Severe sepsis



Systemic inflammatory response syndrome (SIRS)

SIRS criteria is met if 2 or more are present:

  1. Temperature > 38°C or < 36°C.
  2. Pulse > 90 beats/min.
  3. Respiratory Rate (RR) > 20 or PaCO2 < 4.3 kPA.
  4. WBC > 12,000 or < 3000/mm3 (or > 10% immature bands).
  5. Acutely Altered Mentation.
  6. Blood glucose >6.6 (no Hx diabetes).

Lactate in Severe Sepsis

Hi Lactate (& rate of clearance) is prognostic

Initial Lactate

After the initial sepsis care duties have been performed (oxygen, fluids, swabs & cultures, antibiotics, blood tests, urinary catheter for hourly U/O) the Lactate should be repeated:

Repeat Lactate


Definitions

Sepsis is "the systemic inflammatory response syndrome (SIRS) during an infection."

Severe sepsis.

Sepsis and at least 1 organ dysfunction:

Septic shock.

Sepsis and refractory hypotension defined as systolic blood pressure < 90 mm Hg, mean arterial pressure (MAP) < 65 mm Hg, or decrease of 40 mm Hg in systolic pressure compared with baseline; unresponsive to crystalloid fluid challenge of 20 to 40 mL/kg.

Bacteraemia.

Presence of viable bacteria in the blood; found in about 50% of cases of severe sepsis and septic shock; whereas 20% to 30% of patients will have no cause identified from any source.


Initial Resuscitation

Begin resuscitation immediately in patients with hypotension or elevated serum lactate.

Resuscitation goals:


Systemic inflammatory response syndrome(SIRS) Sepsis Severe sepsis Septic shock
Two or more of the following:
  • Temp >38.5 or <35
  • Heart rate >90bpm
  • Resp rate >20bpm or arterial CO2 tension <32mmHg or need for mechanical ventilation
  • WCC >12 or <4 or immature forms >10%
SIRS and documented infection (culture or gram stain of blood, sputum, urine or normally sterile body fluid positive for pathogenic micro-organism; or focus of infection identified by visual inspection). Sepsis and at least one sign of organ hypoperfusion or organ dysfunction:
  • Areas of mottled skin
  • Capillary refilling time ≥3 sec
  • Urinary output <0.5ml/kg for at least 1 hr or renal replacement therapy
  • Lactates >2mmol/L
  • Abrupt change in mental status or abnormal electroencephalogram
  • Platelet count <100x 109/L or disseminated intra-vascular coagulation
  • Acute lung injury – acute respiratory distress syndrome
  • Cardiac dysfunction (echocardiography)
Severe sepsis and one of:
  • Systemic mean blood pressure <60mmHg (<80mmHg if previous hypertension) after 40-60ml/kg saline, or pulmonary capillary wedge pressure between 12 and 20 mmHg.
  • Need for dopamine >5mcg/kg per min or norepinephrine or epinephrine >0.25mcg/kg per min to maintain mean blood pressure above 60 mmHg (80 mmHg if previous hypertension).

Initial Fluid therapy


Diagnosis

Take Blood cultures before antibiotics

Antibiotics

Source control


Vasopressors

Steroids

Or


Sepsis goals
Sepsis goal therapy

Fluid therapy

Blood products

ARDS

Glucose control

Recombinant human activated protein C (rhAPC)

rhAPC is recommended in patients at high risk of death (APACHE II ≥ 25, sepsis-induced multiple organ failure, septic shock, or sepsis-induced acute respiratory distress syndrome) and with no absolute contraindication related to bleeding risk or relative contraindication that outweighs the potential benefit of rhAPC.


Renal replacement


DVT

Provide stress ulcer prophylaxis.


Links


Content by Dr Íomhar O' Sullivan. Reviewed by Dr ÍOS 16/05/2005, 18/11/2005, 17/10/2008. Reviewed by Dr Chris Luke 04/11/2008, Dr ÍOS 06/07/2009. Last review Dr ÍOS 26/05/14.