Sepsis

1. Sepsis Jay Green, PGY-3 Dr. Jason Lord October 2, 2008

2. Thanks • Dr. Jason Lord • Dr. Dan Howes • Dr. Trevor Langhan • Dr. Aric Storck

3. Outline • Case • Definitions • Keys to sepsis management • Recognition! • Early abx • EGDT • etc • Put together the pocket cue card version

4. Epidemiology • Severe sepsis/septic shock mortality 20-50% • Incidence increasing • 10th most common cause of death in the US • 2-10% of hospital admissions

5. Not all SIRS is Sepsis • Non-infectious causes of SIRS • Tissue damage • Surgery, trauma, DVT, MI, PE, pancreatitis, etc • Metabolic • Thyroid storm, adrenal insufficiency • Malignancy • Tumor lysis syndrome, lymphoma • CNS • SAH • Iatrogenic • Transfusion rx, anesthetics, NMS, etc

6. Case • 72F generalized abdo pain x 3d, weak x 1d • PMH • RA, HTN, gout • HR 109, bp 85/45, T 38.9, RR 20, SpO2 94% • CVS unremarkable • Resp scattered crackles • Abdo tender LLQ/RLQ/suprapubic, +BS • CNS AAOx3, screening exam N

8. Cue card SIRS T<36 or >38 HR>90 RR>20 WBC<4, >12 or >10% bands

9. The Septic Spectrum • Two of: • HR > 90 • RR > 30 • T > 38 or < 36 • WBC > 12 or <4 SIRS SIRS + Infection SEPSIS Mortality10%

10. The Septic Spectrum SEPSIS • Lactic Acidosis • Oliguria • Altered mental status SEPSIS + Organ Dysfunction SEVERE SEPSIS Mortality16%

11. The Septic Spectrum SEVERE SEPSIS • Severe Sepsis +/- hypotension despite adequate fluid resuscitation SEPTIC SHOCK Mortality46%

12. The Septic Spectrum SIRS SEPSIS Mortality:10% SEVERE SEPSIS Mortality:16% SEPTIC SHOCK Mortality:46%

13. Case • 72F generalized abdo pain x 3d, weak x 1d • HR 109, bp 85/45, T 38.9, RR 20, SpO2 94% • You think she’s septic • ?Urosepsis?

14. Cue card SIRS T<36 or >38 HR>90 RR>20 WBC<4, >12 or >10% bands

15. #1 priority in sepsis?

16. Survival With Delay in ABX Kumar et al. Crit Care Med 2006;34(6):1589

17. ABX! • After hypotension onset • Each hour delay = 7.6% increase mortality (first 6hrs) • 9.9% increase in the first hour • Mortality increases 9%/hour in hospitalized pts for every hour of delay Kumar et al. Crit Care Med 2006;34(6):1589 Garnacho-Monero et al.Crit Care 2006;10(4):R111

18. Source of Infection Kumar et al. Crit Care Med 2006;34(6):1589

19. ABX Selection • Chest • Levo • Azithro + ceftriaxone • Abdo • Pip/tazo or AGF or ceftriaxone/Flagyl • GU • Gent or cefriaxone • Skin • Ancef +/- vanco • Head • Ceftriazone + vanco + dex

20. ABX – General Concepts • Get them in fast!! • ‘STAT’, communication, check back • Cultures prior to abx if possible • Blood, urine, csf • Remove the source if possible • Foley, cvc • Abscess, necrotizing fasciitis • MRSA coverage? • Nursing home, other hospital, homeless, etc

21. Surviving Sepsis Campaign • Antibiotics • Start within first hour of recognition • Cultures before Abx if possible • Source control • Exclude surgical sources within 6h Crit Care Med 2008;36(1):296

22. Cue card SIRS T<36 or >38 HR>90 RR>20 WBC<4, >12 or >10% bands

23. Case • 72F abdo pain & weakness • HR 109, bp 85/45, T 38.9, RR 20, SpO2 94% • C/S 13.4

24. Case • Does this patient have SIRS? • Sepsis? • Severe sepsis? • Septic shock?

25. Case • Investigations? • Initial management priorities? • CBC, lytes, BUN, Cr, cultures • CXR • ABC’s ✓ • O2, IV x 2, monitor applied ✓ • ABX ✓ • Fluids ✓ • How much? • 20-30cc/kg over 30min Anything else? -Lactate!

26. Case • Persistent hTN despite 2.5L NS over first 90min • Labs returning • U/A +nit, +leuks • WBC 20.4 (3 bands), lytes/Cr N, lactate 5.2 • Why is lactate important? • What does she have? • What evidence is there to guide you now? You can’t act early if you don’t know the clock is ticking!

27. The Septic Spectrum SIRS SEPSIS Mortality:10% SEVERE SEPSIS Mortality:16% SEPTIC SHOCK Mortality:46% EGDT EGDT Mortality: 30%

28. Prospective RCT • Standard therapy vs EGDT protocol (<6h) • N=263 • Inclusion criteria • 2/4 SIRS criteria • sBP < 90 after 30cc/kg bolus OR lactate >= 4mmol/L • Exclusion criteria • Many

31. Followed pts for 60d • Primary outcome • In hospital mortality • ICU staff blinded to group

32. Results

34. EGDT Reduces Mortality • 46% vs 30% in hospital mortality in septic shock • ARR = 16% • NNT = 6

35. What Are The Components of Septic Shock • Hinshaw & Cox. The Fundamental Mechanisms in Shock. Plenum Press, New York. 1972. ✓ • Hypovolemic • Distributive • Cardiogenic • Obstructive ✓ ✓ ✗

36. EGDT Addresses The Components of Septic Shock ✓ • Hypovolemic • Distributive • Cardiogenic ✓ ✓

37. Hypovolemic Distributive Cardiogenic

38. You ordered NS… Hypovolemic

39. Hypovolemic Shock • Why are patients in hypovolemic shock? • Venodilation • 3rd spacing • Losses (vomiting, diaphoresis) • Recent poor PO intake

40. Crystalloid vs colloid • Meta-analysis • SAFE trial • Cochrane review

41. Meta-analysis • 19 RCT’s, N = 1315 • Trauma, surgery, burn, sepsis (1) BMJ 1998;316:961

43. DBRCT, N=6997, pts admitted to ICU • 4% albumin vs NS • Volume titrated to clinical status • Primary outcome • 28d mortality • 18% had sepsis (predefined subgroup) NEJM 2004;350:2247

45. Crystalloid vs Colloid • Cochrane Systematic Reviews, 2005. • 19 Trials reported data on mortality • N= 7576 • RR from these trials was 1.02 (0.93, 1.11). • No evidence of meaningful benefit to colloids vs crystalloids • Normal Saline • Cheap, available • USE IT FIRST

46. Surviving Sepsis Campaign • Colloid or crystalloid • Goal • CVP >=8 (>=12 in ventilated patients) • Fluid challenge technique • >=1L crystalloid (300-500mL colloid) over 30min • As long as hemodynamic improvement • Reduce rate when CVP increases without hemodynamic improvement Crit Care Med 2008;36(1):296

47. Hypovolemic Shock • How fast? • 1000mL crystalloid q30min • How much volume? • Depends • Goal: CVP 8-12 • Rivers study: avg 5L in first 6h

48. Cue card SIRS T<36 or >38 HR>90 RR>20 WBC<4, >12 or >10% bands EGDT CVP 8-12 Crystalloid (1L q30min)

49. Case • BP 80/50 despite 2.5L NS • You’ve addressed the hypovolemic shock • What is her MAP? • What next?

50. Distributive