Wes Theurer, DO. Recognize sepsis early Understand therapeutic principles Cultures before antibiotics Crystalloid fluid resuscitation Antimicrobials.

2012 Sepsis GuidelinesOverview

Wes Theurer, DO

Objectives

Recognize sepsis early Understand therapeutic principles

Cultures before antibiotics Crystalloid fluid resuscitation Antimicrobials Vasopressor agents

Role of imaging and other cultures

Recognition

Sepsis: suspected infection + systemic

manifestations▪ See Table 1

Severe Sepsis Defintion

Severe Sepsis: acute organ dysfunction secondary to documented or suspected infection

Septic Shock: severe sepsis not reversed with fluid resuscitation

More definitions

Sepsis-induced hypotension systolic blood pressure (SBP) < 90 mm Hg

or mean arterial pressure (MAP) < 70 mm Hg or a SBP decrease > 40mm Hg or less than two standard deviations below normal for age in the absence of other causes of hypotension.

Sepsis-induced tissue hypoperfusion infection-induced hypotension that persists

after fluid challenge, elevated lactate, or oliguria.

Cultures

How many? Two (1 or 2 percutaneous, one from

every pre-existing line) Do it before IV Antimicrobials Draw a lactate while you’re at it

Crystalloid

Crystalloid (1B) – 30mL/kg (or more) (1C)

Albumin for those who continue to require lots of crystalloid (2C)

DON’T use hetastarch (1C)

If not responsive to fluids vasopressors

Kill the Bugs

Antimicrobials within one hour!

Which ones? Many options – probably need

combination

Most common organisms

1. Gram positive bacteria2. Gram negative bacteria3. Mixed bacterial organisms

Viral and fungal are not as common but should be considered.

Antibiotics

Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrug- resistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B).

For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B).

A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B).?

Abx stuff continued

Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).

Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, un-drainable foci of infection, bacteremia with S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia (grade 2C).

Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).

Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause (UG).

Vasopressor Agents

1. Norepinephrine – 1st choice vasopressor (to MAP >65 mm HG) (1B)

2. Epinephrine – 2nd line/additional agent (2B)

3. Vasopressin (0.03 U/min) can be added (UB)

Vasopressor agents continued

Dopamine is not recommended (highly select circumstances) (2C)

Dobutamine if myocardial dysfunction (low filling pressures/ cardiac output) (1C)

IV Hydrocortisone – don’t use if fluids and vasopressor therapy work (2C)

Imaging & other cultures

Prompt imaging studies (to confirm source)

Cultures of other sites if doing so does not cause significant delay in antibiotic administration (grade 1C).

Sim Day Suggestion

Rapid Recognition Treatment

ABC’s IV, O2, Monitor Crystalloid resuscitation Blood Cultures, Lactate Broad spectrum antimicrobials Imaging and other cultures judiciously Vasopressors if not responsive to crystalloid Early consultation

Summary

Recognize sepsis early Understand therapeutic principles

Cultures before antibiotics Crystalloid fluid resuscitation (30mL/kg) Broad spectrum antimicrobials within 1 hour Vasopressor agents when crystalloid not

enough Image to confirm infection source Other cultures if no delay for antibiotics

Key Recommendations

Early quantitative resuscitation within 6 hrs of recognition Blood cultures before antibiotics (1C) Prompt imaging studies (to confirm source) Broad spectrum antibiotics within 1 hour of recognition (1B) Goal: severe sepsis without septic shock Crystalloid (initial fluid) (1B) – 30mL/kg (or more) (1C) Albumin for those who continue to require lots of crystalloid (2C) DON’T use hetastarch (1C) Norepinephrine – 1st choice vasopressor (to MAP >65 mm HG) (1B) Epinephrine – 2nd line/additional agent (2B) Vasopressin (0.03 U/min) can be added last (UB) Dopamine is not recommended (highly select circumstances) (2C) Dobutamine if myocardial dysfunction (low filling pressures/ cardiac

output) (1C) IV Hyxrocortisone – don’t use if fluids and vasopressor therapy work

(2C) Hemoglobin goal: 7-9 g/dL (unless other complication (1B)

Reference

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 Critical Care Medicine February 2013. Vol. 41. No.2