Sepsis and septic shock





This chapter will review the recommendations from the 2016 Surviving Sepsis Campaign by Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM).


Definitions





  • Sepsis: life-threatening organ dysfunction caused by a dysregulated inflammatory response to an infection.



  • Septic shock: a severe form of sepsis characterized by circulatory, cellular, and metabolic dysfunction.



Organ dysfunction can be identified as a change in the sepsis-related organ failure assessment (SOFA) score of 2 points or higher





  • Quick-SOFA(Q-SOFA):




    • A predictive tool that calculates the risk of death from sepsis.



    • Three components, each of which are allocated one point:




      • Respiratory rate ≥22 per minute



      • Altered mentation



      • Systolic blood pressure ≤100 mm Hg





  • A score ≥2 is associated with poor outcomes due to sepsis.



Management of sepsis and septic shock


Volume resuscitation


Intravascular hypovolemia is typical and may be severe in sepsis. Rapid, large volume infusion is the cornerstone of initial resuscitation to achieve tissue perfusion.


Crystalloids ( table 12.1 )





  • 30 mL/kg within the first 3 h (each 1000 mL over 30 min), unless pulmonary edema



  • Normal saline has a risk of hyperchloremic acidosis



Table 12.1

Comparison of Crystalloids












































SOLUTIONS Na (mEq/L) K (mEq/L) Cl (mEq/L) BUFFERS (mEq/L) Ca (mEq/L) Mg (mEq/L) pH OSMOLALITY (mOsm/L)
0.9% NaCl 154 154 5.7 308
Lactated Ringer 130 4 109 Lactate 28 2.7 6.5 274
PlasmaLyte, Normosol 140 5 98 Acetate 27Gluconate 23 3 7.4 294

Na , Sodium; K , Potassium; Cl , Chloride; Ca , Calcium; Mg , Magnesium.


Colloids





  • Albumin 5% 250–500 mL over 30–60 min. Form: 5% (250 mL, 500 mL), 25% (50 mL, 100 mL)



  • No difference in mortality when albumin compared with crystalloids



  • Synthetic colloids (e.g., hydroxyethyl starch) are not recommended due to coagulopathy and risk of acute kidney injury



Vasopressors





  • Use intravenous vasopressors if patients remain hypotensive despite adequate fluid resuscitation or patients develop cardiogenic pulmonary edema ( Table 12.2 )



    Table 12.2

    Vasopressors





































































    DRUG RECEPTORS
    CLINICAL EFFECTS
    POTENCY STANDARD DOSING (IV) COMMENTS



    • Norepinephrine (Levophed)




    • Alpha-1



    • Beta-1



    • Beta-2




    • +++



    • ++



    • ++




    • Start at 5 mcg/min



    • Titrate by 2 mcg/min q1min to MAP 65



    • Maximum: 50 mcg/min




    • First-line



    • If inadequate, add epinephrine or vasopressin




    • Epinephrine (Adrenalin)




    • Alpha-1



    • Beta-1



    • Beta-2



    • SVR




    • ++



    • +++



    • ++



    • ++




    • Start at 5 mcg/min



    • Titrate by 2.5 mcg/min q10min to MAP 65



    • Maximum: 30 mcg/min




    • Useful for anaphylactic shock




    • Vasopressin (Pitressin)




    • V1, V2



    • SVR




    • N/A



    • ++




    • 0.03 units/min



    • Do not titrate



    • Range: 0.01–0.04 units/min



    • Maximum: 0.04 units/min




    • Add to norepinephrine to improve MAP or decrease norepinephrine requirements




    • Dobutamine (Dobutrex)




    • Alpha-1



    • Beta-1



    • Beta-2



    • CO




    • +/−



    • +++



    • ++



    • +




    • 5 mcg/kg/min



    • Do not titrate



    • Range: 5–40 mcg/kg/min



    • Maximum: 40 mcg/kg/min




    • First-choice inotrope



    • May cause hypotension




    • Dopamine




    • <5 mcg/kg/min



    • Beta-1



    • Dopamine



    • CO



    • 5–10 mcg/kg/min



    • Alpha-1



    • Beta-1



    • Dopamine



    • SVR



    • CO



    • 10–20 mcg/kg/min



    • Alpha-1



    • Beta-1



    • Dopamine



    • SVR





    • +



    • ++



    • +



    • +



    • ++



    • ++



    • +



    • +



    • ++



    • ++



    • ++



    • ++




    • Start at 5 mcg/kg/min



    • Titrate by 5 mcg/kg/min q10min to MAP 65



    • Maximum: 40 mcg/kg/min




    • Alternative to norepinephrine if bradycardia and low risk of tachyarrhythmias




    • Phenylephrine (Neosynephrin)




    • Alpha-1



    • SVR




    • +++



    • ++




    • Start at 50 mcg/min



    • Titrate by 10 mcg/min q1min to MAP 65



    • Maximum: 180 mcg/min




    • Consider for patients in whom norepinephrine is CI due to arrhythmias or who have failed other agents

    Legend
    Receptor Cardiovascular Effect
    Alpha-1 Vasoconstriction, inotropy
    Beta-1 Inotropy, chronotropy
    Beta-2 Vasodilation, bronchodilation, inotropy
    Dopamine Vasodilation, vasoconstriction
    V1 Vasoconstriction
    V2 Water reabsorption

    CI , Contraindicated; CO , Cardiac output; IV , Intravenously; MAP , Mean arterial pressure; N/A , Not applicable; SVR , systemic vascular resistance

    Drugs without brand names are denoted by generic name only



Corticosteroids (3–7 days)





  • For patients with septic shock refractory to adequate fluid resuscitation and vasopressor administration.




    • Hydrocortisone:




      • A pharmacologic form of cortisol



      • Most commonly used glucocorticoid in large randomized trials



      • Dose: 50 mg intravenous (IV) q6h.




    • The adrenocorticotropic hormone (ACTH) stimulation test has failed to consistently identify patients with septic shock who benefit from glucocorticoid use.



    • Hydrocortisone 50 mg IV q6h and fludrocortisone 50 mcg NG every morning decreased 90-day all-cause mortality in septic shock.




Antimicrobials (7–10 days)


Recommend starting empiric broad spectrum IV antimicrobials (gram-negative and -positive organisms and, if suspected, fungi and viruses) within 1 h of presentation. For septic shock, recommend at least two antimicrobials from two different classes (i plus ii or iii; Table 12.3 ). Once pathogen identified and susceptibility data return, deescalate antibiotics.


Feb 28, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Sepsis and septic shock
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