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Sepsis: Current Diagnosis & Treatment Guidelines
California Academy of PAs: Summer Conference 2019
Gerald Kayingo, PhD. , PA‐C.University of California‐Davis
• Be able to recognize & appropriately manage a patient who
presents with sepsis
• Discuss current diagnostic & treatment options for sepsis
• Be able to prevent nosocomial infections
Learning Outcomes:
Let us start with a case
• 80‐year‐old pt brought to the ED confused & fatigued. Patient was well up until one week ago when he complained of frequent urination prompting a visit to his PC who prescribed “some type of antibiotic” and advised him to increase fluids. Last 3 days he has not eaten much (25%), is more fatigued, and per daughter noted to be somewhat confused and unwilling to get out of the bed this am. Past medical history: hypertension, osteoporosis, DM.
Initial Vital Signs:» T: 38.0 (100.4) » HR: 114 » RR: 24 » BP: 100/60» SaO2: 96% on room air » Finger Stick: 110 mg/dl (MA)
• Appearance: confused, moderately lethargic elderly male in NAD.
• Skin: warm, intact, capillary refill 3‐4 sec, no clubbing, cyanosis, or signs of cellulitis
• Heart: tachycardic, regular, S1+S2+, no murmurs.
• Lungs: tachypnea, good air entry bilateral, clear throughout.
• Abdomen: normal bowel sounds, mildly tender flank, bilaterally, no organomegaly.
• Back and Extremities: no edema, pulses 1+ symmetrical throughout.
• Neurological: GCS 12 with some repetitive questioning, otherwise CN II‐XII intact, sensation
intact, strength intact 4/5 to upper and lower extremities. No signs of meningitis.
Physical Exam
Background • Infections & sepsis are the leading cause of death in non‐cardiac ICUs
• Account for approximately 40% of all ICU expenditures
• Common infectious syndromes in the ICU are: ventilator‐associated pneumonia catheter‐related bloodstream urinary tract infections.
• Etiology includes nosocomial and community‐acquired pathogens
What is Sepsis • Sepsis is a systemic inflammatory response syndrome that results from an
infection
Sepsis is defined as a Life‐threatening organ dysfunction caused by dysregulated host response to infection
• Septic Shock: Subset of sepsis with circulatory & cellular/metabolic dysfunction associated with higher risk of mortality
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis‐3). JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287
What is Septic Shock?
• Septic Shock refers to: Subset of sepsis with circulatory & cellular/metabolic dysfunction associated with higher risk of mortality
JAMA. 2016;315(8):801‐810.
• What is the difference between sepsis and septic shock?Mortality: Septic shock patients have greater risk of mortality
Definition and Terminology
• Sepsis definition has undergone chainages since the inception of standardized definitions in 1991.1
• Definition has shifted away from the systemic inflammatory response syndrome (SIRS) criteria previously utilized. 2
• 2016, Society of Critical Care Medicine & the European Society of Intensive Care Medicine task force + expert consensus process, agreed on updated definitions.3
• 1. Chest.1992;101(6):1644‐1655. 2. Crit Care Med.2003;31(4):1250‐2156, 3. JAMA. 2016;315(8):801‐810
Definition and Terminology • The Third International Consensus Definitions for Sepsis and Septic Shock (“Sepsis‐3”) redefined sepsis as “life‐threatening organ dysfunction caused by a dysregulated host response to infection.”3
• Septic shock was redefined as “hypotension not responsive to fluid resuscitation,” with the added requirement for vasopressors to maintain a mean arterial pressure (MAP) ≥ 65 mm Hg and a lactate > 2 mmol/L.
• Definitions were adopted by the 2016 Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock. 4
• 3. JAMA. 2016;315(8):801‐810, 4Crit Care Med. 2017;45(3):486‐552.
Sequential Organ Failure Assessment (SOFA) Score
Respiration system
Cardiovascular system (Hypotension, mean arterial pressure MAP)
Nervous system (Glasgow Coma Score)
Liver (Bilirubin mg/dL)
Kidneys (Creatinine or urine output)
Coagulation (Platelets )
Evolution of Sepsis definition Sepsis Category Sepsis‐3 2001 Sepsis CMS SEP‐1
Sepsis SOFA score ≥ 2 + suspected infection
2 of 4 SIRS criterial + suspected infection
2 of 4 SIRS criteria + suspected infection
Severe Sepsis Not applicable Sepsis + Organ dysfunction, hypoperfusion, or hypotension
Sepsis + sepsis‐induced organ dysfunction
Septic Shock Vasopressor requirements to maintain MAP ≥ 65 mm Hg + serum lactate level > 2mmol/L in the absence of hypovolemia
Sepsis‐induced hypotension persisting after adequate IV fluid resuscitation + presence of perfusion abnormalities or organ dysfunction
‐Lactate > 4mmol/L‐SBP <90 mmHg, not responsive to fluids OR‐MAP < 70 mmHg not responsive to IV fluids
Sepsis bedside definition
• Among patients with suspected infection;
• SOFA score ≥ 2 (or a change from baseline ≥ 2)
Sequential Organ Failure Assessment (SOFA) Score
quick SOFA (qSOFA) score Bedside assessment tool for sepsis screening
The Third International Consensus Definitions for Sepsis and Septic Shock (“Sepsis‐3”) also derived a bedside assessment tool for sepsis screening in patients with infection who are not in intensive care units (ICUs).
This is called the quick SOFA (qSOFA) score
Quick SOFA SCORE: qSOFA
A bedside tool to identify patients with suspected infection who are at greater risk for a poor outcome outside the intensive care
Presence of 2 or more qSOFA points near the onset of infection is associated with a greater risk of death or prolonged intensive care unit stay.
Reference: qSOFA :: What is qSOFA?". www.qsofa.org. Retrieved 2019-07-18
Which Screening Tool to Use
SIRS, SOFA, LODS, qSOFA
SOFA & LODS superior in the ICUqSOFA great outside the ICUSIRS not great, out of favor
What Pathogens Cause Sepsis
The spectrum of sepsis causing pathogens is rapidly
changing from predominantly gram‐negative
organisms to gram‐positive organisms
How to Recognize Sepsis • Common clinical features for sepsis are
• Fever (>38.3 C)• Hypothermia (<36 C)• Heart rate (>90 bpm)
• Tachypnea
• Altered mental status
• Edema
• Hyperglycemia (plasma glucose >120mg/dL)
How to Recognize Sepsis • Sepsis causes inflammatory, metabolic, coagulation alterations. Laboratory evaluations may reveal:Leukocytosis (WBC count >12000/µL)Leukopenia (WBC count <4,000/ µL)Plasma C‐reactive protein Plasma procalcitonin
How to Recognize Sepsis • Hemodynamic and tissue perfusion changes in a septic patient may includeArterial hypotension Hyperlactatemia (>1 mmol/L)Decreased capillary refill
What to do when sepsis is suspected? • When sepsis is suspected, clinicians should rapidly administer broad‐spectrum antibiotics
• Surviving sepsis campaign bundle recommends the following:Measure and monitor lactate levelObtain blood cultures prior to administration of antibioticsBegin rapid administration of crystalloid to manage hypotension and elevated lactate (>4 mmol/L)
Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain mean arterial pressure (MAP) ≥65 mm Hg
Treatment Guidelines & Best Practices
Sources: Surviving Sepsis Campaign
Society of critical care medicine
Recommendations:
Sepsis and septic shock are medical emergencies: It is recommended that treatment and resuscitation begin immediately
Initial Resuscitation
–Start early‐ (give antibiotics)
–Correct hypovolemia
–Restore perfusion pressureAt least 30ml/kg of intravenous crystalloid fluid be given within the first 3 hours.Additional fluids be guided by frequent reassessment of hemodynamic status.
Recommendations on Antibiotics • Administration of IV antimicrobials be initiated as soon as possible after recognition and within 1 h for both sepsis and septic shock.
• Use empiric broad‐spectrum therapy with one or more antimicrobials to cover all likely pathogens.
Recommendations on Antibiotics • Administration of IV antimicrobials be initiated as soon as possible after recognition and within 1 h for both sepsis and septic shock.
• Use empiric broad‐spectrum therapy with one or more antimicrobials to cover all likely pathogens.
• Recommended that empiric antimicrobial therapy be narrowed once pathogen identification and sensitivities are known
Recommendations on Antibiotics • Combination therapy should not be routinely used for on‐going treatment of most other serious infections, including bacteremia and sepsis without shock
(Weak recommendation; low quality of evidence)
• Recommended against combination therapy for the routine treatment of neutropenic sepsis/bacteraemia
(Strong recommendation; moderate quality of evidence)
Recommendations on Vasoactive Agents
• Use norepinephrine as the first choice vasopressor
Recommendations on Steroids
• Advised against using intravenous hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability.
• If hemodynamic stability is not achievable, then use intravenous hydrocortisone at a dose of 200 mg per day. (Weak recommendation; low
quality of evidence)
Recommendations on Glucose Control
• Start insulin dosing when 2 consecutive blood glucose levels are >180 mg/dL.
• Target an upper blood glucose level ≤180 mg/dL rather than an upper target blood glucose ≤110 mg/dL.
• Monitor glucose values every 1 to 2 hrs until stable
Recommendations on Nutrition
Advise against the administration of early parenteral nutrition
alone or parenteral nutrition in combination with enteral
feedings (but rather initiate early enteral nutrition) in critically
ill patients with sepsis or septic shock who can be fed enterally.
Key Points • Sepsis is a prevalent life‐threatening condition and a leading cause of death globally
• Sepsis results when the body’s response to infection causes life‐threatening organ
dysfunction.
• Septic shock is sepsis that results in tissue hypoperfusion, hypotension and elevated
lactate levels
• Sepsis management is complicated requiring early recognition, management of
infection, hemodynamic issues, and other organ dysfunctions
Key Points • Important to start resuscitation early with source control,
intravenous fluids & antibiotics.
• Frequently assess patients’ volume status throughout the
resuscitation period.
• Guide resuscitation to normalize lactate in patients with
elevated lactate levels as a marker of tissue hypoperfusion
Key Resources
• European Society of Intensive Care Medicine and the Society of Critical Care Medicine (SCCM)
• The Surviving Sepsis Campaign (SSC)
Let us Revisit Our Case
80‐year‐old pt brought to the ED confused & fatigued. Patient was well up until one week ago when he complained of frequent urination prompting a visit to his PC who prescribed “some type of antibiotic” and advised him to increase fluids. Last 3 days he has not eaten much (25%), is more fatigued, and per daughter noted to be somewhat confused and unwilling to get out of the bed this am. Past medical history: hypertension, osteoporosis, DM2.
Initial Vital Signs:» T: 38.0 (100.4) » HR: 114 » RR: 24 » BP: 100/60» SaO2: 96% on room air » Finger Stick: 110 mg/dl (MA)
• Appearance: confused, moderately lethargic elderly male in NAD.
• Skin: warm, intact, capillary refill 3‐4 sec, no clubbing, cyanosis, or signs of cellulitis
• Heart: tachycardic, regular, S1+S2+, no murmurs.
• Lungs: tachypnea, good air entry bilateral, clear throughout.
• Abdomen: normal bowel sounds, mildly tender flank, bilaterally, no organomegaly.
• Back and Extremities: no edema, pulses 1+ symmetrical throughout.
• Neurological: GCS 12 with some repetitive questioning, otherwise CN II‐XII intact, sensation
intact, strength intact 4/5 to upper and lower extremities. No signs of meningitis.
Physical Exam
• What are you going to do in the first five 5 mins?
• What labs are you going to order?
• What are your treatment goal?
Management of this Patient?
Acknowledgements
European Society of Intensive Care Medicine and the Society of Critical Care Medicine (SCCM)
The Surviving Sepsis Campaign (SSC)
UC Davis Betty Irene Moore School of Nursing