Definition: Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
Diagnosis
H&P consistent with sepsis.
Labs:
-CBC w/ diff, CMP, Coags (PT/INR), D-dimer
-Serum lactate
-ABG (as needed to eval for acidosis, hypoxemia, or hypercapnia).
-Cultures (see below).
-UA, Procalcitonin.
-Imaging targeted at suspected site of infection (e.g. CXR, CT chest/and or abd).
Diagnostic criteria for sepsis reviewed.
qSOFA score:
SOFA score:
Treatment
-ABCs: Secure the airway (if indicated), correct hypoxemia, and establish IV access for the early administration of fluids and antibiotics ASAP.
-Broad-spectrum antibiotics (after getting cultures).
-IVF Resuscitation: Sepsis Bundles initiated. 30 mL/kg of NS or LR given as boluses unless there is clear pulmonary edema. This is often 2 to 3 liters in the first 3 hours. More if needed.
-Mgt of Septic Shock with fluids and pressors reviewed.
Choosing antibiotics
In choosing antibiotics, consider the “patient’s history (eg, recent antibiotics received, previous organisms), comorbidities (eg, diabetes, organ failures), immune defects (eg, human immune deficiency virus), clinical context (eg, community- or hospital-acquired), suspected site of infection, presence of invasive devices, Gram stain data, and local prevalence and resistance patterns. Antimicrobial choice should be tailored to each individual.”
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**Consult this uptodate.com article if you have access to it.
Cultures: Both aerobic and anaerobic peripheral blood cultures (from at least two different sites) and “cultures from suspected sources (e.g, sputum, urine, intravascular catheter, wound or surgical site, body fluids) from readily accessible sites. For patients with a central vascular catheter(s) suspected to be the source, blood should be obtained both from the catheter(s) and from peripheral sites.”UTD
“Empiric antibiotic therapy is targeted at the suspected organism(s) and site(s) of infection and preferably administered within the first hour”
What to do when lactate is > 4
-After giving initial 30 mg/kg fluids, reassess lactate.
-Give additional 20 mg/kg fluid and reassess lactate.
-Give abx quickly.
-Your target is a lactate < 2
“Broad spectrum is defined as therapeutic agent(s) with sufficient activity to cover a broad range of gram negative and positive organisms and, if suspected, against fungi and viruses.”
“An elevated serum lactate (eg, >2 mmol/L or greater than the laboratory upper limit of normal) may indicate the severity of sepsis and is used to follow the therapeutic response”
Important Articles
- Sepsis page.
- Sepsis Mnemonic.
- “Other interventions in early goal-directed therapy that have been shown to improve mortality rates ‘in sepsis patients’ include blood transfusions, low-dose corticosteroid therapy, and conventional (not intensive) glycemic control with a target glucose level of <180 mg/dL. Intensive management of glucose in critically ill adult patients (a target glucose level of 80–110 mg/dL) has been shown to increase mortality.” ABFM critique
For patients who are vasopressor dependent, low-dose corticosteroids can be considered.
References
http://www.survivingsepsis.org/Guidelines/Pages/default.aspx
Gauer RL: Early recognition and management of sepsis in adults: The first six hours. Am Fam Physician 2013;88(1):44-53. 2) Seymour CW, Rosengart MR: Septic shock: Advances in diagnosis and treatment. JAMA 2015;314(7):708-71