SepsisSepsis

54 year old man with a past history of smoking 54 year old man with a past history of smoking and diabetes presents to the emergency and diabetes presents to the emergency department with a one week history of department with a one week history of progressive unwellness.progressive unwellness.

He describes fever and chills over the last three He describes fever and chills over the last three days with cough and swelling around his left days with cough and swelling around his left ankle.ankle.

At the triage desk, his blood pressure is 83/44, At the triage desk, his blood pressure is 83/44, heart rate 105, and oxygen saturations 87%heart rate 105, and oxygen saturations 87%

Does this patient have sepsis?Does this patient have sepsis?

What is the definition of SIRS, sepsis, What is the definition of SIRS, sepsis, severe sepsis, and septic shock?severe sepsis, and septic shock?

SIRS – Two or more of the following:SIRS – Two or more of the following:– Temperature >38.5 or <35.0Temperature >38.5 or <35.0– Heart rate >90Heart rate >90– Respiratory rate >20 or PaCO2 <32Respiratory rate >20 or PaCO2 <32– WBC >12 or <4 or >10% bandsWBC >12 or <4 or >10% bands

Sepsis – SIRS in response to documented Sepsis – SIRS in response to documented infectioninfection

Severe Sepsis – Sepsis and at least one of the Severe Sepsis – Sepsis and at least one of the following signs of organ hypoperfusion or following signs of organ hypoperfusion or dysfunction:dysfunction:– Mottled skinMottled skin– Capillary refill > 3 secondsCapillary refill > 3 seconds– Urine output < 0.5 mL/kg for at least one hourUrine output < 0.5 mL/kg for at least one hour– Lactate > 2 mmol/LLactate > 2 mmol/L– Change in mental statusChange in mental status– Platelet count < 100Platelet count < 100– DICDIC– ARDSARDS– Cardiac dysfunction on echocardiogramCardiac dysfunction on echocardiogram

Septic Shock – Severe sepsis and MAP < 60 Septic Shock – Severe sepsis and MAP < 60 mmHg and need for vasopressorsmmHg and need for vasopressors

After bringing the patient into the acute After bringing the patient into the acute care area of the ER, he appears more care area of the ER, he appears more tachypneic and confused.tachypneic and confused.

What should you do next?What should you do next?

After starting flush oxygen and inserting After starting flush oxygen and inserting two IVs, the patient continues to be two IVs, the patient continues to be confused, hypotensive, tachycardic and confused, hypotensive, tachycardic and tachypneic.tachypneic.

Initial ABG: pH 7.21, PCO2 27, PO2 95, Initial ABG: pH 7.21, PCO2 27, PO2 95, HCO3 14, lactate 5.2HCO3 14, lactate 5.2

WBC 19.3, Bands 21%WBC 19.3, Bands 21%

Creatinine 213, Urea 17.3Creatinine 213, Urea 17.3

This patient meets the criteria for sepsis. What This patient meets the criteria for sepsis. What are the possible sources?are the possible sources?

What should be done within the next hour?What should be done within the next hour?

Why is source control and early antibiotics Why is source control and early antibiotics critical in sepsis?critical in sepsis?

After securing the airway, inserting a central line After securing the airway, inserting a central line and arterial line, starting antibiotics and sending and arterial line, starting antibiotics and sending cultures, the patient’s CVP is 4.cultures, the patient’s CVP is 4.

Is this a problem and what should be done?Is this a problem and what should be done?

After giving 2 litres of normal saline, the After giving 2 litres of normal saline, the CVP is 10 but the MAP is 60 mmHg.CVP is 10 but the MAP is 60 mmHg.

Is this acceptable and what should be Is this acceptable and what should be done about it?done about it?

Levophed is started and titrated to a goal Levophed is started and titrated to a goal of 65 mmHg. The central venous of 65 mmHg. The central venous saturations are now 56%.saturations are now 56%.

What would you do next?What would you do next?

What is the pathophysiological relationship What is the pathophysiological relationship between inflammation and complement between inflammation and complement activation, coagulation, and antifibinolysis?activation, coagulation, and antifibinolysis?What adjunct treatments can be used in What adjunct treatments can be used in sepsis to modulate the inflammatory sepsis to modulate the inflammatory system?system?What is the role of other supportive What is the role of other supportive therapies such as steroids, vasopressin, therapies such as steroids, vasopressin, and insulin? and insulin?

Questions??Questions??