Sepsis/Septic Shock

Life threatening acute organ dysfunction due to infection

Sepsis

How many SIRS criteria for suspected or proven infection

2 or more

SIRS Criteria

Temperature >38C/100.4F or <36C/96.8F

HR > 90

RR >20

WBCs > 12,000/mm³ or < 4,000 or >10% bands

Sepsis + persistent Hypotension

Septic Shock

What is given to sepsis patients with hypotension and/or elevated lactate within 3 hours

Initial resuscitation of 30mL/kg (actual body weight) IV Crystalloids

• use balances solutions ex. Lactated ringers or Plasmalyte

Route, frequ, duration of initial fluid resuscitation

IV at 1000mL/hr

When is ideal body weight used for fluid dosing

BMI > 30

Calculate IBW in women

45.5 + [2.3 x (height in inch - 60)]

Calculate ideal body weight in men

50 + [2.3 x (height in inch - 60)]

What is considered elevated serum lactate

>2 mmol/L

What is given is patient is STILL hypotensive after initial fluid resuscitation

NE Vasopressor continuous IV infusion

• start peripherally rather than delayed administration until central access is secured

When are Vasopressors and fluid resuscitation given concurrently

Life-threatening end-organ hypoperfusion

When are Vasopressors and fluid resuscitation given concurrently

Life-threatening end-organ hypoperfusion

0.9% NaCl toxicity

Hyperchloremic metabolic acidosis

AKI

Peripheral / Pulmonary edema

Lactated Ringers toxicity

Peripheral / pulmonary edema

Hyperkalemia

Hypercalcemia

Plasmalyte toxicity

Peripheral / pulmonary edema

Hyperkalemia

Which IV access is used for long term vasopressor

Central IV line

Which IV access is used for short term vasopressor

Peripheral acceptable until central access obtained

NE toxicity monitoring

Tachycardia

Arrhythmia

Decreased GI & digital perfusion

Epi toxicity monitoring

Tachycardia

Arrhythmia

Impaired splanchnic circulation

Lactate production

Hyperglycemia

Vasopressin toxicity monitoring

Splanchnic / digital / cardiac ischemia

When is D5W given during fluid resuscitation

Hypoglycemic

Fluid responsiveness assessment if hypotension and/or lactate elevation persist after initial fluid resuscitation

• Dynamic measures (change in stroke volume, pulse pressure with passive leg raise of fluid bolus)

• Trend lactate & capillary refill time

• measure BP hourly (consider continuous monitoring via arterial line)

What supplemental adjuvant is considered after persistent hypotension and/or lactate elevation after initial fluid resuscitation or has cirrhosis

Albumin

When is albumin avoided

Traumatic brain injury

What can be used if NE requirement persists

Hydrocortisone (50mg IV q6) ± Fludrocortisone

What can be given is NE dose is increasing

Vasopressin

What is the third-line agent if NE dose is still increasing

Epinephrine

What can be given if cardiac dysfunction is present after persistent hypotension and/or elevated lactate

Dobutamine

What is collected prior to antimicrobial initiation

Two sets of blood cultures

Source control for antimicrobials in sepsis / septic shock

Remove infected devices

Surgical debridement (damaged tissue removal)

Timing of antimicrobial therapy that is strongly recommended ± presence of shock

Administer therapy immediately, ideally within 1 hour of recognition

Timing of antimicrobial therapy that is conditionally recommended if shock is absent

Rapid assessment of infection vs noninfectious causes of acute illness

Administer antimicrobial therapy within 3 hours if concerns persist

Risk factors for empiric anaerobic coverage

IAI

Deep seated gynecological or obstetric infection

Necrotizing soft tissue

Head/Neck infection

CNS abscesses or empyema (pus development)

Risk factors for Multidrug resistant pathogens for empiric Tx

Colonization with specific MDR pathogen

Previous infection with MDR pathogen

Prolong broad-spectrum Abx use

Prolonged hospitalization w/ high MDR pathogen prevalence

Although not recommended, when is antifungal used for empiric antimicrobial selection

Immunosuppression

Prolonged Abx

Prolonged hospitalization

IAI

Empiric Antimicrobial Tx & Dosing for Sepsis

Cefepime 2g IV q8h AND Vanco IV

Empiric Antimicrobial Tx & Dosing for Septic Shock

Cefepime 2g IV q8h AND Vanco IV

± Tobramycin IV

Empiric Tx for mod-high risk or PCN allergy

Meropenem 2g IV q8 PLUS Vanco IV

± Tobramycin IV

OR

Aztreonam 2g IV q8 PLUS Vanco IV PLUS Tobra IV

Empiric Tx with any source of Multi-drug resistant gram negative risk factors

Meropenem 2g IV q8 PLUS Vanco IV

± Amikacin IV if septic shock

Antimicrobial dosing for beta lactams

Initial bolus followed by prolonged infusions

Antimicrobial duration

5-8 days

Beta lactam toxicity monitoring

Seizures

rash

Anaphylaxis

Diarrhea

Acute interstitial nephritis

Vancomycin toxicity monitoring

Flushing syndrome

Thrombocytopenia (platelets)

Rash

Ototoxicity

Renal failure

AUC:MIC ratio

What can be used to aid antimicrobial d/c decisions

Procalcitonin + clinical evaluation

• dropped PCT levels indicate infection improvement

Low HCO3

Metabolic acidosis

High PaCO2

Respiratory acidosis

Anion gap

Na - Cl - HCO3

When is stress ulcer prophylaxis indicated

High risk bleeding

Coagulopathy

Chronic liver disease

Shock

VTE prophylaxis

LMWH > UFH

Mechanical prophylaxis unnecessary

Target blood glucose

140-180 mg/dL

Treatment for blood glucose >180mg/dL

Insulin gtt