Giving IV Fluids. Dr. Tannous (critical care) and Dr. Anderson (ED) say that they try to give the 30ml/kg fluids to patients with sepsis even if they are not hypotensive or have lactate > 4. Doctor Anderson said people with hypotension or lactate definitely have to receive the 30ml/kg as found in the 3-hour sepsis bundles. However, he gives the same fluids to all patients with sepsis regardless of hypotension or lactate level.
SIRS, Sepsis, and Septic Shock Calculator
Antibiotic Duration by Disease State
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THE NEW SEPSIS DEFINITION
Sepsis Organ Failure Assessment (SOFA). Note if you google, “Sepsis Organ Failure Assessment”, you will see several journals call SOFA that way. It’s also called Sequential [Sepsis-related] Organ Failure Assessment. I prefer Sepsis Organ Failure Assessment.
Sepsis = Life-threatening organ dysfunction 2/2 a dysregulated host response to infection.
*The SOFA criteria are basically the same as the main organ dysfunction symptoms in the old definition of severe sepsis.
“Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.
These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.” Sepsis-3
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This JAMA article is the official publication of the definition of sepsis, Sepsis-3.
qSOFA does not replace SIRS in the definition of sepsis
http://www.qsofa.org/research.php
http://www.sccm.org/Research/Quality/Pages/Sepsis-Definitions.aspx
http://jama.jamanetwork.com/article.aspx?articleid=2492856
“According to the new definitions, sepsis is now defined as evidence of infection plus life-threatening organ dysfunction, clinically characterized by an acute change of 2 points or greater in the SOFA score. The new clinical criteria for septic shock include sepsis with fluid-unresponsive hypotension, serum lactate level greater than 2 mmol/L, and the need for vasopressors to maintain mean arterial pressure of 65 mm Hg or greater. A major change in the new definitions is the elimination of mention of SIRS. Components of SIRS include tachycardia, tachypnea, hyperthermia or hypothermia, and abnormalities in peripheral white blood cell count. Many studies have shown that the presence of SIRS is nearly ubiquitous in hospitalized patients and occurs in many benign conditions, both related and not related to infection, and thus is not adequately specific for the diagnosis of sepsis. It is a strength of the consensus definition that it no longer includes SIRS.”
Notes from discussion with Mdulli
- The Surviving Sepsis Campaign 3 hour guidelines start when you diagnose sepsis ( 2 SIRS + Infection). You should not wait till severe sepsis to do that. That means that you should get a lactate, blood Cx, start broad-spectrum abx, and administer fluids to every patient who has any infection source (known or suspected) like CAP, UTI, etc. and meets SIRS criteria. Dr. Mdulli told me this. I also talked with Dr. Kenneth Wyse, ICU doctor who said the same thing. I asked him, does it mean most people admitted to the hospital with any infection like CAP should get a lactate, BCx, start broad-spectrum abx, IVF etc? His response was, “Yes, immediately and repeat lactate in three hours.”
- If a patient has CAP and meets SIRS criteria, the right way to right the diagnosis is Sepsis 2/2 CAP.
- The DRMC antibiotic guidelines for sepsis is for sepsis where the source is NOT known. When the source is known, then you use broad-coverage specific to that system.
- Mdulli doesn’t consider Altered mental status, hyperglycemia, and edema as primary SIRS criteria but as additional criteria. He says that those ones almost always come after the changes in Temp, Resp, Pulse, and WBC. As such, focus on getting two out of those for to meet SIRS criteria and then note the others in addition to those two.
- After 72 hours of therapy is when he recommends reevaluating antibiotics. If there is no symptomatic /clinical improvement, then change the abx. By this time, cultures would have come back since they do so after 2 days. If no cx, consider changing them to something else that is more probable. E.g. if Mdulli has a patient with sepsis 2/2 to CAP (i.e. 2 SIRS + CAP) who is on ceftriaxone and azithromycin on the floor, he will reassess in 72 hours.
- However, if his CAP patient on ceftriaxone and azithromycin goes downhill and is requiring ICU care because of severe sepsis and septic shock, he will escalate the antibiotic coverage to include Vanc + Ceftriaxone + Azithromycin even if he is sure that the source is pulmonary from the CAP. He says many people will go for Vancomycin and Zosyn which is also good at this point.
- But if a patient is so sick as to be in the ICU b/c of sepsis, it is best to air on the side of using broader coverage and going say from ceftriaxone and azithromycin for a CAP source to Vanc + Zosyn. It’s not simply being in the ICU that is the problem but the fact that the sepsis is so bad as to cause the patient to require ICU care that causes you to broaden the spectrum beyond just the source to include covering other possible pathogens as a matter of erring on the side of safety.
Questions from discussion with Dr. Tannous
Dr. Tannous says, “I’d rather over order lactate than under order”. He was saying this in response to some physicians complaining that nurses might be using SIRS criteria + infection too aggressively.
Dr. Tannous says, for the 3-hour sepsis bundle, you give the 30 ml/kg fluid as fast as you can. E.g. a 70kg person would be 2.1 liters. You give that as a bolus. After giving that fluid, no more bolus, then next level is to give them maintenance fluids.
If they are still hypotensive after the 30ml/kg, then you go to pressors, no more boluses.
Dr. Tannous also said that the central venous catheter has fallen out of favor. Research has shown that there is no proof that it helps. He doesn’t do that in the ICU anymore for the purpose of CVP and ScvO2.
However, he said that when a patient gets to the point where they need pressors, they need a central venous catheter because you give pressors through a central venous catheter.
** About the 30ml/kg, he says you give it even if they have CHF or ESRD unless that those are the reasons for admission. For example, if a patient has a history of CHF and is admitted for CAP with sepsis, then you give all of the 30ml/ kgs. He says studies have shown that is the right course to take.
Dr. Tannous says a lactate of greater than 2 for our lab at DRMC and most other labs around the country qualifies as SEVERE sepsis!
Dr. Tannous said the 3-hour bundle
Sepsis, Severe Sepsis, and Septic Shock have distinct ICD-10 codes (found this on Google)
DRMC Sepsis Protocol
Sepsis Nursing Protocol Guideline (DRMC)
Sepsis Identification And Management in Adults (DRMC)
Stony Brook Medicine Sepsis Protocol
Surviving Sepsis Campaign Page
Stony Brook Medicine Sepsis Protocol
Definitions
SIRS (Systemic inflammatory response syndrome): The clinical syndrome that results from a deregulated inflammatory response or to a noninfectious insult.
Sepsis: SIRS that is secondary to infection that has been diagnosed clinically. Positive cultures add to the validity but are not required for the diagnosis.
Severe Sepsis: Sepsis plus at least one sign of hypoperfusion or organ dysfunction (see below), that is new, and not explained by other known etiology of organ dysfunction.
Septic Shock: Severe sepsis associated with refractory hypotension (BP<90/60) despite adequate fluid resuscitation and/or a serum lactate level >=4.0 mmol/L. http://www.survivingsepsis.org/sitecollectiondocuments/protocols-sepsis-treatment-stony-brook.pdf
Sepsis Protocol, Stony Brook Medicine
http://www.survivingsepsis.org/sitecollectiondocuments/protocols-sepsis-treatment-stony-brook.pdf
Surviving Sepsis Campaign Bundles
To be measured within 3 hours
1. Draw Lactate: Measure lactate level
2. Draw Blood Cx: Obtain blood cultures prior to administration of antibiotics
3. Antibiotics: Administer broad-spectrum antibiotics
4. Fluids: Administer 30ml/Kg crystalloid for hypotension or lactate ≥ 4 mmol/L
To be completed within 6 hours
5. Vasopressors: Apply vasopressors (for hypotension that doesn’t respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥ 65 mm Hg
6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥ 4 mmol / L (36 mg/dL):
-Measure central venous pressure (CVP)*
-Measure central venous oxygen saturation (ScvO2)*
7. Draw Lactate: Remeasure lactate if initial lactate was elevated*
*Targets for quantitative resuscitation included in the guidelines are CVP of ≥ 8mm Hg, ScvO2 of ≥ 70%, and normalization of lactate.
Source: http://www.survivingsepsis.org/Bundles/Pages/default.aspx
** The 30ml/kg mentioned in the 3h bundle is given as a bolus. The 30ml/kg bolus is only applicable if there is hypotension or if lactate is > 4
SIRS, Sepsis, Septic Shock Calculator, Mdcalc.com
http://www.mdcalc.com/sirs-sepsis-and-septic-shock-criteria/
Other resources
“In 1992, an international consensus panel defined sepsis as a systemic inflammatory response to infection, noting that sepsis could arise in response to multiple infectious causes and that septicemia was neither a necessary condition nor a helpful term.4 Instead, the panel proposed the term “severe sepsis” to describe instances in which sepsis is complicated by acute organ dysfunction, and they codified “septic shock” as sepsis complicated by either hypotension that is refractory to fluid resuscitation or by hyperlactatemia. In 2003, a second consensus panel endorsed most of these concepts, with the caveat that signs of a systemic inflammatory response, such as tachycardia or an elevated white-cell count, occur in many infectious and noninfectious conditions and therefore are not helpful in distinguishing sepsis from other conditions.5 Thus, “severe sepsis” and “sepsis” are sometimes used interchangeably to describe the syndrome of infection complicated by acute organ dysfunction.” http://www.nejm.org/doi/full/10.1056/NEJMra1208623?rss=mostViewed&
Managing Sepsis in ICU
Young pregnant woman who suffered sepsis complicated by DIC leading to bilateral lower extremity amputation!
Pathophysiology of Sepsis
https://www.youtube.com/watch?v=psB-vYa4Zqw&list=PLI3Wi5O-sngg35YJhMUGi_e7_KmAlV0j1
Sepsis Lecture from UofLIM
Other resources to consult for sepsis
- Pocket Medicine, The Massachusetts General Hospital Handbook of Internal Medicine, 2-23 (5th edition)
- Bacteremia and Sepsis by Russell J. McCulloh and Steven M. Opal in Cecil Essentials of Medicine, 9th Edition, Chapter 89
- Uptodate Article #1: Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis
- Uptodate Article #2: Evaluation and management of severe sepsis and septic shock in adults
- Uptodate Article #3: Pathophysiology of sepsis
- Sepsis and Septic Shock, Infectious Disease Society of America
- AAFP, Early Recognition and Management of Sepsis in Adults: The First Six Hours