Intern Boot Camp: Sepsis - PowerPoint PPT Presentation

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Intern Boot Camp: Sepsis

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Severe sepsis. Septic shock. SIRS Physiology. Inflammatory state affecting the whole body. Release of cytokines acute phase reaction fever, leukocytosis – PowerPoint PPT presentation

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Title: Intern Boot Camp: Sepsis


1
Intern Boot CampSepsis
  • Cassie Kovach
  • PGY-3

2
Outline/Objectives
  • Identification of sepsis
  • Work up of sepsis
  • Triaging sepsis
  • Treatment of sepsis

3
Outline/Objectives
  • Identification of sepsis
  • Work up of sepsis
  • Triaging sepsis
  • Treatment of sepsis

4
Sepsis is a continuum
  • SIRS (Systemic Inflammatory Response Syndrome)
  • Sepsis
  • Severe sepsis
  • Septic shock

5
SIRS Physiology
  • Inflammatory state affecting the whole body
  • Release of cytokines
  • ? acute phase reaction? fever, leukocytosis
  • ? vasodilation/vascular leak? hypotension,
    tachy, edema, hypoxemia, tissue
    hypoperfusion
  • Non-specific

6
SIRS Criteria
  • Temperature
  • gt 38.0 or lt 36.0
  • HR
  • gt 90
  • Respiratory status
  • RR gt20 or PaCO2 lt32
  • WBC
  • gt12,000 or lt4,000 or gt10 bands

BP IS NOT A SIRS CRITERIA
7
Sepsis
  • 2/4 SIRS criteria identified or suspected
    infection

8
Severe sepsis
  • Sepsis with organ dysfunction
  • Cardiovascular
  • Sepsis-induced hypotension SBP lt90 or MAP lt70
    mmHg or SBP decr gt40 or lt2 SD below normal for
    age in absence of other causes
  • Elevated lactate
  • UOP lt 0.5 mg/kg/hr for 2 hrs despite adequate
    hydration
  • Pulmonary
  • ALI with PaO2/FiO2lt250 in the absence of PNA
  • ALI with PaO2/FiO2lt200 in the presence of PNA
  • Liver
  • Bili gt 4.0
  • Renal
  • Cr gt2.0 (incr gt0.5)
  • Hematologic
  • Plt lt 100,000
  • INR gt 1.5

9
Septic shock
  • Sepsis hypotension despite adequate fluid
    resuscitation

10
Sick or not sick?
  • Severe sepsis/septic shock mortality 18-46
  • 10 of all pts in ICU
  • Most common cause of death in ICU

11
Case 1
  • 38 yo F just finished running marathon, goes to
    medical tent because of lightheadedness
  • VS 37.4, 130, 88/60, 24, 97 RA
  • Labs not available
  • How many SIRS criteria?
  • 2
  • Does this patient have sepsis?
  • No

12
Case 2
  • 65 yo M presents with productive cough, fever,
    chills.
  • VS 38.1, 92, 120/80, 16, 90 RA
  • Labs WBC 3.8, Hb 9, plt 180
  • RFP WNL, HFP WNL, lactate WNL, coags WNL
  • How many SIRS criteria?
  • 3
  • Does this patient have sepsis?
  • Yes
  • Would it make a difference in diagnosis of sepsis
    if had CXR which showed LLL infiltrate?
  • No
  • Does this patient have severe sepsis?
  • No
  • Does this patient have septic shock?
  • No

13
Case 3
  • 89 yo F sent from NH with confusion, diarrhea
  • VS 35.8, 98, 22, 85/45, 97 RA
  • Labs WBC 10,000 with 12 bands, Hb 10, plt 160
  • bicarb 15, Cr 1.3 (baseline 0.7), lactate 4.1
  • ABG 7.29/25/89
  • How many SIRS criteria?
  • 4
  • Does this patient have sepsis?
  • Yes
  • Does this patient have severe sepsis?
  • Yes
  • Does this patient have septic shock?
  • Possibly- will need to see how her BP
    responds to IVFs

14
SIRS Criteria
  • Temperature
  • gt 38.0 or lt 36.0
  • HR
  • gt 90
  • Respiratory status
  • RR gt20 or PaCO2 lt32
  • WBC
  • gt12,000 or lt4,000 or gt10 bands

BP IS NOT A SIRS CRITERIA
15
Outline/Objectives
  • Identification of sepsis
  • Work up of sepsis
  • Triaging sepsis
  • Treatment of sepsis

16
History?
  • Source
  • Severity

17
History?
  • Source
  • Lung
  • Cough, sore throat, rhinorrhea
  • Sick contacts
  • Blood
  • Fatigue, lines in place, IVDU
  • Urine
  • Dysuria, hematuria, flank pain
  • GI
  • Diarrhea, nausea, vomiting, abd pain
  • Recent abx or hospitalization, recent travel,
    sick contacts
  • Other Skin/soft tissue, bone/joint, ascites,
    CNS, heart
  • Skin changes, rash, joint pain, HA, confusion,
    back pain, neck stiffness, photophobia

18
History?
  • Severity
  • Fevers/chills, appetite, po intake
  • Progression
  • Onset

19
Labs?
  • Source
  • Severity

20
Labs?
  • Source
  • Lung
  • sputum cx
  • Blood
  • Bcx 2 peripheral 1 from each line the pt has
    (central lines, HD lines, art lines, etc)
  • Urine
  • UA Ucx
  • GI
  • C diff, fecal leuks, stool cx
  • Other
  • culture of any drainage, diagnostic paracentesis,
    LP, ESR, CRP

ALWAYS CULTURE BEFORE STARTING ANTIBIOTICS

21
Labs?
  • Severity
  • Does patient have evidence of any organ damage?
  • ? Need to evaluate organ systems to determine
  • CBC
  • RFP
  • HFP
  • Lactate
  • Coagulation screen
  • ABG
  • ScvO2

22
Studies?
  • Source
  • Severity

23
Studies?
  • Source/Severity
  • Lung
  • CXR, CT chest
  • Blood
  • TTE
  • Urine/GI
  • CT abd
  • Other
  • CT head, MRI (for OM)

24
Outline/Objectives
  • Identification of sepsis
  • Work up of sepsis
  • Triaging sepsis
  • Treatment of sepsis

25
When to transfer to MICU
  • Sepsis
  • Usually can treat on the floor
  • Severe sepsis
  • Floor or MICU depending on how severe the organ
    dysfunction is
  • Severe lactic acidosis? MICU
  • Respiratory distress requiring intubation? MICU
  • Septic shock
  • MICU

26
Outline/Objectives
  • Identification of sepsis
  • Work up of sepsis
  • Triaging sepsis
  • Treatment of sepsis

27
Treatment
  • Early Goal Directed Therapy
  • Rivers et al 2001
  • Surviving Sepsis Campaign
  • International guidelines last came out in 2012
  • Recently updated in April 2015 to incorporate new
    studies on sepsis

28
Early Goal Directed Therapy
  • Single center, 263 enrolled patients
  • Purpose evaluate efficacy of 6 hrs of EGDT prior
    to admission to ICU
  • Results
  • 30.5 mortality in EGDT group compared to 46.5
    mortality in standard therapy (p0.009)
  • During interval from 7-72 hrs, pts in EGDT had
    higher mean ScvO2, lower lactate, higher pH than
    standard therapy
  • We typically follow a version of the algorithm
    from this trial in the ICU

29
Early Goal Directed Therapy algorithm
EARLY Initial 6 hrs of resuscitation in the ED
GOAL DIRECTED
CVP gt 8
MAP gt65
ScvO2 gt70
30
CVP??
  • Approximation of R atrial pressure
  • Gives an idea of volume status
  • Measured by the nurses off of a central line
    (terminates in the SVC near the R atrium)
  • Mechanical ventilation increases CVP (because of
    PEEP)

31
MAP??
  • Mean arterial pressure
  • Approximates average blood pressure throughout
    the cardiac cycle
  • MAP 2/3 DBP 1/3 SBP
  • Automatically calculated in our EMR and on BP
    monitor

32
ScvO2??
  • Central venous O2 saturation
  • the oxygen saturation of blood that is
    returning to the R atrium (lowest O2sat in the
    body before going to lungs)
  • Drawn from a central line
  • Indication of tissue hypoxia (more tissue hypoxia
    ? more oxygen extraction at tissue level ?
    decreased O2 saturation of blood returning to
    heart)

33
Early Goal Directed Therapy algorithm
EARLY Initial 6 hrs of resuscitation in the ED
GOAL DIRECTED
CVP gt 8
MAP gt65
ScvO2 gt70
34
ProCESS Trial
  • Published in NEJM May 1, 2014
  • Multicenter, 1341 patients enrolled
  • Purpose to determine if EGDT is generalizable
    and if all aspects of protocol are necessary
  • Results
  • At 60 days no sig difference between EGDT and
    either protocol-based standard therapy group or
    usual-care group
  • No sig difference in 90 day mortality, 1 yr
    mortality, or need for organ support
  • Conclusion protocol-based resuscitation of
    patients in whom septic shock was diagnosed in
    the emergency department did not improve
    outcomes.

35
ARISE Trial, ProMISE Trial
  • Published in NEJM in Oct 2014 and April 2015
  • Also multicenter, large trials (ARISE Australia,
    New Zealand, ProMISE England)
  • General conclusion from both Strict EGDT
    protocol did not improve outcome

36
Surviving Sepsis Campaign
  • Takes several studies into account when
    developing international guidelines for treating
    sepsis
  • Splits care in to 2 bundles one to be
    completed within 3 hrs and the other within 6
  • Note all groups in ProCESS trial essentially
    followed the 3 hr bundle
  • Updated in April 2015 to take into account the 3
    new trials evaluating EGDT

37
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38
Surviving Sepsis Campaign Update
39
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40
Initial Treatment
  • Antibiotics
  • If source is known, cater abx to the source
  • If source is unknown, use broad spectrum
  • Vanc/zosyn
  • Fluids
  • Fluids
  • Fluids
  • Remove potential source (line holiday) within 12
    hrs
  • Obtain labs to help determine severity (lactate)

WHEN GIVING FLUIDS, KEEP IN MIND PTS RENAL
FUNCTION AND EF
41
Hypotension
  • If not responsive to adequate hydration, will
    need pressors in the MICU
  • Adequate 30 cc/kg (in 70 kg person, 2 L)

42
Pressors
  • Need central line
  • Aggressive fluid resuscitation
  • Administration of pressors
  • Measure CVP
  • Need arterial line
  • More accurate BP monitoring
  • Know second-to-second changes in BP

43
Pressors
  • Norepinephrine (Levophed) is 1st pressor used in
    sepsis
  • Others you can add on if necessary
  • Vasopressin
  • Epinephrine
  • Phenylephrine
  • Dopamine

44
Goals for treatment
  • MAP gt65
  • CVP 8-12 (not intubated), 12-15 (intubated)
  • ScvO2 gt70
  • Normal lactate
  • UOP gt 0.5 ml/kg/hr

45
Tools for treatment
  • Fluids
  • Antibiotics
  • Pressors
  • Blood products- if Hb lt7, plt lt10,000
  • (Albumin)
  • Steroids- only if fluids/pressors not adequate
  • Mechanical ventilation
  • Central lines/arterial lines
  • Nutrition- in first 48 hrs
  • DVT/stress ulcer ppx

46
Summary
  • SIRS criteria Tgt 38.0 or lt 36.0, HRgt 90, RR gt20
    or PaCO2 lt32, WBC gt12,000 or lt4,000 or gt10 bands
  • Sepsis workup should focus on identifying source
    and severity
  • Initial treatment cx, abx, fluids
  • Patients with septic shock and some with severe
    sepsis require MICU
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