Sepsis Management PDF

# Sepsis 17/04/24, 0:30 Sepsis is a potentially life-threatening condition caused by the body's response to an infection. Septic shock is a subcategory of sepsis that requires vasopressors to maintain a MAP of 65 mmHg and a lactate level > 2 mmol. ## SIRS (Systemic Inflammatory Reponse Syndrome)...

# Sepsis 17/04/24, 0:30 Sepsis is a potentially life-threatening condition caused by the body's response to an infection. Septic shock is a subcategory of sepsis that requires vasopressors to maintain a MAP of 65 mmHg and a lactate level > 2 mmol. ## SIRS (Systemic Inflammatory Reponse Syndrome) * **Fever:** > 38°C * **Heart Rate:** > 90 bpm * **Respiratory Rate:** > 20 bpm * **White Blood Cell Count:** < 4,000 or > 12,000 * **Altered Mental Status:** * Confusion * Hyperglycemia * Protien C Reactive > 120 * Hypothermia PaTi < 300 The management of severe sepsis and septic shock requires: * **Reanimation** * **Antibiotics** * **Drainage of the focus of infection** * **Monitoring** * **Specific Medications** * **Supportive Measures** ### Management of Sepsis * **First Hour Management Goal:** MAP of 65 mmHg * **Rapid and repeated infusions of fluids:** * Crystalloids * Vasopressors * Norepinephrine or Dopamine * Dobutamine * **Low tidal volume oxygen** * **Early, broad-spectrum empiric antibiotic therapy:** Including at least 10 medications; Evaluate antibiotic schema after 72 hours; Continue antibiotic therapy for 7-14 days. ### Control of Sepsis * **Control of the focus of infection** * **Continuous insulin infusion:** 1000 units of rapid insulin (lispro) in 100 mL of normal saline IV = 1 min; Monitor glucose levels and administer supplemental glucose as needed; Consider parenteral glucose at 10%, 1000 mL/24h. * **Control of hyperglycemia:** * Insulin infusion * Dietary control (150 mg/day) * **Steroids:** Hydrocortisone 200 mcg/day, P30-4 doses, for septic shock. * **Other Treatments:** * HIV/Cancer: Amphotericin B ## SOFA (Sepsis Related Organ Failure Assessment) Score | Organ | Points: 0 | Points: 1 | Points: 2 | Points: 3 | Points: 4 | | -------------- | -------- | -------- | -------- | -------- | -------- | | **Respiration** | ≥ 400 | < 400 | < 300 | < 200 | < 100 | | PaO2/FiO2 | | 221-301 | 142-220 | 67-141 | < 67 | | SaO2/FiO2 | | | | | | | **Coagulation** | > 150 | < 150 | < 100 | < 50 | < 20 | | Platelets (10^9/mm³) | | | | | | | **Hepatic** | < 1.2 | 1.2-1.9 | 2-5.9 | 6-11.9 | ≥ 12 | | Bilirubin (mg/dl) | | | | | | | **Cardiovascular** | PAM ≥ 70 | PAM < 70 | DA ≥ 50, < 6 | DA> 5.1-15 | DA > 15 | | Arterial Pressure (mmHg) | | | OR DBT | OR N/A ≤ 0.1 | OR N/A> 0.1 | | **Central Nervous System** | 15 | 13-14 | 10-12 | 6-9 | < 6 | | **ECG** | | | | | | | **Renal** | < 1.2 | 1.2-1.9 | 2-3.4 | 3.5-4.9 | < 500 | | Creatinine (mg/dl) | | | | | | | Urine Output (mL/day) | | | | | < 200 | To identify patients with infection and sepsis, a SOFA score of 2 is required to indicate organ dysfunction. * SOFA scores of 3 and 4 for respiratory failure only apply if the patient is on mechanical ventilation. * If arterial blood gas is unavailable, a SaO2/FiO2 of 235 is equivalent to a PaO2/FiO2 of 200, and a SaO2/FiO2 of 315 is equivalent to a PaO2/FiO2 of 300. * Vasopressors require at least 1 hour of administration to maintain MAP > 65 mmHg; Vasopressor doses are: * Dopamine (DA) * Norepinephrine (N/A) * Dobutamine (DBT) ## qSOFA (Quick SOFA) Score * **Respiratory Rate:** ≥ 22 breaths/minute * **Altered Level of Consciousness:** Glasgow Coma Scale (GCS) ≤ 14 * **Systolic Blood Pressure** ≤ 100 mmHg A qSOFA score of 2 or greater is suggestive of sepsis. ## Management of Sepsis in the Emergency Department 1. **Present and inform** * Gather patient history, including: * Past conditions * Previous admissions * Ongoing conditions * Contact with infected patients * Medications 2. **Anamnesis and information** * Assess the patient’s mental status, including: * Awareness * Orientation * Level of alertness * Obtain vital signs: * Temperature * Heart rate * Respiratory rate * Oxygen saturation * Blood pressure 3. **Physical exam:** * Assess for signs and symptoms of infection, including: * Redness * Swelling * Tenderness * Drainage 4. **Early orders:** * **Oxygen:** * Assess the need for supplemental oxygen. * If oxygen saturation is < 92% or PaO2 < 300, consider nasopharyngeal or venturi oxygen. * If intubation is necessary, evaluate the following criteria: * Glasgow Coma Scale score <= 9 * Oropharyngeal obstruction * Sepsis * Agitation requiring sedation * Respiratory distress * Hypotension * Cardiac arrest * Extensive burns * Severe respiratory failure * **Two peripheral intravenous lines:** * Insert a 14-16 gauge catheter while ensuring placement is appropriate. * **Lab tests:** * Blood cultures: Obtain 3 sets of blood cultures, 2 aerobic and 1 anaerobic. * Complete blood count, coagulation tests, glucose, electrolyte panel, renal function tests, liver function tests, lactate, and procalcitonin. * Chest x-ray. * If necessary, abdominal x-ray and ultrasound. * **Antibiotics:** * Start with a broad-spectrum antibiotic: * **Gram-negative:** * **Piperacillin/tazobactam** 4.05 g IV q6h * **Meropenem** 1-2 g IV q8h * **Ceftazidime** 2 g IV q8h * **Gram-positive:** * **Vancomycin** 15-20 mg/kg IV q12h * **Daptomycin** 6-10 mg/kg IV q24h * **Linezolid** 600 mg IV q12h * **Pseudomonas:** * **Amikacin** 15-20 mg/kg/day IV infusion over 30 minutes * **Tigecycline** 100 mg IV q12h * **Levofloxacin** 500 mg IV q12h * **Ciprofloxacin** 400 mg IV q12h. * **Fluids:** * Administer crystalloid fluids to maintain adequate fluid volume. * Consider an initial bolus of 30 mL/kg of 0.9% saline. * **Fluid Management:** * If the patient is not responding to fluid resuscitation after receiving 2000 mL of fluids, consider vasopressors. * **Vasopressors:** * **Norepinephrine:** 0.1 mcg/kg/min, titrate up to 0.3 mcg/kg/min as needed * **Vasopressin:** 0.03 IU/min * **Dobutamine:** 5 mcg/kg/min, consider only if the patient has a reduced cardiac output. 5. **If the patient isn’t responding to fluids and vasopressors or has a weak pulse:** * **Corticosteroids** * **Hydrocortisone** 200 mg/day for 5-6 days * **Methylene blue** * 100 mg IV infusion for 8 hours ## Management of Sepsis by Area * **Respiratory** * Ceftriaxone 1 g IV q12h * Ceftazidime 2 g IV q8h * Azithromycin 500 mg IV q24h * Linezolid 600 mg IV q12h * Oseltamivir 75 mg IV q12h * **Abdominal:** * Ceftriaxone 1 g IV q12h * Metronidazole 500 mg IV q8h * Piperacillin/tazobactam 4.05 g IV q6h * Daptomycin 6-10 mg/kg IV q24h * Vancomycin 15-20 mg/kg IV q12h ## Other considerations: * **Hypothermia:** * Keep the patient warm and monitor body temperature. * Warm IV fluids to 39°C * **Prevention of stress ulcers:** * Administer proton pump inhibitors (e.g., omeprazole 80 mg IV daily) ## Note: * This is just a basic guide for the treatment of sepsis in the Emergency Department. * It is vital to consult with a medical professional for specific advice on how to best treat sepsis. * Monitoring and careful management are crucial for improving the chances of survival.