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
- Acute myocardial infarction
- Pulmonary embolism
- Anaphylaxis
- Pancreatitis
- Diabetic ketoacidosis
- Hypovolemia
- Small bowel obstruction
- Medication intoxication or adverse reaction
- Adrenal insufficiency
- Severe anemia
- Heart failure
- Inflammatory bowel disease
- Systemic lupus erythematosus
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
- Slight improvement in mortality seen in one trial
- May be beneficial in shock
- A systematic review from BMJ
