Multisystem - Sepsis/Septic Shock, Anaphylactic Shock, MODS

Systemic Inflammatory Response Syndrome (SIRS) - what is it?

• a systemic inflammatory response to a wide variety of severe clinical insults, manifested by 2 or more of the following

  • temperature > or = to 38 C or < 36 C

  • heart rate > 90 bpm

  • respiratory rate > 20 breaths/min or PaCO2 <32

  • WBC > 12000 or < 4000 OR bands > 10% (“shift to the left”) (INCREASE IN IMMATURE NEUTROPHIL FORMATION)

Systemic Inflammatory Response Syndrome (SIRS) - can a patient have SIRS without sepsis?

YES!! → such as traumatic injuries, pancreatitis, or burns; SIRS is a poor predictor of sepsis according to studies

Sepsis - definition? suspected infections?

• a life-threatening organ dysfunction that is caused by an abnormal host response to an infection; initially, the infection may be “suspected,” rather than “proven,” based on the clinical examination and the patient’s history (SEPSIS = infection + organ dysfunction)

• a “suspected” infection is the presence of one or more of the following:

  • positive cultures from blood, sputum, urine, etc

  • receiving ABX, anti-fungals, or another anti-infective therapy

  • altered mental status in elderly

  • possible pneumonia (infiltrate on chest radiograph)

  • nursing home patient with indwelling urinary catheter

  • pressure ulcers

  • acute abdomen

  • infected wounds, especially with history of diabetes

  • immunosuppression

Sepsis - examples of organ dysfunction

• HYPOTENSION!!

• acute hypoxemia (LUNG dysfunction)

• acute drop in UOP (<0.5 mL/kg [<30-40 mL/hr])

• lactate of 2 or greater

• abrupt mental status change

• platelets below 100,000; coagulopathy

Sepsis - qSOFA (quick sepsis related organ failure assessment) score

• a bedside evaluation (WITHOUT LABS) to identify patients with suspected organ dysfunction

• evaluates 3 criteria (1 point for each)

  • systolic BP LESS than or equal to 100

  • respiratory rate greater than or equal to 22/min

  • glasgow coma scale <15 (altered mentation)

    • score of 2-3 indicates a high probability of organ dysfunction

Septic Shock - what is it?

• clinically identified by an infection, PLUS

  • vasopressor requirement to maintain a MAP GREATER than or equal to 65, despite adequate fluid resuscitation

  • serum lactate > 2, despite fluid resuscitation

Infection vs. Sepsis vs. Septic Shock (identification based on vitals/interventions)

• infection - BP 110/80, pH 7.34, lactate 1.5, temp 39C, WBC 15000, acute abdomen

• sepsis - BP 78/36 BEFORE fluids, 102/58 after 500 mL fluid bolus, base excess -5 (BASE DEFICIT, ACIDOSIS), pH 7.30, lactate 3, acute abdomen

• septic shock - BP 78/36 BEFORE fluids, UNCHANGED after 500 mL fluid bolus x4; base excess -5; pH 7.31, lactate 6

Sepsis/Septic Shock (PATHOPHYSIOLOGY)

• INFECTING ORGANISM → uncontrolled inflammatory response response due to release of mediators

  • →vasodilation →DECREASED SVR

  • →INCREASED capillary permeability/significant leak →DECREASED vascular tone

  • →impaired O2 extraction/utilization; maldistribution of blood flow →ANAEROBIC METABOLISM

  • →accelerated coagulation and micro-emboli formation →DIC

  • → myocardial dysfunction → DECREASED CO (late sign)

  • →pulmonary dysfunction → ARDS

    • *activation of coagulation, inflammatory cytokines, complement, and kinin CASCADES with the release of a variety of endogenous mediators*

Sepsis - RISK FACTORS

• extremes of age

• chronic health problems

• invasive procedures/devices

• surgical wounds

• genitourinary infections

• prolonged hospitalizations

• translocation of GI bacteria (NPO)

• acquired immunodeficiency syndrome (AIDS)

• use of cytotoxic and immunosuppressive agents

• alcoholism

• malignant neoplasms; bone marrow suppression

• transplantation procedures

• history of splenectomy

Septic Shock (EARLY signs/symptoms)

• tachycardia, bounding pulse

• BP is low, RESPONSIVE to vasopressors

• skin is warm, flushed

• respirations are deep, somewhat fast

• lactate >2

• confusion → mental status change (ESPECIALLY in elderly people)

• oliguria

• fever (temp >38C)

Septic Shock (LATER/PROGRESSIVE signs and symptoms)

• HYPOTENSION, may NOT be responsive to vasopressors

• tachycardia, pulse is WEAK and THREADY

• lactate 4

• skin is cool, pale

• respirations are rapid OR may be slow

• lethargy, coma

• anuria

• hypothermia (temp <36C)

Real or Myth? - a patient with sepsis or septic shock always has a fever, an elevated WBC and positive blood cultures?

MYTH MYTH MYTH MYTH (ABSOLUTELY NOT REAL)

Septic Shock - Hemodynamics (EARLY vs. LATE)

• EARLY

  • INCREASED CO/CI (body is COMPENSATING!!)

  • DECREASED CVP (PRELOAD), PAP, and PAOP

  • DECREASED SVR

  • INCREASED SvO2 (d/t impaired oxygen consumption)

  • INCREASED O2 DELIVERY

  • DECREASED O2 CONSUMPTION

• LATE

  • DECREASED CO/CI

  • INCREASED CVP (PRELOAD), PAP, and PAOP

  • SVR (variable)

  • SvO2 (variable)

  • DECREASED O2 DELIVERY

  • DECREASED O2 CONSUMPTION

Septic Shock - DIAGNOSTIC TEST RESULTS (Early vs. Late)

• EARLY

  • ABGs → respiratory alkalosis, mild decreased PaO2, or may have combined respiratory alkalosis and metabolic acidosis

  • PT/PTT INCREASED or NO CHANGE

  • Platelets DECREASED or NO CHANGE

  • WBC (variable)

  • Bands INCREASED

  • Glucose INCREASED

  • Lactate INCREASED

  • Troponin INCREASED

• LATE

  • ABGs→ metabolic acidosis; SEVERELY LOW PaO2

  • PT/PTT SEVERELY INCREASED

  • Platelets SEVERELY LOW

  • WBC LOW

  • Bands SEVERLY INCREASED

  • Glucose DECREASED (liver dysfunction →reduced gluconeogenesis)

  • BUN, creatinine INCREASED

  • Liver enzymes INCREASED

  • Lactate INCREASED

  • Troponin INCREASED

Septic Shock - TREATMENTS (fluids, pressors)

• INITIAL FLUID CHALLENGE (30mL/kg of crystalloid (2.1 L for 70 kg) ASAP to achieve these goals:

  • MAP greater than or equal to 65; UOP greater than or equal to 0.5 mL/kg/hr (30mL/hr), decrease in tachycardia

• hypotension persists? →vasopressors (LEVO is first-line; epinephrine is recommended when a second vasopressor agent is needed)

  • no response? → may have catecholamine-refractory septic shock (alpha receptors in arterial bed are not responsive to pressors)

    • START VASO!! (0.03-0.04); enhances effectiveness of initial pressor

      • still not effective? → consider extreme metabolic acidosis or corticosteroid insufficiency related to critical illness; SODIUM BICARB or STEROIDS may be considered, although neither have demonstrated to improve mortality rates

Septic Shock - TREATMENTS (in addition to fluids/vasopressors)

• obtain 2 blood cultures ASAP prior to ABX administration

  • begin broad-spectrum ABX ASAP; within 3 hours of recognition of septic shock

• obtain serum lactate ASAP and remeasure within 2-4 hours if first lactate is 2 or greater

• identify source of INFECTION!! → helps direct antibiotic therapy

• MAP remains below 65 OR lactate is 4 or greater, REASSESS FLUID STATUS

  • measure CVP, assess fluid responsiveness with either a passive leg raise or fluid challenge; perform/assess a bedside ECHO; measure ScvO2/SvO2

• INOTROPIC THERAPY (dobumatine!! for patients with cardiac dysfunction, as evidenced by high filling pressures and low cardiac output or clinical signs of hypoperfusion after successfully restoring BP with effective volume resuscitation)

• OXYGENATION GOALS

  • maintain SpO2 95% or greater

  • ScvO2 greater than or equal to 70%; SvO2 greater than or equal to 65% (when CVP and MAP goals are met)

  • →ScvO2/SvO2 not met? →consider further fluids, dobutamine infusion (max 20 mcg/kg/min), consider transfusion of PRBCs if hgb 7 or less

Septic Shock - THERAPEUTIC ENDPOINTS (summary)

• MAP greater than 65

• decreased lactate/improved base deficit

• normalization of heart rate

• UOP greater than 0.5 mL/kg/hr (>30 mL/hr)

• warm extremities

• mental status return to baseline

• source control

• central venous oxygen saturation (ScvO2 > or = to 70%; SvO2 greater than or equal to 60%) → if CVP or PA line is availble

• CVP 8-12

Anaphylaxis - what is it?

• an allergic reaction rapid in onset/may cause death

• occurs after previous exposure to the substance

• hives/angioedema in 88% of cases; respiratory tract involvement in 50% of cases; shock occurs in 30%

Anaphylactic Shock - etiology/PATHOPHYSIOLOGY

• IgE-mediated immediate hypersensitivity reaction to protein substances

  • Penicillin, contrast media, bee stings, foods, latex

• PATHO

  • antigen-antibody reaction → histamine released

    • →INCREASED capillary permeability/massive dilation/DECREASED CO/bronchospasm, laryngeal edema, urticaria (hives)

      • →HYPOTENSION!!

Anaphylactic Shock - TREATMENT

• remove from agent

• O2

• 0.3-0.5 mg of 1:1000 epinephrine INTRAMUSCULAR (more rapid absorption than subq) to decrease dilation/bronchospasms

• aggressive fluid resuscitation (1-4L) to treat relative hypovolemia

• antihistamine (diphenhydramine (Benadryl) 25-50 mg IV to decrease allergic response)

• inhaled beta-adrenergic agents to decrease bronchospasm

• steroids IV (high-dose) → peaks in 4-6 hours, give ASAP to get “on board” to decrease inflammatory response

MODS (multiple organ dysfunction syndrome) - general definition

• the progressive insufficiency of 2 or more organs in an acutely ill patient, such that homeostasis cannot be maintained without intervention

MODS (multiple organ dysfunction syndrome) - cardiovascular, pulmonary, neurological MARKERS

• cardiovascular - hypotension/tachycardia, dysrhythmias, need for vasopressors, decreased SVR, abnormal CVP (low or high), positive troponin

• pulmonary - tachypnea/dyspnea, hypoxemia

• neurological - confusion/delirium/disorientation, lethargy, coma, seizure

MODS (multiple organ dysfunction syndrome) - renal, endocrine, hepatic MARKERS

• renal - elevated Cr/BUN, decreased GFR, oliguria, life-threatening electrolyte imbalances

• endocrine - hyperglycemia OR hypoglycemia, adrenal insufficiency

• hepatic - elevated liver enzymes, hypoglycemia, decreased albumin, jaundice

MODS (multiple organ dysfunction syndrome) - hematological, metabolic MARKERS

• hematological - thrombocytopenia, coagulopathy, increased D-dimer levels, decreased protein C levels (impaired ability to prevent coagulation system from being overactive)

• metabolic - metabolic acidosis, elevated LACTATE

SOFA (Sequential Organ Failure Assessment) Scoring System - what is it?

• unlike qSOFA, this scoring system DOES use lab results to determine extent of organ dysfunction; six organ systems assessed →

  • cardiovascular (HYPOTENSION)

  • neurological (GLASGOW COMA SCALE)

  • pulmonary (PaO2/FiO2)

  • renal (SERUM CREATININE or UOP)

  • hepatic (BILIRUBIN LEVEL)

  • hematologic (PLATELET COUNT)