MICU Intern's survival guide sepsis

# Overview

## Systemic Inflammatory Response Syndrome  
- SIRS can be diagnosed when two or more of the following are present:
Heart rate > 90 beats per minute
Temperature  38 C (100.4 F)
Tachypnea > 20 breaths per minute or, on blood gas, a PaCO2 < 32 mm Hg
White blood cell count  12000 cells/mm3 ( 12 x 109 cells/L), or > 10% band forms (immature white blood cells / bandemia).
- Heart rate > 90 beats per minute
- Temperature  38 C (100.4 F)
- Tachypnea > 20 breaths per minute or, on blood gas, a PaCO2 < 32 mm Hg
- White blood cell count  12000 cells/mm3 ( 12 x 109 cells/L), or > 10% band forms (immature white blood cells / bandemia).
- SIRS can be seen in non infectious conditions like pancreatitis and myocardial infarction.

## Sepsis
- SIRS + Source of infection

## Severe sepsis
- Sepsis + organ dysfunction
- Organ damage can present as decreased urine output, acute kidney injury, and elevated liver function tests.

## Septic shock
- Severe sepsis + persistent hypotension after adequate fluid challenge.

## Multiple organ dysfunctions (MODS)
- Progressive multiple organ failure secondary to severe sepsis.

# Sepsis management

## Source control

### Source identification
- Depending on the patient's history, sputum, blood, urine or other sources can be cultured. In certain cases in which the source is unclear, a pan-culture should be done.
- Based on the patient's history, appropriate imaging studies should be initiated.

### Source management
- Initiation of proper antibiotic within an hour of diagnosis.
- Drainage should be initiated in cases in which an abscess is present.

## Resuscitation

### Hypotension
- Fluids are the first step in management
Crystalloids such as normal saline and Ringer's lactate are the first to be used.
Normal rate of infusion is 40-60 ml/kg.
- Crystalloids such as normal saline and Ringer's lactate are the first to be used.
- Normal rate of infusion is 40-60 ml/kg.
- If the patient is still hypotensive after fluid administrations, plan to insert a central venous line to guide additional fluid therapy. Internal jugular and subclavian lines are preferred.
- CVP should be checked in Q30 minutes for adequate fluid management.
- Target CVP is:
10-12 in non-intubated patients.
12-15 in intubated patients.
- 10-12 in non-intubated patients.
- 12-15 in intubated patients.
- If the patient is still hypotensive start vasopressors.
Norepinephrine is the first line vasopressor agent.
Dopamine and vasopressin are second line agents.
A mean arterial pressure of 65 is the goal.
Continue to check the CVP.
- Norepinephrine is the first line vasopressor agent.
- Dopamine and vasopressin are second line agents.
- A mean arterial pressure of 65 is the goal.
- Continue to check the CVP.
- If the patient is still hypotensive, check ScvO2
ScvO2 is a marker of cardiac output and tissue perfusion.
Target ScvO2 is > 70%
If ScvO2 is < 70% consider transfusing with aim hematocrit of 30
If hematocrit is already 30% consider starting dobutamine.
A ScvO2 of 70% indicates that the tissues are adequately extracting oxygen. Therefore, the blood returning to the heart has a low oxygen saturation level.
A ScvO2 of 80-85%, however, is an ominous sign. It indicates that the tissues are not adequately using oxygen and are currently producing energy anaerobically. In these situations, lactate levels in the blood start increasing.
- ScvO2 is a marker of cardiac output and tissue perfusion.
- Target ScvO2 is > 70%
- If ScvO2 is < 70% consider transfusing with aim hematocrit of 30
- If hematocrit is already 30% consider starting dobutamine.
- A ScvO2 of 70% indicates that the tissues are adequately extracting oxygen. Therefore, the blood returning to the heart has a low oxygen saturation level.
- A ScvO2 of 80-85%, however, is an ominous sign. It indicates that the tissues are not adequately using oxygen and are currently producing energy anaerobically. In these situations, lactate levels in the blood start increasing.