Sepsis

From IDWiki

Definition

  • Life-threatening organ dysfunction caused by a dysregulated host response to infection
  • Characterized by an acute change in SOFA score ≥ 2 points in the context of infection
    • Mortality 10%
  • Septic shock is sepsis with profound underlying circulatory and metabolic derangements
    • Characterized by both lactate >2mmol/L and pressors to keep MAP ≥65 despite fluids
    • Mortality 35-54%

Non-Infectious Differential Diagnosis

Management

  • Based on the Surviving Sepsis Campaign
  • Hour-1 Bundle: to be started within 1 hour of triage
    • Measure lactate, repeat within 2-4h if >2mmol/L
    • Obtain blood cultures, before antibiotics if possible
    • Provide broad-spectrum antibiotics
      • Each hour delay increases mortality by 7.6%
      • Inappropriate initial antibiotics double mortality from 30% to 60%
    • Administer 30ml/kg crystalloid for hypotension or lactate ≥4 mmol/L
    • Vasopressors if needed to maintain MAP ≥65 mmHg
      • Norepinephrine then vasopressin
  • After the hour-1 bundle
    • Don't forget to reassess lactate
    • Assess fluid responsiveness and bolus more fluids, if indicated
      • Passive leg raise
      • Pulse pressure variation
      • SV on PoCUS
      • IVC
        • Intubated/ventilated: distensibility index >15-20%
        • Intubated/breathing: cannot use
        • Not intubated: IVC <2cm and variation >50%
    • Add pressors, if needed to maintain MAP ≥65mmHg
      • Norepinephrine first, at a dose of 0.03-3mcg/kg/min
      • Vasopressin or epinephrine second
      • Dobutamine third
    • Add steroids, if indicated
      • No steroids if they have responded to fluids and pressors
      • If still unwell, give hydrocortisone 200mg IV total daily dose