sepsis: out with the old, in with the new sepsis 2017.pdfsepsis: out with the old, in with the new...

Sepsis:Out with the Old, In with the New

John Park, MD

Assistant Professor of Medicine

[email protected]

Disclosure

• I have no relevant financial conflicts to disclose

©2010 MFMER | slide-2

Objectives

• To be able to recognize sepsis

• Understand the importance of early intervention

• Implement treatment guidelines in management of sepsis


Case 1

A 78 year-old male with history of HTN presents with fever and dysuria for 3 days. VS in the ED: BP = 125/65 (MAP 85), RR = 28, HR = 120, Temp = 38.9⁰C. Urine shows many WBCs, nitrite positive. Blood and urine were sent for cultures.

Does this person have sepsis?

A. Yes

B. No

C. Maybe

Case 2

78 year old male presents with cough and dyspnea for one week. His vitals: temp 37.9, HR 90, RR 15, BP 110/48 (MAP 69). You hear some crackles in the lung fields. Pertinent laboratory findings include WBC of 9 K and lactate of 1.0. Bilirubin is 1.8 (normal < 1.2)and creatinine is 2.0 (normal < 1.2). Chest x-ray shows an infiltrate in the right lower lobe.


A. Yes

B. No

C. Maybe

Sepsis

• SIRS + infection (known or suspected)• Systemic inflammatory response syndrome

• Infection• Non-infectious

• Pancreatitis• Criteria

• Temp > 38.3ºC or < 36ºC• HR > 90/minute• RR > 20/minute• WBC > 12,000 or < 4,000/mm3, or > 10% bands

©2010 MFMER | slide‐7

CCM 2013;41:580Crit Care Med 2013;41:580

In With the New

SEPSIS - 3

• “Life-threatening organ dysfunction caused by dysregulated host response to infection”

• Organ dysfunction is identified by acute change in total SOFA (Sequential Organ Failure Assessment ) score of ≥ 2 points

• This criteria had in-hospital mortality risk of 10%• Compared to 8.1% for STEMI

JAMA 2016;315(8):801

SOFA

JAMA 2016;315(8):801

Case 1

A 78 year-old male with history of HTN presents with fever and dysuria for 3 days. VS in the ED: BP = 125/65 (MAP 85), RR = 28, HR = 120, Temp = 38.9⁰C. Urine shows many WBCs, nitrite positive. Blood and urine were sent for cultures.


A. Yes

B. No

C. Maybe

SEPSIS - 3

• “Severe Sepsis” terminology is…so yesterday!

• Septic shock:• In those with sepsis, those needing vasopressors to

maintain MAP ≥ 65 mmHg and lactate > 2 mmol/L (18 mg/dL) despite adequate volume resuscitation

• These patients have expected hospital mortality of 40%!

JAMA 2016;315(8):801

qSOFA (Quick SOFA)

• Having 2 of 3 criteria in those with infection should alert clinicians to further investigate for potential sepsis, escalate care/therapy, and/or transfer to higher level of care

• Also, having these criteria in those not previously known to have infection, should prompt clinician to look for possible infection

JAMA 2016;315(8):801

Case 3An 85 y/o nursing home resident is admitted to the floor for altered mental status. GCS = 14. He was recently treated for healthcare associated pneumonia with broad spectrum antibiotics. He has had diarrhea and decreased oral intake for 5 days. His BP is 92/50 mm Hg (MAP 64), RR 20/min, HR 120/min, T 37.6 ⁰ C. His C. diff toxin was negative. He has poor skin turgor, and dry skin and oral mucosa. His urine output has been 10 mL for the last 4 hours, and his Cr is 1.9. His serum lactate is 5 mmol/L.

Does he have sepsis?

A. YesB. No

Sepsis• Starts with infection, either suspected or

documented

• Then look for any additional signs of organ dysfunction and hypoperfusion

• Need:• ABG• CBC• Bilirubin• Creatinine• GCS assessment• Lactate


Operationalization of Sepsis Identification

JAMA 2016;315(8):801

Importance of Early Intervention

• N = 9190

• Each 10% increase in lactate was associated with 9.4% increase in odds of hospital death

• Each 7.5 mL/kg increase in fluids was associated with 1.3% decrease in lactate


Ann Am Thorac Soc 2013;10:466

Too Much of a Good Thing


Ann Am Thorac Soc 2013;10:466

Sepsis: Management• Early appropriate antibiotics


Crit Care Med 2006;34:1589

Sepsis Management

• Fluids• If they are hypotensive, have elevated lactate, have

reduced urine output• Recall tachycardia may also be due to fever• 250 mL is NOT a bolus• Bolus is not 100 cc/hr• Bolus is given within 15 minutes

• 500 to 1000 mL at a time


The Volume Properties of 1-L Fluid Infusion

Fluid Volume (mL)Intracellular Extra-cellular Intravascular

InterstitialD5W 660 255 85NS or LR -100 825 2753% NaCl -2950 2690 9905% Albumin 0 500 500Whole blood 0 0 1000

Courtesy: Dr. Afessa

Meta-analysis of Albumin in Sepsis


Hydroxyethyl Starch (HES)

NEJM 2012;367:124

CRISTAL Trial


JAMA 2013;310:1809

Albumin Supplementation: ALBIOS


NEJM 2014;350:2247

Contents of Crystalloids and Colloid

NS LR 5% Alb

Na 154 130 130‐160

Cl 154 109 130‐160

Osm 310 275 310

Lactate 0 28 0

Potassium 0 4 0

Calcium 0 3 0

pH 5 6.5 6.9

Cost 0.6 0.75 80

Type of fluid matters

• Balanced fluid (lactated ringer) appears to be better than normal saline



Type of fluid matters• Chloride restrictive fluids (LR or Plasma-Lyte)

reduces renal injury


JAMA 2012;308:1566

Amount of fluid matters• Giving too much may be harmful



Adjusted for age, APACHE II score, dose of norepinephrine

+710+2880-+4900+8150

Issues Regarding Fluids

• Watch out for hyperchloremic metabolic acidosis with too much NS

• Crystalloid should be the initial resuscitative fluid

• 5% albumin is iso-oncotic whereas 25% albumin is hyper-oncotic

• Chloride-restrictive fluid may have better outcomes

• Too much fluid may be harmful

Sepsis Management

• Early identification• Initially based on suspicion, but adjust accordingly• Procalcitonin

• Not for diagnosis of sepsis • Misses fungal and possibly viral


Sepsis Management

• Early appropriate antibiotics• Targeting suspecting organism• Considering potential resistance

• Sufficient fluid administered• Crystalloid first• Consider chloride-restrictive or balanced fluid


What next?


Early Goal Directed Therapy

NEJM 2001;345:1368

Surviving Sepsis Guideline


CCM 2013;41:580

ProCESS Trial


NEJM 2014;370:1683

ARISE Trial


NEJM 2014;371:1496

ProMISe Trial

NEJM 2015;372:1301

Adapted from NEJM 2014;370:1683

Vasopressors

• Norepinephrine is the first line• Vasopressin can be added

• 0.03 or 0.04 u/min – NOT titrated• If still hypotensive, add steroids

• Hydrocortisone 50 mg Q6 hr

• Next choice of pressors depends• Inotrope• Epinephrine• Phenylephrine

• Dopamine has been associated with worse outcomes!

Vasopressors

• - vasoconstriction

• 1 – increase HR and myocardial contractility

• 2 - vasodilation

Chest 2007;132:1678

Mayo MICU Sepsis Management

• Within the first 3 hours:• Lactate

• If elevated, repeat in 3 hours. If normal, no further testing

• Cultures before antibiotics• Antibiotics• 30 mL/kg IVF bolus

• Noticed: De-emphasized:• CVP, SCVO2, RBC transfusion!


CMS!!!!!

CMS!!!!

Sepsis - Summary

• Early identification• Starts with infection – suspected or documented!

• SOFA• qSOFA• But for CMS – SIRS


Sepsis - Summary

• Early management• Lactate

• Make sure its repeated if > 2 mmol/L, within 6 hours• Cultures before antibiotics• Appropriate antibiotics• Fluids – 30 mL/kg crystalloid


Sepsis - Summary

• Crystalloids• Balanced or chloride-restrictive fluid may be better• 30 mL/kg

• Control the source of infection• Repeat lactate, if initial was elevated, should guide


Sepsis - Summary

• Consider adjunctive therapies• Vasopressors• Hydrocortisone

• Consider cardiogenic issues• Demand ischemia• Stress cardiomyopathy

• Consider transfer to higher level of care• Only if I am not covering the MICU!


GCS

www.glasgowcomascale.org

sepsis: out with the old, in with the new sepsis 2017.pdfsepsis: out with the old, in with the new...

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