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| ==Definition==
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| 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.
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| ==Diagnostic Criteria For Sepsis (Documented/Suspected Infection Plus Inflammatory variables Plus One of The Organ Dysfunction)==
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| :'''General variables'''
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| :*Fever > 38.3°C
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| :*Hypothermia ( core temperature < 36°C )
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| :*Heart rate > 90/min–1 or > 2 SD above the normal value for age
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| :*Tachypnea
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| :*Altered mental status
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| :*Edema
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| :*Positive fluid balance ( > 20 mL/kg over 24 hr)
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| :*Hyperglycemia ( plasma glucose > 140 mg/dL or 7.7 mmol/L ) in the absence of diabetes
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| :'''Inflammatory variables'''
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| :*Leukocytosis ( WBC count > 12,000 µL–1 )
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| :*Leukopenia ( WBC count < 4000 µL–1 )
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| :*Immature WBCs forms are > 10% with normal count
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| :*Plasma C-reactive protein > 2 SD above the normal value
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| :*Plasma procalcitonin > 2 SD above the normal value
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| :'''Hemodynamic variables'''
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| :*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 )
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| :'''Organ dysfunction variables'''
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| :*Arterial hypoxemia ( Pao2/Fio2 < 300 )
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| :*Acute oliguria ( urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation )
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| :*Creatinine increase > 0.5 mg/dL or 44.2 µmol/L
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| :*Coagulation abnormalities ( INR > 1.5 or aPTT > 60 Sec )
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| :*Ileus ( absent bowel sounds )
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| :*Thrombocytopenia ( platelet count < 100,000 µL–1 )
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| :*Hyperbilirubinemia ( plasma total bilirubin > 4 mg/dL or 70 µmol/L )
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| :'''Tissue perfusion variables'''
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| :*Hyperlactatemia > 1 mmol/L
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| :*Decreased capillary refill or mottling
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| ==Diagnostic Criteria for Severe Sepsis (sepsis induced hypoperfusion or organ dysfunction)==
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| Includes any one of the following caused due to the infection:
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| :* Sepsis-induced hypotension
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| :* Lactate above upper limits laboratory normal
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| :* Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
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| :* Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
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| :* Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
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| :* Creatinine > 2.0 mg/dL (176.8 μmol/L)
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| :* Bilirubin > 2 mg/dL (34.2 μmol/L)
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| :* Platelet count < 100,000 μL
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| :* Coagulopathy (international normalized ratio > 1.5)
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| ==Management==
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| {{familytree/start}}
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| {{familytree | | | | | | | | | A01 | | | | | | | | | | |A01= Characterize the symptoms: <br> Fever <br> Hypothermia <br> Altered mental status <br> Mottling <br> Ileus <br> oliguria }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
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| {{familytree | | | | | | | | | B01 | | | | | | | | | | |B01= Examine the patient: <br> Tachycardia <br> Tachypnea <br> Edema <br> Hyperglycemia <br> Hypotension after an initial 30 ml/Kg bolus <br> Decreased capillary refill }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
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| {{familytree | | | | | | | | | C01 | | | | | | | | | | |C01=Order labs: <br> Random blood sugar (RBS) <br> Complete blood count (CBC) <br> Plasma C reactie 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) }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
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| {{familytree | | | | | | | | | D01 | | | | | | | | | | |D01=Consider alternative diagnosis: <br> Infections <br> Acute pancreatitis <br> Diabetic ketoacidosis <br> Lower gastrointestinal bleeding <br> Myocardial infarction }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
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| {{familytree | | | | | | | | | E01 | | | | | | | | | | |E01=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% }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
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| {{familytree | | | | | | | | | F01 | | | | | | | | | | |F01=Diangosis: <br> 2 sets of blood cultures (aerobic and anaerobic) atleast, before starting antibiotics <br>
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| :# Drawn percutaneously <br>
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| :# Drawn through each vascular access device present for > 48 hours <br>
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| 1,3 beta-D_glucan assay, mannan, anti-mannan antibody assay if available <br> Imaging studies as appropriate to locate a source }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
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| {{familytree | | | | | | | | | G01 | | | | | | | | | | |G01=Antimicrobial therapy: <br> Initiate within 1st hour of diagnosis <br> Daily reassessment of regimen <br> Low procalitonin level for prognosis <br> Usual duration of therapy 10 days <br> Longer in neutropenics, slow responders, undrainable foci, immunologically compromised }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
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| {{familytree | | | | | | | | | H01 | | | | | | | | | | |H01=Choice of antibiotics }}
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| {{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | }}
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| {{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 }}
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| {{familytree | |`|-|-|-|^|-|-|-|+|-|-|-|^|-|-|-|'| | | }}
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| {{familytree | | | | | | | | | J01 | | | | | | | | | |J01=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
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| ----
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| Oral chlorhexidine gluconate to reduce oral contamination as a risk factor for ventilator associated pneumonia }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
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| {{familytree | | | | | | | | | K01 | | | | | | | | | |K01=Hemodynamic support <br> Fluid therapy: <br>Administer crystalloids, 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
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| ----
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| 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 phenyephrine usage
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| ----
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| Inotropic therapy: <br> Trial of dobutamine infusion 20 μg/Kg if cardiac output low with elevated cardiac filling pressure }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
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| {{familytree | | | | | | | | | L01 | | | | | | | | | |L01=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 }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
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| {{familytree | | | | | | | | | M01 | | | | | | | | | |M01=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 }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
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| {{familytree | | | | | | | | | N01 | | | | | | | | | |N01=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>
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| :# Pt arousable
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| :# Hemodynamics stable
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| :# No new complications
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| :# Low ventilatory/fiO<sub>2</sub> requirements <br>
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| Extubate when weaning successful}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
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| {{familytree | | | | | | | | | O01 | | | | | | | | | |O01=Other supportive therapy <br> Sedation & neuromuscular blockade: <br> Use minimal sedation/neuromuscular blockade in mechanically ventilated patients
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| ----
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| Glucose control: <br> Blood glucose target value should be ≤ 180 mg/dL <br> Use insulin infusion and 1-2 hourly monitoring to achieve target
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| 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
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| DVT prophylaxis: <br> Do pharmacoprophylaxis with low molecular weight heparin (LMWH), if no contraindications present <br> Use pneumatic compression devices whenever possible
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| Stress ulcer prophylaxis <br> Consider prophylaxis if risk factors are present
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| ----
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| Feeding: <br> Enteral & oral feeding preferred over total parenteral feeding (TPN) <br> Adjust calorie requirement in subsequent days, as tolerated
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| ----
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| Goals of care: <br> Discuss goals or care, patient aspirations and future directives with family with 72 hours of admission }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
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| {{familytree/end}}
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