Sepsis and Septic Shock

“Top 5 Management Pearls”

IDENTIFY!!!

Diagnostic Criteria: you should memorize these…

SIRS

Requires 2 of the following:

Severe SIRS

Must meet criteria for SIRS, plus 1 of the following:

a. Temp >38.3° or <36.0° C

b. Tachypnea (RR>20 or MV>10L)

c. Tachycardia (HR>90, in the absence of intrinsic heart disease)

d. WBC >10,000/mm3 or <4,000/mm3 or

>10% band forms on differential

a. Altered mental status

b. SBP<90mmHg or fall of >40mmHg from baseline

c. Impaired gas exchange (PaO2/FiO2 ratio<200-250)

d. Lactic acidosis (pH<7.30 & lactate > 1.5 x upper limit of normal)

e. Oliguria or renal failure (<0.5mL/kg/hr)

f. Hyperbilirubinemia

g. Coagulopathy (platelets < 80,000-100,000/mm3, INR >2.0,

PTT >1.5 x control, or elevated fibrin degredation products)

Sepsis = >2 SIRS + source
Septic shock = Sepsis + hypotension

TREAT!!!

Fluids

The average sepsis patient is down 4-8L!!!

Go get 4 bags yourself, put the first two on pressure bags and harass the nurses to get the next two in!

Even CHFers need fluids!!!

Check their IVCP (see Ultrasound video) and if they are dry, hammer them with fluids, give them 500-1000 ml boluses every 30 min until there MAP > 65 or IVC variation on US is < 30% (see below).
If you are really good, take a look at their contractility yourself with the US to assess diastolic vs systolic dysfxn

During the first 24h, pt’s need fluids
If you start pressors, continue to give them fluids
If they go into pulmonary edema, tube them

Decreases work of breath and further pulmonary fluid losses

Antibiotics

Start them early, hit them broad!

Multiple studies validate that mortality is directly attributed to narrow spectrum/inappropriate antibiotics started in the ED (5x increased mortality)

MONITORING!!!

IVC Pressures: >16-30% variation indicates volume depletion
Goal CVP is 8-12 in non-intubated pts but 12-15 in intubated pts

All CVP sites are created equal when it comes to monitoring, INCLUDING femoral
If you are using CVP, give a fluid challenge…(2-5 Rule)

CVP changes <2, give more fluids
CVP changes 2-5, wait 10min and reassess
CVP changes >5, hold on fluids

Arterial line: respirophasic variation >15% indicates dehydration

Goal MAP 85-100

Lactate clearance (serial ABG/VBGs) should be your resuscitative marker

ADJUNCTS!!!

Steroids

Give early if septic and COPD
Give low-dose, hydrocortisone 50mg q6h when initiating pressors

Calcium

Consider as an adjunct to improve cardiac contractility

Glucagon

Consider in pt’s on CCBs/BBs

Glucose

Goal blood sugar is b/w 90-120, use the insulin drips!

ONGOING MANAGEMENT!!!

These are NOT auto-pilot protocol patients…doctors save septic patients, not nurses
Check in on them often, repeat blood-work, consider things you are missing, re-examine

In the real world these are patients that you will bill heavy critical care hours for