02= '''Neutropenic pt with severe sepsis (goal is to cover Acinetobacter & Pseudomonas spp)''' <br> ❑ Use combination empirical therapy |I03='''Severe infections + resp failure + septic shock''' <br> ❑ Extended spectrum beta lactam and aminoglycoside/fluoroquinolone |I04= '''Streptococcus pneumoniae'' <br> ❑ Beta lactam + macrolide |I05='''Culture specific organism''' <br> ❑ Shift to appropriate anti-bacterial, antiviral or antifungal }}
| |
| {{familytree | | | | | | | | | | | | | | | | | | | | | }}
| |
|
| |
| {{familytree | |`|-|-|-|^|-|-|-|+|-|-|-|^|-|-|-|'| | | }}
| |
| {{familytree | | | | | | | | | J01 | | | | | | | | | |J01=<div style="float: left; text-align: left "> '''Remove source/foci of infection:''' <br> ❑ Use minimally invasive process <br> ❑ Source removal best done in first 12 hours <br> ❑ Remove intravascular access devices if they are a possible source
| |
| ----
| |
| ❑ Oral chlorhexidine gluconate to reduce oral contamination as a risk factor for ventilator associated pneumonia </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | K01 | | | | | | | | | |K01=<div style="float: left; text-align: left "> Hemodynamic support <br> '''Fluid therapy:''' <br> ❑ Administer crystalloids, use albumin when demand for fluids is too high <br> ❑ Use dynamic variables (change in pulse pressure, stroke volume) and static variables (arterial pressure,heart rate) to assess status
| |
| ----
| |
| '''Vasopressors (to achieve target MAP 65 mm Hg):''' <br> ❑ Place arterial line as soon as feasible <br> ❑ Administer norepinephrine as 1st choice drug <br> ❑ Use epinephrine - when additional agent needed <br> ❑ Use vasopressin 0.03 units/minute to raise MAP or decrease norepinephrine usage <br> ❑ Selective dopamine (absolute or relative bradycardia) and phenylephrine usage
| |
| ----
| |
| '''Inotropic therapy:''' <br> ❑ Trial of dobutamine infusion 20 μg/Kg if cardiac output low with elevated cardiac filling pressure </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | L01 | | | | | | | | | |L01=<div style="float: left; text-align: left "> '''Corticosteroids:''' <br> ❑ Use continuous flow IV hydrocortisone 200 mg/day if shock doesn’t improve with fluids & vasopressor <br> ❑ Taper when vasopressors no longer required </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | M01 | | | | | | | | | |M01=<div style="float: left; text-align: left "> '''Blood products:''' <br> ❑ Transfuse blood when hemoglobin < 7.0 g/dL <br> ❑ Transfuse platelets if < 10,000/mm<sup>3</sup> or < 20,000/mm<sup>3</sup> in those with high risk </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | N01 | | | | | | | | | |N01=<div style="float: left; text-align: left "> '''Mechanical ventilation for sepsis induced ARDS':'' <br> ❑ Target tidal volume of 6 mL/Kg <br> ❑ Target plateau pressure ≤ 30 mm Hg <br> ❑ Use PEEP (positive end expiratory pressure) to avoid alveolar collapse <br> ❑ Raise patients bed to 30-45° <br> ❑ Attempt weaning when all foll. criteria are met: <br>
| |
| :# ❑ Pt arousable
| |
| :# ❑ Hemodynamics stable
| |
| :# ❑ No new complications
| |
| :# ❑ Low ventilatory/fiO<sub>2</sub> requirements <br>
| |
| ❑ Extubate when weaning successful </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | O01 | | | | | | | | | |O01=<div style="float: left; text-align: left "> Other supportive therapy <br> '''Sedation & neuromuscular blockade:''' <br> ❑ Use minimal sedation/neuromuscular blockade in mechanically ventilated patients
| |
| ----
| |
| '''Glucose control:''' <br> ❑ Blood glucose target value should be ≤ 180 mg/dL <br> ❑ Use insulin infusion and 1-2 hourly monitoring to achieve target
| |
| ----
| |
| '''Renal replaement therapy:''' <br> ❑ May be used for management of fluid balance in hemodynamically unstable patients <br> ❑ Use for septic patients with acute renal failure
| |
| ----
| |
| '''DVT prophylaxis:''' <br> ❑ Do pharmacoprophylaxis with low molecular weight heparin (LMWH), if no contraindications present <br> ❑ Use pneumatic compression devices whenever possible
| |
| ----
| |
| '''Stress ulcer prophylaxis''' <br> ❑ Consider prophylaxis if risk factors are present
| |
| ----
| |
| '''Feeding:''' <br> ❑ Enteral & oral feeding preferred over total parenteral feeding (TPN) <br> ❑ Adjust calorie requirement in subsequent days, as tolerated
| |
| ----
| |
| '''Goals of care:''' <br> ❑ Discuss goals or care, patient aspirations and future directives with family with 72 hours of admission </div>}}
| |
| {{familytree | | | | | | | | | | | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | | | | | | | | | | | | | }}
| |
| {{familytree/end}}
| |
|
| |
|
| |
| ==Do's==
| |
|
| |
| * Patients who are suspected of being severely infected, should be routinely screened for sepsis.
| |
|
| |
| * Administer antimicrobial therapy within 1 hour of diagnosis of sepsis.
| |
|
| |
| * Delay intervention, if source/foci of infection is peri-pancreatic necrosis.
| |
|
| |
| ==Dont's==
| |
|
| |
| * Antimicrobial Therapy:
| |
|
| |
| ** Do not use empiric combination therapy for more than 3-5 days.
| |
|
| |
| ** Do not use antimicrobial agents in severely inflamed patients, from a non-infectious cause.
| |
|
| |
| * Fluid therapy:
| |
|
| |
| ** Do not use hydroxyethyl starch for resuscitation of severe sepsis and septic shock.
| |
|
| |
| * Vasopressors:
| |
|
| |
| ** Do not use low dose vasopressin/dopamine/phenylephrine as monotherapy.
| |
|
| |
| ** Do not use low dose dopamine for renal protection.
| |
|
| |
| * Corticosteroids:
| |
|
| |
| ** Do not use corticosteroids in absence of shock.
| |
|
| |
| * Blood products:
| |
|
| |
| ** Do not use erythropoietin as a specific treatment of anemia associated with sepsis.
| |
|
| |
| ** Do not use antithrombin.
| |
|
| |
| ** Do not use fresh frozen plasma to correct clotting abnormalities in the absence of bleeding or planned invasive procedure.
| |
|
| |
| * Other supportive therapy:
| |
|
| |
| ** Do not use following therapies as their role is not clear:
| |
|
| |
| : IV immunoglobulins
| |
|
| |
| : IV selenium
| |
|
| |
| ** Do not use pulmonary artery catheters routinely.
| |
|
| |
| ** Do not use bicarbonate therapy as prophylaxis of hypoperfusion induced lactic acidosis if pH > 7.15.
| |