Approach to Sepsis and Shock K A R E N T R A N P G Y 5 G I M F e l l o w J U L Y 9 , 2 0 1 5
Objectives To develop an approach to the evaluation of patient with fever To develop an approach to assess a patient for the presence of SIRS, sepsis, severe sepsis, and septic shock To learn how to triage and manage patients with sepsis To learn evidence base management of sepsis To become familiar with the sepsis protocols
Sepsis in Canada 30,000 Canadians are hospitalized for sepsis each year • 30.5% mortality rate all comers (45.2% with severe • sepsis) 9300 sepsis deaths in Canada per year (11% of all • hospital deaths) 56% increased death rate if diagnosed after admission • rather than in the ER Early recognition and antibiotics increases survival rate • by up to 50% Failure to recognize sepsis occurs most commonly in • post-op patients, elderly > 70 years old, or chronically ill/immunocompromised Canadian Institute for Health Information. 2009
Rationale: Sepsis is a serious life threatening medical condition One of most common admission to hospital/CTU/ICU Increased awareness, modified triage tools and targeted management strategies have the potential to improve sepsis outcomes
“However, when detected early and “… inadequate patient assessment” treated aggressively, people can be spared the “ravage of sepsis”
Sepsis Video https://vimeo.com/129916157
Mr. Rivers 45M presents to ER with 2 day history of fevers PMHx: Hypertension and Type 2 DM Medications: Ramipril 10 mg once daily and metformin 500 mg po BID NKDA ROS: Abdominal pain with N/V
What is your approach and differential diagnosis of fever?
Approach to Fever M -malignancy (primary, hematologic, metastatic) A -autoimmune (RA, SLE, vasculitis, CTD) I -Infection I - Inflammatory (Pancreatitis, hepatitis, IBD) D -Drugs (Prescription medications, recreational drugs- intoxication, withdrawal, NMS, Serotonin syndrome, toxidromes) E -Endocrine (Thyroid storm, Pheochromocytoma, Cushings, Adrenal insufficiency) V -Vascular (ACS, PE, HUS/TTP)
What’s your approach to Infections?
Approach to Infectious Causes CNS: meningitis, encephalitis, brain abscess H&N: Sinusitis, Dental abscess CVS: Bacteremia, Infective endocarditis, myocarditis Resp: Pneumonia (bacterial, mycobacterium, viral, fungal), Empeyma Abdo: Ascending cholangitis, perforation, pancreatitis complications, abscess, diarrhea (C.diff), peritonitis GU: Pyelonephritis, renal abscess, prostatitis, UTI Gyne: Pelvic abscess Derm: Cellulitis, Erysipelas, Necrotizing fasciitis Other: Lines (IHD, portacath for chemo)
How do you recognize sepsis?
Definitions • Systemic Inflammatory Response System (SIRS) • Manifested by 2 of the following criteria: • Temp > 38.3 0 C or < 36 0 C • HR > 90 bpm RR > 20 or PaCO 2 <32 • WBC > 12 or < 4 or > 10% bands • • Infection: Pathological process caused by invasion of normal sterile fluid/body cavity by pathogenic or potentially pathogenic microorganisms Dellinger RP et al. Intensive Care Med. 2013l 39(2):165-228.
Definitions • Sepsis = SIRS + suspected/potential source of infection • Severe Sepsis = Sepsis + end organ dysfunction or hypoperfusion • Septic Shock = Sepsis + hypotension (SBP < 90, MAP < 70 or SBP decrease > 40 from baseline) not resolved with fluids Dellinger RP et al. Intensive Care Med. 2013l 39(2):165-228
Dellinger RP et al. Intensive Care Med. 2013l 39(2):165-228
! clinical insult inflammation SIRS ischemia → → severe sepsis septic shock trauma → Sepsis infection ! 2 of the following: SIRS w/ organ sepsis with BP ! temp >38.3 ° or <36 ° hypoperfusion or <90mmHg or organ dysfunction <70mmHg MAP ! WBC >12000,<4000,>10% IB despite adequate fluid ! HR > 90 bpm resuscitation ! RR>20 or PaCO 2 <32 mmHg MODS ! ! urine output <0.5ml/kg/h ! lactate >4mmol/L ! Cr>177 m mol/L ! Plt<100000 m L ! bili>34 m mol/L ! INR>1.5 ! ALI PaO2/FiO2<250 ! ALI PaO2/FiO2<200 w/ p Dellinger RP et al. Intensive Care Med. 2013l 39(2):165-228
Organ Dysfunction CNS Metabolic encephalopathy CVS Shock, demand ischemia Resp Acute lung injury, ARDS GI Gastroparesis, ileus Liver Cholestasis Kidney Acute tubular necrosis Heme Coagulopathy (DIC) Endo Adrenal insufficiency
Approach to Shock Definition: Acute circulatory failure resulting in hypoperfusion and end organ injury Does not necessarily imply hypotension Patients can have “normal BP” and have relative hypotension if BP is normally high
Types of Shock Etiologies Cardiogenic = pump failure Distributive = peripheral vascular resistance failure Hypovolemic = lack of fluid/blood
BP = CO x SVR HR x Stroke Volume Contractility Afterload Preload
Distributive Shock BP = CO x SVR HR x Stroke Volume Contractility Afterload Preload Cardiogenic/Obstr Hypovolemic uctive Shock Shock
Approach to Shock S- septic H- hypovolemic 2 0 GI loss, hemorrhage, burns, third spacing, pancreatitis O- obstructive PE, RV infarct, tamponade C- cardiogenic ACS, heart failure C- catch all Anaphylaxis, neurogenic shock
Hemodynamic Profiles of Various Forms of Shock Type of RA PCWP CO SVR Shock Sepsis Variable Variable Hypovolemic Obstructive N or Tamponade Cardiogenic N or
Sepsis Management “The speed and appropriateness of therapy administered in the initial hours after severe sepsis develops will have a large influence on outcome” Recognize 1. clinical experience • screening tools • Triage 2. Order appropriate investigations, esp: lactate and cultures • IV fluids and IV antibiotics • Consult appropriate health care providers (ICU) • Respond 3. early goal directed therapy •
Sepsis Management ABC MOVII Monitored setting, Oxygen, Vital signs, IV access, Investigations IV fluids with crystalloid Broad spectrum IV antibiotics Oxygen supplementation Early Goal Directed Therapy
Sepsis Management Early Goal Directed Therapy CVP 8-12 mm Hg MAP > 65 mm Hg S cV O 2 > 70% Urine output ≥ 0.5cc/kg/hr Target lactate as marker of hypoperfusion Source Control – early OR for debridement, ERCP in cholangitis, chest tube for empeyma, etc. Ask for help Senior residents, staff physician, CA Consult ICU early if not responding to medical therapy
What investigations would you want to order?
Investigations CBCD Consider: Sputum C&S Peripheral blood smear CT head +/- LP Lytes, BUN, Cr CT Abdo Lactate Abdo U/S (if elevated LFT INR, PTT and Bili) Liver enzymes Influenza NP Swab Troponin BCx x 2 U/A, Urine C&S CXR PA/lateral ECG
Rivers et al. NEJM. 2001. 345(19):1368-1377.
Rivers Trial 263 patients presenting to urban ER with sepsis or septic shock prior to admission to ICU Randomized to EGDT vs. standard care Primary endpoint: in hospital mortality EGDT decreased mortality among patients with severe sepsis or septic shock (30.5% vs. 46.5%) Rivers et al. NEJM. 2001. 345(19):1368-1377.
NNT of 6 to prevent one hospital death Rivers et al. NEJM. 2001. 345(19):1368-1377 .
Criticisms Single center study, ED staff not blinded to treatment Difficult to determine which intervention was the most successful S cv O 2 and CVP monitoring is controversial RBC transfusion is controversial as other studies TRICC and TRISS have shown increased mortality with liberal blood transfusions Control group had an above average mortality Rivers et al. NEJM. 2001. 345(19):1368-1377.
So what do we do?
Approach to Sepsis Management 1. Target CVP 8-12 with IV crystalloid for hypotension or lactate >4 mmol/L Clinical volume assessment with JVP, urine output, U/S 2. Target MAP > 65 mm Hg If MAP < 65, consult ICU for IV vasopressors (norepinephrine) 3. Target S cv O 2 > 70% or lactate clearance If S cv O 2 < 70% and Hct > 30%, start IV inotropes (dobutamine) If S cv O 2 < 70% and Hct < 30% or Hg <70, transfuse 1 U PRBC
Volume Resuscitation Crystalloid preferred for hypotension or elevated lactate Use NS or Ringers Lactate for bolus If patient acidotic or severe sepsis consider Plasmalyte Aim for 30 cc/kg No survival benefit with colloid (hydroxyethyl starches) Reassess the patient to see if intervention is improving hemodynamics, volume status, urine output and lactate clearance
Vasopressors Aim for MAP >65 mm Hg Need central line/arterial line Consult ICU early Preferred agent is norepinephrine (same as levophed) Mostly α -adrengeric effect with vasoconstriction Could consider low dose vasopressin (0.03 U/min) to be added to levophed
De Becker et al. NEJM. 2010. 362(9): 779-89.
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