SEPSIS Case 2014 - August-2

7/24/2019 SEPSIS Case 2014 - August-2

1/45

SEPSIS

Humberto M. Guiot, MD, FACP

Infectious DiseaseUPR School of Medicine


2/45

Objectives

To discuss the definition of sepsis

To differentiate between bacteremia, systemicinflammatory response syndrome (SIRS), severe

sepsis, septic shock, and multi-organdysfunction syndrome

To establish strategies for management and

treatment of patients in sepsis


3/45

Vignette A 69-year-old is brought to the emergency by his son

because of hypoactivity and drowsiness. On physical examination, temperature is 40.1C, heart

rate is 132 bpm, respiratory rate is 32/min, and bloodpressure is 76/34 mmHg. The patient looks critically ill

and lethargic. Pulse oxymetry reveals an oxygensaturation of 78%.


4/45

Q: What is thedifferential diagnosis?


5/45

Definitions SIRS systemic inflammatory response syndrome to a

variety of severe clinical insults, most commonlyinfectious, but also non infectious pancreatitis, ischemia, multiple trauma, and tissue injury,

hemorrhagic shock, immune-mediated organ injury, andexogenous administration of inflammatory mediators (tumornecrosis factor or other cytokines).

2 or more of the following: T > 38 C or 90 beats/min RR > 20 breaths/min or pCO2 < 32 mmHg

WBC >12,000 cells/mm3, 10% bands


6/45

Definitions Sepsis SIRS to an infection.

Severe sepsis Sepsis associated to an organdysfunction, perfusion abnormalities (lactic acidosis,oliguria, AMS), or hypotension (systolic BP


7/45


8/45

Vignette The patient is immediately intubated and placed on

mechanical ventilation with 100% oxygen. Lungs showbilateral fine expiratory ronchi. The extremities are coldand clammy with evidence of cyanosis.

The patient has a history of type-2 diabetes mellitus and

benign prostatic hypertrophy. According to the son, hewas recently complaining of urinary hesitance, dribbling,and suprapubic abdominal pain.

Immediate fluid challenge with 2L of 0.9% saline

solution is started After 30 minutes, blood pressure is 82/50 mmHg


9/45

Vignette CBC:

WBC 23,000 cells/mcL

Hct 17.2 g/dL PTL 80,000 cells/mcL

ABGs:

pH 7.180 pCO2 56.7 mmHg

pO2 67.8 mmHg

HCO3 13.2 mEq/L

Electrolytes: BUN 98 mg/dL

Creat 5.4 mg/dL


10/45

Q: What is theprecise diagnosis now?


11/45

Sepsis and Septic Shock

13th leading cause of death in U.S. 500,000 episodes each year

35% mortality

30-50% culture-positive blood


12/45

Factors Associated withHighest Mortality

Respiratory > abdominal > urinary Nosocomial infection

Hypotension, anuria

Isolation of enterococci or fungi

Gram-negative bacteremia

Body temperature lower than 38C Age greater than 40

Underlying illness: cirrhosis or malignancy


13/45


14/45

Predisposing UnderlyingDiseases

Heart disease-rheumatic or congenital

Splenectomy

Intraabdominal sepsis Septic abortion or pelvic infection

Intravenous drug abuse

Immunocompromised


15/45

Most Common Etiologies

Gram-negative bacilliE. coli

Klebsiella pneumonia

ProteusPseudomonas

Gram-positive cocci

Gram-negative anaerobes


16/45

Organisms Responsible for Septic

Shock in Relation to Host Factors

Asplenia Encapsulated organismsPneumococcusspp.,Haemophilus influenzae,Neisseria meningtidis,

CapnocytophagiacanimorsusBabesiosisCirrhosis Vibrio, Yersinia, and

Salmonellaspp., other

Gram-ne ative rods GNRsencapsulated organismsAlcoholism Klebsiella spp.,

pnemococcus


17/45

Diabetes Mucormycosisand Pseudomonasssp.(malignant external otitis), Escherichiacoli

Steroids Tuberculosis, fungi, herpesvirus

Neutropenia Enteric GNR, Pseudomonas,Aspergillus, Candida, and Mucorspp.,

Staphylococcus aureusT-cell abnortmalities

Listeria, Salmonella, and Mycobacterias . her es virus rou her es sim lexvirus, cytomegalovirus, varicella zoster

virus)


18/45

Vignette The patient persists on mechanical ventilation

with 100% FiO2.

No urine output has been reported.

V/S: BP: 88/56 mmHg; HR: 122/min; RR:28/min; T: 34 degrees

A thermal blanket is placed and the nephrologistis consulted


19/45

Q: What is the mostappropriate next step?


20/45

Surviving Sepsis Campaign

International initiative:

To reduce mortality rate

To improve standards of care

To secure adequate funding


21/45

Initial Resuscitation Begin as soon as the sepsis syndrome is recognized.

CVP 8-12 mmHg Mean Arterial Pressure > 65 mmHg Urine output >0.5mL/kg / hr Central venous pressure venous oxygen saturation

>70% If not achieved with fluid resuscitation (CVP 8-12 mm HG)

during first 6 hours, then transfuse PRBC (to achieve HCT >30%) or admister vasopressors


22/45

Fluid Resuscitation

Natural or artificial colloids (Dextran, gelatin) or

crystalloids (NSS, D5W, Lactate) No evidence to support one over the other

Resuscitation with crystalloids requires more fluid(because Vd is much larger)

Fluid challenge (500 1000 cc over 30 min) in

patients with suspected hypovolemia


23/45

Vassopressors When fluid resuscitation fails to restore BP and organ perfusion

To sustain life and maintain perfusion in life-threateninghypotension even during fluid challenge

First choice vasopressor: norepinephrine and dopamine(through central catheter)

Both are preferred over epinephrine Norepinephrine is more potent than dopamine and may be more

effective

Vasopressin for refractory shock despite adequate resuscitation

and high dose conventional vasopressors


24/45

Inotropic Therapy

Dobutamine may be used to increase cardiac

output. If used during low blood pressure, it should be

combined with vasopressor therapy


25/45

Vignette V/S are now: BP: 92/61 mmHg; HR: 102/min; RR:

22/min; T: 36 degrees

B/C: positive for GNB in 2 hours

U/A: turbid urine with sediments. WBC are TNTC,many bacteria, positive nitrites, positive leukoesterase

Abdominopelvic CT scan shows an enlarged prostate.There is bilateral obstructive ureterolithiasis withhydronephrosis and prominent perinephric fat stranding

suggestive of bilateral pyelonephritis.


26/45

Q: How should theinfection be treated?


27/45

PRIOR TO ANTIBIOTICS:

Diagnosis!!! Cultures are to be obtained before antimicrobials are

started At least 2 B/C (one peripherally and one through

central catheter)

Culture of other sites (CSF, urine, wounds, respiratorysecretions)

Imaging studies and sampling of likely sources ofinfection should be performed, but some patients may

be too unstable.


28/45

Antibiotic Therapy Started within 1 hour of recognition

One or more drugs with activity against themost likely pathogens and that penetrate thepresumed source of sepsis

Guided by susceptibility pattern Use of procalcitonin (or similar markers) to

assist clinicians in the discontinuation ofantibiotics

Re-assess after 48-72 hours with the aim ofnarrowing spectrum


29/45

Antibiotic Therapy Duration: 7-10 days and guided by clinical

response (longer courses in MRSA, some fungaland viral infections in immunodeficiencies,patients with slow clinical response, etc)

Combination therapy against Pseudomonas andAcinetobacterand in neutropenic patients

Stop antibiotics if clinical syndrome isdetermined not to be infectious


30/45

Antibiotic Therapy Urosepsis

(Piperacilllin/tazobactam, higher generalcephalosporin or carbapenem) aminoglycoside

Intra-abdominal infection

(Piperacilllin/tazobactam, higher generalcephalosporin or carbapenem) aminoglycoside metronidazole

Pneumonia (Cefepime, meropenem or impinem) PLUS

(aminoglycoside or quinolones) (vancomycin or

linezolid)


31/45

Antibiotic Therapy CNS infection

Vancomycin PLUS (ceftriaxone or cefotaxime orcefepime or meropenem) ampicillin acyclovir

Skin infection

(linezolid or vancomycin) (piperacillin/tazobactam or cephalosporins orcarbapenem)

Endocarditis

depending on organism


32/45

Source control Evaluate the presence of a focus of infection amenable for

source control measures within 12 hours, if feasible Drainage of abscess Debridement of infected necrotic tissue Removal of infected device

Source control with the least physiological effect

Percutaneous rather than surgical drainage, for example Source control as soon as possible following initial resuscitation

GI perforation Intestinal ischemia

Promptly remove infected central lines/intravascular devices


33/45

Vignette The patient was administered meropenem and

gentamicin On the following day, the patient undergoes

hemodialysis. Urologic Surgeon performs a bilateral double-J catheter

placement


34/45

Q: What otherstrategies are

recommended in thetreatment of sepsis?


35/45

Corticosteroids IV Hydrocortisone (200-300 mg/day) is recommended for 7 days in patients

with septic shock requiring vasopressors

Three or four divided doses or continuous infusion Rationale: a trial showed shock reversal and reduction in mortality in patients

with relative adrenal insufficiency (post-adrenocorticotropic hormone cortisolincrease 9mcg/dL increase in cortisol). No

steroids for responders, as these patients do not have relative adrenalinsufficiency. Taper steroids after resolution of shock Other authorities taper doses of corticosteroids at the end of therapy No high dose hydrocortisone (>300 mg/day)

No shock = no steroids Dexamethasone does not interfere with ACTH test


36/45

Activated Protein C Recombinant human activated protein C

(rhAPC or drotrecogin alfa, Xigris) wasrecommended in patients at high risk of death(APACHE II>25, sepsis-induced MOF, septic

shock, or sepsis-induced ARDS) with noabsolute contraindication (mostly related tobleeding or risk of bleeding).

Withdrawn from the US Market on October2011 due to failure to show survival benefit


37/45

Blood Product Administration After initial resuscitation

PRBC transfusion for Hb < 7 g/dL to a target of 7-9 g/dL Erythropoetin is not recommended as specific treatment of

anemia associated to severe sepsis No FFP in the absence of bleeding or planned procedure

Antithrombin administration is not recommended for thetreatment of severe sepsis and shock

Platelet transfusion 50,000 for surgery of invasive procedure


38/45

Glucose Control BS < 150 mg/dL

Studies have used continuous infusion of insulin andglucose

Best results with BS between 80-110 mg/dL

Glucose should be monitored frequently afterinitiation of the protocol (every 30-60 mins) and ona regular basis (every 4 hours) once BS has beenstabililized.

Nutrition protocol with preferential use ofenteric route


39/45

DVT Prophylaxis Severe sepsis patients should receive prophylaxis

with low-dose unfractionated heparin orLMWH.

In patients who have contraindications for heparin

use, mechanical prophylactic device (compressionstockings, intermittent compression device) isrecommended


40/45

Stress Ulcer Prophylaxis Should be given to all patients with severe sepsis

H2 receptor blockers are more efficacious thansucralfate

PPIs have not been assessed in a direct comparisonwith H2 receptor antagonists


41/45

Vignette 72 hours after admission:

Vasopressors could be discontinued Creat is now 1.5 mg/dL and dialysis is put on hold

FiO2 has been decreased to 40%

Final B/C and U/C report: MDSE. coli

WBC are 11,000 cells/mcL while PTL count is 140,000cells/mcL


42/45

Q: What is the mostappropriate next step?


43/45

Q: What would bedone if the course had

been different?


44/45

Consideration for Limitation of Support

Advance care planning (communication of likely

outcomes and realistic goals) should bediscussed with patients and relatives.

Decisions for less aggressive support orwithdrawal of support may be in the patientsbest interest.


45/45

References Surviving Sepsis Campaign: International

Guidelines for the Management of Severe Sepsisand Septic Shock. Crit Care Med. 2013; 41:580-637.

Surviving Sepsis Campaign: Guidelines for theManagement of Severe Sepsis and SepticShock. Crit Care Med. 2004; 32: 858-873.

Gorbach SL. Infectious Diseases, 3rd edition.

Documents

SEPSIS Case 2014 - August-2