SEPSISEM Student Lecture Series

CASE STUDYA 53-year old woman presents complaining of

several days of fever, generalized malaise, nausea & vomiting. She has a PMH of diabetes and HTN and takes Glucophage and Lisinopril.

Initial VS: 105/54 110 24 100.4 O2 sat 96%

PE: significant for mild lethargy (but she is A&Ox4); mild diffuse abdominal tenderness to palpation – otherwise WNL

WHAT NOW?List 5 initial steps in the management of this

patient

List 5 differential diagnoses

List 5 tests or interventions

SEPSISA continuum … from

SIRSSepsisSevere SepsisSeptic ShockDEATH

SIRSRequires 2 out of 4 of the following:

Temp >38.0 or <36.0HR>90 RR>24 or PaCO2<32WBC<4000 or >12000 OR bands >10%

SEPSISSystemic response to host infectionSIRS + A SOURCE

Encompasses body’s own response to pathogen – characterized by derangements in inflammation, coagulation & fibrinolysis

May progress to abnormal vasodilation, tissue hypoperfusion, microcirculation thrombosis … to ORGAN DYSFUNCTION

Increased risk in ...

SEVERE SEPSISSepsis + organ failure OR lactate level >4

CNSPulmonary (ALI)Heme (coags & platelets)Liver ( bili)Kidney (AKI)Circulatory system

SEPTIC SHOCKSepsis + hypotension

Unresponsive to initial bolus (20-30 cc/kg)Most septic patients are UNDER-resuscitated

Hypotension = SBP<90 OR 40 mmHg below baseline

OR MAP <65 mmHg or >25mmHg below baseline

EPI/PATH OF SEPSIS10th leading cause of mortality750,000 hospitalizations/yearMost common sources:

LungAbdomenGUSkin/soft tissueCNS

ED WORKUP OF SEPSISCAREFUL history

Complaints may be nonspecific, especially very old/young

VITAL SIGNS ARE JUST THAT … but lack of fever rules out nothing

CAREFUL physicalInspect every inch/every orifice

BE SUSPICIOUS

ED WORKUP OF SEPSISLabs

The usuals – CBC, CMP, U/A, CXR, EKGThe unusuals:

Lactate ?procalcitonin? Cultures of every fluid

ImagingXRUS – RUSH protocol/IVC collapseCT

>50% collapse during inspiration indicates low CVP/likely fluid responsiveness

TREATING SEPSIS: EGDTLandmark study (2001) showed that

“bundling” sepsis management techniques and starting them in the ED showed mortality benefit (NNT=6)

Focuses on aggressively managingPreloadAfterloadOxygenationSource control

EGDT ALGORITHM

THE ABCs of EGDT“Are you OK?”

Rapid identification of the septic patientInitiating diagnostic steps immediately (IV,

monitor, early lactate measurement)

THE ABCs of EGDTA & B – oxygenation status & work of

breathingObvious airway compromise/respiratory

distress = easy!Measures of poor oxygenation:

Lethargy, restlessness, altered MS Pulse Ox/RR/PaCO2 ScvO2 – what the heck is that??

poor oxygen delivery to tissues/overwhelming oxygen debt

(<70% = poor O2 delivery)Early intubation & mechanical ventilation

THE ABCs of EGDTOther adjuncts to A&B

Transfusion if hematocrit <30%Lactate – measure of anaerobic metabolism of

tissues Even mild elevations (>2) associated with increased

mortality

THE ABCs of EGDTC – circulatory statusBP is an imperfect gauge of true circulation!

Look for subtle signs of hypoperfusion … like:

Going IN: Rapid central venous access (<2hr)Preload – multiple IVF bolusesAfterload – pressors (generally

norepinephrine)Coming OUT: measure strict UOP

THE ABCs of EGDTD&E – disability & exposure

WHERE IS THE SOURCE?? Full inspection of the patient Lung – most common Kidneys/bladder Skin/soft tissue GI GU/GYN Other (FBs, CNS, bone, etc) UNKNOWN in up to 1/3 of cases

BROAD Abx coverage until you know what bug (culture, culture, culture!)

GOALS OF EGDT – when to stop?Airway/Breathing

ScvO2 >70% By means of: intubation/ventilation; transfusion +/- addition of inotrope if Hct<30% Improving lactate level

CirculationCVP 8-12 (must measure thru central line;

also use IVC)Uop >0.5 cc/kg/hrMAP 65-90 mmHg

ADJUNCT SEPSIS THERAPIESSteroids – very controversial

Generally reserved for the patient in septic shock unresponsive to pressor & fluid therapy

Mechanical ventilation lung-protective strategies Low TV, low plateau pressures

Aspiration precautionsTight glucose controlGI/ulcer & DVT prophylaxis

PATIENT DISPOAdmit, admit, admit!!To the floor ONLY if mild sepsis and

responding to ED therapyTHESE PATIENTS GET WORSE QUICKLYMortality rates

20% sepsis40% severe sepsis60% septic shockIncrease with every organ system involved

BACK TO THE CASE …Significant labs:

WBC 9,000 15% bandsH/H 9.2/28.3Glu 186HCO3 16U/A + nitritesCXR clear

How would you manage this patient??

SEPSIS: TIME=MORTALITY