Sepsis

Objectives

● Define SIRS / sepsis / severe sepsis / septic shock

● Early recognition of Sepsis
● Early Goal Directed Therapy
 CASE

● 64yr male
● 24 hr Fever, productive cough, SOB and delirium
● Initial Obs
○ HR 162, RR 40, sats 90% on 15l, BP 85/50 (60), T 103

● History
○ 24 hr Fever, productive cough, SOB and delirium. Last few
hours with altered mental status and progressively less
responsive to wife and inability to complete sentences 2/2
SOB. Wife called 911
 Definitions

● A continuum of severity describing the host systemic

inflammatory response
 SIRS

● SIRS – systemic inflammatory response syndrome

● Must have at least 2 of the following:
○ Temperature >38.5ºC or <36ºC
○ Heart rate >90 beats/min
○ Respiratory rate >20 breaths/min or PaCO2 <32
mmHg
○ WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 %
immature (band) forms
● SIRS is the body’s response to infection,
inflammation, stress.
PATOFISIOLOGI DAN PATOGENESIS SEPSIS
Infeksi adalah istilah untuk menamakan keberadaan berbagai kuman yang masuk ke dalam
tubuh manusia. Bila kuman berkembang biak dan menyebabkan kerusakan jaringan disebut
penyakit infeksi.

Pada penyakit infeksi terjadi jejas sehingga timbul reaksi inflamasi. Meskipun dasar proses
inflamasi sama, namun intensitas dan luasnya tidak sama, tergantung luas jejas dan reaksi
tubuh.

Inflamasi akut dapat terbatas pada tempat jejas saja atau dapat meluas serta menyebabkan
tanda dan gejala sistemik. Sepsis adalah suatu sindroma klinik sebagai manifestasi proses
inflamasi imunologik yang terjadi karena adanya respon tubuh (imunitas) yang berlebihan
terhadap rangsangan produk mikroorganisme .
 Manifestasi klinik inflamasi sistemik disebut systemic inflamation respons syndrome
(SIRS), sedangkan sepsis adalah SIRS ditambah tempat infeksi yang diketahui. Meskipun
sepsis biasanya berhubungan dengan infeksi bakteri, namun tidak harus terdapat
bakteriemia.

Berdasarkan konferensi internasional tahun 2001 memasukkan petanda procalcitonin

(PCT) sebagai langkah awal dalam mendiagnosa sepsis. Purba D(2010) di Medan, pada
penelitian prokalsitonin sebagai petanda sepsis mendapatkan nilai PCT 0,80 ng/ml sesuai
untuk sepsis akibat infeksi bakteri dan kadarnya semakin meningkat berdasarkan keparahan
penyakit.
 Sepsis and Severe Sepsis

● Sepsis – SIRS + suspected or confirmed infection

(documented via cultures or visualized via physical
exam/imaging)
● Severe Sepsis – Sepsis + at least one sign of organ
hypo-perfusion or dysfunction
Areas of mottled skin Disseminated intravascular coagulation
Capillary refill > 3 secs AKI
UOP < 0.5cc/kg /hr ARDS or acute lung injury (ALI)
Lactate > 2mmol /L Cardiac dysfunction on echo
Altered mental status Plt < 100
Abnormal EEG Troponin Leak
 Septic Shock

● Septic Shock - Severe sepsis plus one of the following

conditions:
○ MAP <60 mm Hg (<80 mm Hg if previous hypertension) after
adequate fluid resuscitation
○ Need for pressors to maintain BP after fluid resuscitation
○ Adequate fluid resuscitation = 40 to 60 mL/kg saline solution
(NS 5L-10L)
○ Lactate > 4mmol /L
 SURVIVING SEPSIS CAMPAIGN

● STEP 1: Identify SEPSIS

● STEP 2: Categorize SEPSIS
● STEP 3: Initiate TREATMENT
We recommend the protocolized, quantitative
resuscitation of patients with sepsis- induced tissue
hypoperfusion. During the first 6 hours of
resuscitation, the goals of initial resuscitation should
include all of the following as a part of a treatment
protocol:
a) CVP 8–12 mm Hg
b) MAP ≥ 65 mm Hg
c) Urine output ≥ 0.5 mL/kg/hr
d) Scvo2 ≥ 70%.
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION*:
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
* “Time of presentation” is defined as the time of triage in the emergency department
or, if presenting from another care venue, from the earliest chart annotation
consistent with all elements of severe sepsis or septic shock ascertained through
chart review.
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
5. Apply vasopressors (for hypotension that does not respond to initial fluid
resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
6. In the event of persistent hypotension after initial fluid administration (MAP < 65
mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue
perfusion and document findings according to Table 1.
7. Re-measure lactate if initial lactate elevated.
DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH
EITHER
• Repeat focused exam (after initial fluid resuscitation) by licensed independent
practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findin
OR TWO OF THE FOLLOWING:
• Measure CVP
• Measure ScvO2
• Bedside cardiovascular ultrasound
• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
 Antibiotics

○ Cultures / Antibiotics / Labs

• Cultures PRIOR to Antibiotics ( 2 Sets, one peripheral and one
from any line older than 48hrs)
• IV Abx within 3 hrs in the ED, within 1 hr in the ICU
○ Broad Spectrum, combination therapy for neutropenic and
patients with pseudomonas risk factors
○ Vancomycin
○ Consider need for Source Control !
• Drainage of abscess or cholangitis, removal of infected catheters,
debridement or amputation of osteomyelitis
 Fluid therapy

● Central Line Access (Fluid hydration +/- pressor)

● 1st line therapy – fluids, fluids, fluids!
● Crystalloid equivalent to colloid
● Initial 1-2 Liters (20mg /kg) crystalloid or 500 ml
colloid
● Careful in CHF patients !!
 Pressors

● See separate lecture on vasopressors

○ Start with Levophed (norepinephrine) as first line therapy +/-
Vasopressin
○ Consider Dopamine
 Corticosteroids

● Use in Septic Shock, if NO response to vasopressors

and fluids

○ HYDROCORTISONE 200mg -300mg / day Divided doses

(Q6hrs)
• Initial Dose 100mg IV x1
 KEY TAKE HOME POINTS

● Recongnize Sepsis EARLY and determine SEVERITY

● EARLY Antibiotics are critical to resolution of shock
● RESUSCITATE severe sepsis and septic shock
● EARLY GOAL DIRECTED THERAPY