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Sepsis

Sepsis. Paul Szczybor PA-C. The Name Game. Sepsis Severe Sepsis Septic Shock. Septicemia. Urosepsis. What Sepsis is NOT…. Bacteremia Metabolic acidosis Patient looks toxic!. SIRS. Infection. Sepsis. Systemic Inflammatory Response Syndrome (SIRS).

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Sepsis

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  1. Sepsis Paul Szczybor PA-C

  2. The Name Game • Sepsis • Severe Sepsis • Septic Shock Septicemia Urosepsis

  3. What Sepsis is NOT… • Bacteremia • Metabolic acidosis • Patient looks toxic!

  4. SIRS Infection Sepsis

  5. Systemic Inflammatory Response Syndrome (SIRS) • Temperature: >100.4˚(38˚C) or < 96.8˚(36˚C) • Heart Rate: > 90 beats per minute • Respiratory Rate: > 20 breaths per minute or PaCO2 < 32mm Hg • WBC count: >12,000 or <4,000 or > 10% Bands

  6. Sepsis SIRS + infection Severe Sepsis Sepsis + end organ dysfunction Septic Shock Severe sepsis + ↓BP unresponsive to IVF

  7. End Organ Dysfunction Cardiovascular CNS Pulmonary Renal Hematologic GI

  8. “…except on a few occasions the patient appears to die from the body’s response to the infection rather than from it.” Sir William Osler 1904

  9. Proinflammatory Mediators Infection Cytokines SIRS Endothelial cell dysfunction

  10. Endothelial Cell Dysfunction Microvascular thrombi Platelet clumping Unable to regulate blood flow Microvascular permeability Vasodilation Fluid transudation Ischemia Organ dysfunction / Shock SIRS

  11. Mortality

  12. Severe Sepsis is Common* Rate per 100,000 Population † * Calculated data based on information compiled from the American Heart Association, American Cancer Society, National Center for Health Statistics and the US Census Bureau (1995-1999) † Severe sepsis mortality rates range from 28%-50% (79/100,000 to 141/100,000 population).

  13. Severe Sepsis is Increasing in Incidence 600 1,800 Severe Sepsis Cases US Population 1,600 500 1,400 Total US Population (million) Sepsis Cases (x103) 1,200 400 1,000 300 800 2001 2025 2050 Year Angus DC, et al. JAMA 2000;284:2762-70. Angus DC, et al. Crit Care Med 2001;29:1303-10.

  14. Sepsis-Growing Incidence • Increased awareness / uniform definitions • Increased # immunocompromised patients • More aggressive invasive procedures • Resistant organisms • Increased # of elderly patients

  15. Case #1 • 82 yo W ♂ NH resident … “change in mental status” • PMH: CAD, HTN, BPH • Meds: metoprolol 50mg BID ASA 81mg qday simvastatin 20mg qday ● NKA

  16. Case #1 • lethargic, disoriented • BP 100/60 HR 74 RR 26 T 100.5 SpO2 92% • HEENT: dry mucosa, flat neck veins • lungs: coarse crackles RUL • heart: regular, 2/6 systolic murmur • abdomen: benign • extremities: no edema or cyanosis

  17. Case #1 Hgb12 WBC21plt 128 Hct 35 Na140Cl104 BUN50 K4.8CO2 20Cr2.8 Lactate 4.0

  18. What’s next… • Administer antibiotics • Start IVF • Begin “vasopressors” • Check insurance card

  19. Fill the Tank!

  20. Initial Fluid Bolus Normal saline or Lactated Ringers 20-30 ml/kg wide open

  21. Severe Sepsis Fluid unresponsive Lactate > 4.0 Global Tissue Hypoxia Early Goal Directed Therapy

  22. Early Goal-Directed Therapy • Central Venous Pressure (CVP 8-12) • Urine Output (0.5ml/kg/hour) • Mean Arterial Pressure (MAP >65) • ScvO2 (≈ 70%) Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377.

  23. Special Article Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 R. Phillip Dellinger, MD; Mitchell M. Levy, MD; et al for the International Surviving Sepsis Campaign Guidelines Committee Crit Care Med 2008 Vol. 36, No. 1

  24. Antibiotics “Hit ‘em hard and hit ‘em fast!”

  25. Antibiotic Timing 0.8 Survival Fraction 0.7 Fraction of total patients 0.6 0.5 0.4 0.3 0.2 0.1 0.5 1 2 3 4 5 6 9 12 24 36 Time (hrs) Kumar A,Crit Care Med 2006; 34(6): 1589-96

  26. Antibiotic Timing … every hour delay was associated with an approximately 12% decreased probability of survival… Kumar A, Crit Care Med 2006; 34(6): 1589-96

  27. Empiric Antibiotics • Blood Stream Infections (BSI) Mortality • appropriate 20% • inappropriate 34% Leibovici L, J Intern Med 1998; 244:379-386

  28. Cephalosporins Aminoglycosides Penicillins Carbapenem Monobactam Vancomycin Fluoroquinolones Chloramphenicol Macrolides Folic Acid Antagonists Antifungals

  29. Antibiotic Choices Source Host Bug

  30. Case # 2 • 28 yo woman with 3 day h/o abdominal pain following laparoscopy • confusion, BP 80/40 HR 140 R 32 Temp 101° diffuse abdominal tenderness, rigidity • WBC 24k Hgb 15 Hct 45% Bands 46% Platelets 104,000 Lactate 8.7

  31. Control the Source

  32. Glucose control • Maintain serum glucose <150 mg/dL • IV vs. SQ insulin • Start enteral nutrition ASAP Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008 Jan; 36(1): 296-327

  33. Steroids? • Unresponsive to vasopressors • “Stress” dosing • Hydrocortisone 50mg IV q6h Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008 Jan; 36(1): 296-327

  34. Activated Protein C • APACHE II score >25 • Vasopressors • Mechanical ventilation Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008 Jan; 36(1): 296-327

  35. Homeostasis is Unbalanced in Severe Sepsis FIBRINOLYSIS COAGULATION INFLAMMATION Homeostasis Carvalho AC, Freeman NJ. J Crit Illness 1994;9:51-75. Kidokoro A, et al. Shock 1996;5:223-8. Vervloet MG, et al. Semin Thromb Hemost 1998;24:33-44.

  36. Sepsis SIRS + infection Severe Sepsis Sepsis + end organ dysfunction Septic Shock Severe sepsis + ↓BP unresponsive to IVF

  37. Severe sepsis Septic shock + Lactate >4.0 Persistent ↓BP Start E.G.D.T.

  38. Surviving Sepsis Early recognition IV fluid resuscitation Early antibiotics Source control Glucose control Steroids Activated protein C

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