Sepsis

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