Sepsis

Jacob Lee, Jessica Reed

Definitions (Sepsis 3)

  • Sepsis: Organ dysfunction (change in total SOFA score ≥ 2 points) from dysregulated host response to infection
  • Septic shock: Sepsis + vasopressor requirement to maintain MAP ≥ 65 mmHg + serum lactate > 2 mEq/dL despite adequate volume resuscitation

Evaluation: Early screening for identification of infection

  • Screening: preferably incorporate multiple
    • SIRS, NEWS, MEWS superior to qSOFA as single-agent-screening tools (more sensitive)
      • SIRS:
        • RR >20 / min
        • T <36C or >38C
        • HR >90 bpm
        • WBC <4 or >12x10^9/L or >10% bands
    • SOFA (less sensitive, more specific): PaO2/FiO2, Thrombocytopenia, Hyperbilirubinemia, Hypotension, AMS, Kidney Injury, UOP.
    • Source Evaluation: Cultures before starting antibiotics is preferred. However, do not delay antibiotics for cultures if unable to obtain them promptly. Blood cx x2 (preferably from peripheral veins via venipuncture), Urine cx. Culture from central access points if present and patient is newly being admitte
    • Consider sputum cx, wound cx, other body fluid cx (thoracentesis, paracentesis, LP, joint aspiration) based on clinical picture
    • Make sure to do a full body physical exam to assess for SSTI/obvious wounds.
    • Provide source control as soon as possible; Limitations to source control: lines, drains, catheters, ports, hardware, etc.
  • Labs: Lactate, CBC w/ diff, BMP, HFP
    • Consider DIC labs for septic shock if clinical suspicion (LDH, Haptoglobin, Fibrinogen, PT, PTT, INR)
  • Imaging: X-ray, CT, or US depending on suspected source

Management: After screening, early antibiotic administration and fluid resuscitation

Antiobiotics

  • Earlier = better (septic shock – within 1 hour; sepsis alone – within 3 hours)
  • Empiric treatments: should target organisms based on suspected source
    • MRSA coverage: Vancomycin/daptomycin (unless PNA suspected)/linezolid/ceftaroline
      • Risk factors for MRSA: Previous MRSA infection, known MRSA colonization, close contact with MRSA, cavitation on CXR, dialysis, immunosuppressed, recent antibiotics, recent hospitalization, recent influenza illness
    • Pseudomonas coverage: Piperacillin-tazobactam/cefepime/gentamicin
      • Preferred for sicker patients with MDR risk factors (recent antibiotics, recent hospitalization, immunosuppression, hemodialysis)
    • Fungal coverage: Fluconazole/micafungin
      • Fluconazole/micafungin: If high risk for candida (neutropenic, receiving TPN, abdominal surgery, recent antibiotic usage, >1 site of colonization)
      • Voriconazole/itraconazole: If high risk for aspergillus (asthma with hemoptysis, nodules/cavitations on lung imaging)
      • Liposomal amphotericin if high risk for mucor/Rhizopus or disseminated crypto (uncontrolled DM with sinus pain/proptosis, uncontrolled HIV, immunosuppression with nodules on lung imaging)
    • MDR coverage: if prior MDR infection (-penem) or high risk (dual Gram-Negative coverage)
      • During the day, will need ID attending approval. Overnight, can order one dose but will need ID approval for following doses
    • Anaerobic coverage: Metronidazole/Piperacillin-tazobactam/Ampicillinsulbactam/Clindamycin
      • Recommended for lung abscess or empyema and intra-abdominal infections
      • Generally, not recommended for aspiration PNA (low quality evidence, guidelines mixed). Consider if poor dentition and higher likelihood of anaerobic involvement
    • Atypical coverage: Consider if concern for community respiratory source (Azithromycin/Levofloxacin/Doxycycline); should be given to any patient admitted to ICU for community-acquired pneumonia
  • Source Control: If unable to find source despite routine imaging, could consider PET vs tagged WBC scan
  • De-escalation: When source control obtained, use susceptibilities, MRSA nasal swab results, and clinical evaluation to decide how and when to de-escalate and discontinue antimicrobials; procalcitonin trend may also be helpful in certain clinical situations

Fluids

  • Initial resuscitation with at least 30 mL/kg (ideal body weight) of balanced IV crystalloid fluid (prefer LR > NS), given within the first 3 hours.
  • Assess fluid responsiveness with an intravascular volume assessment (leg raise, US IVC, pulse pressure)
  • Blood: When Hb < 7 or active and large volume bleed (Hb <8 for CAD, brisk bleed suspected)

Post-resuscitation management

Access

  • Arterial line: Preferred for hemodynamic monitoring when in shock
  • Central line: For pressor administration
    • Can run peripherally if line is above the AC, levophed is running less than 15 mcg/min, and if needing for <48 hours

Vasopressors

  • Start if MAPs persistently < 65 mmHg after fluid resuscitation
  • Via CVC, PICC, or Port, or sometimes briefly peripherally (see above)
  • Target MAP ≥ 65 mmHg. Use lactic acid, mentation, and urine output as guides to adequate perfusion
  • 1st Line NE, 2nd Line Vasopressin, 3rd Line Epi, 4th Line Ang II/Dopamine
    • SOAP II Trial: NE > Dopamine (less arrhythmias)
  • Other options:
    • Phenylephrine - May be useful in tachyarrhythmias to slow HR. Also comes in the code cart which makes this a good option if other pressors aren’t immediately available
    • Ang II - Contraindicated in patients with CHF, VTE/hypercoagulable, thrombocytopenia <50k, severe bronchospasm
      • Needs approval from MICU director for order
    • Low CO: Dobutamine + NE OR Epi single agent
  • Need ulcer prophylaxis w/ PPI or H2 blocker (preferably PO if possible)

Steroids

  • Persistent septic shock w/ ongoing pressor requirements, consider IV corticosteroids (particularly beneficial in ARDS, severe CAP)
  • Hydrocortisone 100 mg q8 or 50 mg q6 IV +/- fludrocortisone 50 μg (if concerned for adrenal insufficiency) enteral daily for 7 d or until out of shock

Additional management

  • NaHCO3 – may be useful if pH ≤ 7.1  
  • Early enteral nutrition (within 72 hours) if possible, would start at a trickle / trophic rate
  • AVOID beta-blockers unless you think HR compromising cardiac output by limiting diastolic filling/lack of atrial kick in afib; this is a physiologic compensatory response
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