Sepsis and Septic Shock

What are the hemodynamic goals of shock?

MAP > 65, HR < 100, SvO2 > 65% and ScvO2 > 70%

What are the renal perfusion goals of shock?

urine output > 0.5 mL/kg/hr

What are the oxygen deficiency goals of shock?

lactate normalize to < 2 mmol/L

What are the brain perfusion goals of shock?

improved mental status

What is sepsis?

life threatening organ dysfunction caused by a dysregulated host response to infection

What is septic shock?

subset of sepsis with profound circulatory, cellular and metabolic abnormalities; require vasopressors for MAP > 65 with serum lactate > 2 mmol/L in the absence of hypovolemia

What assessment can be used to determine clinical organ dysfunction?

sequential organ failure assessment (SOFA)

What are the two main features of sepsis?

immune dysregulation and dysregulated vasculature

What is immune dysregulation?

hyperinflammation and immunosuppression

What are host factors that affect immune dysregulation?

innate immune activation, relative immunosuppression, maladaptive tolerance mechanisms

What is seen in relative immunosuppression?

neutrophils and more numerous but relatively hypofunctional; development of lymphopenia

What is seen in maladaptive tolerance mechanisms?

monocytes develop impaired cytokine release; high energy expenditure leads to metabolic failure causing depleted and/or hypofunctional immune cells

What is dysregulated vasculature?

endothelium has quick and large response to sepsis inflammation → vasodilation; the glycocalyx is shed, leaving endothelial tissue exposed and easily damaged; complement system over activity leads to tissues damage, and the regulation of endothelial permeability is lost

What are the MAJOR impacts of dysregulated vasculature in sepsis?

profound vasodilation and loss of circulating blood volume

What are two ways that you can identify sepsis?

qSOFA and SIRS criteria

True or False: guidelines recommend using any one screening tool exclusively

false

What is the qSOFA scoring?

at least two of the following:

• SBP < 100 mmHg

• respiratory rate > 22

• altered mentation

What is the SIRS criteria?

at least two of the following:

• temperature > 38 or < 36

• HR > 90

• RR > 20

• WBC > 12 × 10^9 or < 4 × 10 ^9

What are the main components of septic shock management?

correction of underlying cause

fluid resuscitation

vasopressors

inotropes

corticosteroids

What is step 1 of the 1-hour bundle?

measure lactate level; remeasure if initial is elevated

What is step 2 of the 1-hour bundle?

obtain blood cultures before administering antibiotics

What is step 3 of the 1-hour bundle?

administer broad-spectrum antibiotics

What is step 4 of the 1-hour bundle?

begin rapid administration of fluids for hypotension or lactate > 4

What is step 5 of the 1-hour bundle?

apply vasopressors if hypotensive during or after fluid resuscitation to maintain a MAP of at least 65

What is the urgency of initiating antibiotics based on?

the acuity of the patient and likelihood of sepsis

True or False: delay in antibiotics in sepsis is associated with increased mortality

true

What are possible harms of unnecessary antimicrobials?

allergic reactions, kidney injury, thrombocytopenia, C diff infections, and antimicrobial resistance

When is it ok to NOT administer antibiotics immediately?

if the patient is not in shock and sepsis is not definitive

What are patient specific risk factors for MRSA?

• prior history of MRSA infection or colonization

• recent IV antibiotic use

• history of recurrent skin infections or chronic wounds

• presence of invasive device

• hemodialysis

• recent hospital admission

• severity of illness

What are patient specific risk factors for multi-drug resistant organisms?

• proven infection of colonization with resistant organisms within the preceding year

• recent broad spectrum IV antibiotic use within previous 90 dyas

• travel to highly endemic country within previous 90 days

• local prevalence of antibiotic resistant organisms

• hospital acquired infections

What is the goal of fluid therapy?

increase SV, CO, DO2

What is the recommended fluid therapy in sepsis?

30 mL/kg over 15-30 mins of crystalloids

followed by 10 mL/kg boluses as needed

When should albumin be considered in sepsis?

in addition to crystalloids when patients require a substantial amount of crystalloids

What does 1L of crystalloids yield?

250 mL of intravascular volume

What are examples of crystalloidsolutions?

lactated ringers, normal saline, plasma-lyte

What clinical pearls does lactated ringer’s have?

lactate metabolized rapidly; may produce hyponatremia

What clinical pearls does normal saline have?

may produce hypernatremia, hyperchloremia, and metabolic acidosis, possible risk of increase AKI

What are examples of colloids?

albumin, starches, and blood products

What concentration of albumin is used for fluid resuscitation?

5%

What concentration of albumin is used for fluid mobilization?

25%

True or False: starches are recommended for resuscitation in septic shock

false

Why are starches not used?

increased risk of mortality, AKI, and bleeding

What were the results of the SAFE trial?

no differences in days spent in ICU, days of mechanical ventilation, days of renal replacement therapy

What were the results of the ALBIOS trial?

mortality in albumin + crystalloid group was about the same as the crystalloid group

When should you initiate a vasoactive agent in septic shock?

when MAP remains < 65 mmHg despite fluid administration

What is the purpose of placing an arterial line?

more accurate blood pressure monitoring

What is the purpose of a central venous catheter?

generally required for vasopressor administration; short term peripheral administration can be done to allow early initiation

What is the goal of vasopressors?

primarily increase blood pressure by causing arterial constriction

What is the goal of inotropes?

increase cardiac output by increasing the force at which the heart contracts

What is the first line choice vasopressor in septic shock?

norepinephrine

When can vasopressin be added?

if patient has inadequate MAP while on norepinephrine

When can epinephrine be added?

if blood pressure goals not achieved with norepinephrine and vasopressin

What is the role of dopamine in septic shock?

limited utility

Why does dopamine have limited utility in septic shock?

increased risk of tachyarrhythmias and is generally inferior to norepinephrine as a vasopressor

When should dobutamine be added to treatment of shock?

when patients require cardiac output support

When is angiotensin II used?

reserved for refractory distributive shock

When is phenylephrine used?

not in guidelines; used when tachycardia limits norepinephrine utility

Why are steroids used in sepsis?

improves the physiologic response to sepsis:

• regulates the pro-inflammatory state

• inhibition of inducible nitric oxide synthease

• reverses adrenergic receptor desensitization

• increases sodium and water retention (to increase intravascular volume)

When should steroids be used in septic shock?

after poor response to fluids and vasopressors (refractory); usually still hypotensive

What dose of hydrocortisone is used in refractory shock?

200 mg IV daily for about 3-7 days (can taper)

• 50 mg IV q6h OR 200 mg/day as continuous infusion

What dose of fludrocortisone is used in refractory shock?

50 mcg PO daily

What are the benefits of steroids in septic shock?

improved time to shock resolution, increase in vasopressor free days