Severe sepsis and septic shock

SIRS Criteria (U+22652 of the following are required)
Fever or hypothermia <36°C (96.8°F) or >38°C (100.4°F)
Tachycardia HR >90 bpm
Tachypnea RR >20 or PaCO2 <32 mmHg
Leukocytosis/leukopenia <4000/microliter, >12 000/microliter, or >10% bands

Critical presentation

  • Hypotension: systolic blood pressure <90 mmHg or mean arterial pressure <65 mmHg.

    • Beware of relative hypotension in patients with chronic hypertension.

  • Encephalopathy and altered mental status.
  • Acute kidney injury presenting as oliguria or anuria.
  • Cardiogenic shock: decreased left ventricular ejection fraction on echocardiogram, troponin leak.
  • Lung injury or acute respiratory distress syndrome (ARDS).
  • Disseminated intravascular coagulation (DIC).

Diagnosis and evaluation

Step 1: Confirm the diagnosis and determine the severity of illness.

  • Basic metabolic panel: U+2191creatinine (acute kidney injury), U+2191glucose (increased insulin resistance).
  • CBC with differential: WBC <4000/microliter or >12 000/microliter (SIRS), U+2193platelets (DIC).
  • Coagulation profile: U+2191PT/INR/PTT (DIC).
  • Lactate: U+22654 mmol/L (evidence of cellular anaerobic respiration and threshold to initiate EGDT).
  • Arterial blood gas: U+2193pH (metabolic acidosis).
  • Liver function tests: U+2191AST, U+2191ALT, U+2191bilirubin (shock liver).
  • Cardiac markers: U+2191troponin (cardiac injury).

Step 2: Determine the etiology.

  • Chest radiograph to evaluate for pulmonary processes.
  • Urine analysis to rule out a urinary tract infection.
  • Lumbar puncture if symptoms are concerning for meningitis.
  • Cultures:

    • Blood (two different sites + one from each chronically indwelling catheter).
    • Urine.
    • Sputum if there is a suspicion for pneumonia.
    • Cerebrospinal fluid if clinically indicated.

  • Imaging as indicated by symptoms (computed tomography (CT) of the abdomen and pelvis, ultrasound, etc.).

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Feb 17, 2017 | Posted by in CRITICAL CARE | Comments Off on Severe sepsis and septic shock

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