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:
If initial Lactate was >2 but <4 then this is
Severe Sepsis unless the BP is low (see
If initial Lactate was >4 then this indicates
>4 Septic Shock (NB if BP
was never low then =‘Cryptic Shock’).
If, despite initial resuscitation (O2, fluids, swabs & cultures, antibiotics, blood tests and urinary
catheter for hourly U/O), the BP remains low (SBP<90, MAP<65) then this is Septic Shock
irrespective of the Lactate.
Sepsis is "the systemic inflammatory response syndrome (SIRS) during an infection."
Sepsis and at least 1 organ dysfunction:
Skin: Areas of mottled skin or Cap Refill Test >3sec.
Neurological: New altered mental status.
Haematologic: Platelets < 100,000; INR >1.5; PTT >60 sec
Renal: creatinine > 2.0 mg/dL without prior chronic renal disease; or increase 0.5 mg/dL; acute oliguria urine output <0.5 mL/kg/hr for at least 2 hours despite fluid resuscitation.
Pulmonary: RR > 20, oxygen (O2) saturation < 90% or < 94% with supplement O2, or mechanical ventilation.
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.
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.
Begin resuscitation immediately in patients with hypotension or elevated serum lactate.
Central venous pressure: 8-12 mm Hg.
Mean arterial pressure ≥ 65 mm Hg.
Urine output ≥ 0.5 mL / kg / hr.
Central venous or mixed venous oxygen saturation ≥ 70%.
If central venous oxygen sat. or mixed venous O2 sat. of 70% is not achieved (with a CVP 8-12 mm Hg), then transfuse packed red blood cells to haematocrit ≥ 30% and/or administer a Dobutamine infusion(up to max of 20 μg / kg / min).
Systemic inflammatory response syndrome(SIRS)
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
Abrupt change in mental status or abnormal electroencephalogram
Platelet count <100x 109/L or disseminated intra-vascular coagulation
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.
Intermittent haemodialysis and CVVH are considered equivalent.
CVVH offers easier management in haemodynamically unstable patients.
Do not use bicarbonate therapy to improve haemodynamics (e.g. "lactic acidosis")
Use either low-dose unfractionated heparin or LMWH.