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Peculiar features in sepsis.pptx

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A 74-year-old woman presented to the emergency department with fever, flank pain, dysuria, and altered mental status for 3 days. Her vital signs and physical exam were notable for a temperature of 38.1属C, heart rate of 120, blood pressure of 120/70, tenderness on exam of the costovertebral angle, and a Glasgow Coma Scale of 14/15. Laboratory tests showed a white blood cell count of 8,000 with 65% neutrophils and leukocytes and bacteria found on urinalysis. The document defines sepsis and septic shock, reviews screening tools like SIRS, qSOFA, NEWS, and lactate levels. It also outlines the management of sepsis,

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Update on Sepsis and Septic shock By Mekonnen A.(ECCMR1) Moderator- Dr. Berihu(ECCMR3)
CASE PRESENTATION A 74-year-old woman presents to the ED complaining of fever of 3 days duration Other histories - flank pain and dysuria and change in mentation of similar duration. NO Past medical history. P /E Irritable T属- 38.1属c, RR 20 ,BP 120/70,PR 120 CVA tenderness GCS- 14/15 WBC 8000, Neut, 65% UA- many wbc, leucocyte +2
Out lines Introduction Definition of sepsis Sepsis screening tools Management Monitoring
Specific Objectives Define Sepsis Identify Screening Tools Describe The Managements Of Sepsis And Septic Shock Explain How To Monitor Sepsis And Septic Shock
Introduction Incidence increasing Reasons for a possible increased rate of sepsis include - advancing age - immunosuppression - multidrug-resistant infections -It may also be due to the increased detection of early sepsis from aggressive sepsis education and awareness campaigns
Definition Sepsis is a clinical syndrome that has physiologic, biologic, and biochemical abnormalities caused by a dysregulated host response to infection.
Cont. Sepsis A 2016 SCCM/ESICM task force has defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection (Sepsis-3)
Cont. Organ dysfunction Organ dysfunction is defined by the 2016 SCCM/ESICM task force as an increase of two or more points in the SOFA score.
Septic Shock who fulfill the criteria for sepsis , despite adequate fluid resuscitation, require vasopressors to maintain a mean arterial pressure (MAP) 65 mmHg and have a lactate >2 mmol/L (>18 mg/dL)
Old terms The term severe sepsis, and the term systemic inflammatory response syndrome are no longer used since the 2016 sepsis and septic shock
Sepsis screening tools SIRS qSOFA NEWS MEWS Lactate => Sepsis screening tools are designed to promote early identification of sepsis.
Cont. qSOFA is more specific but less sensitive than having two of four SIRS criteria for early identification of infection induced organ dysfunction Neither SIRS nor qSOFA are ideal screening tools for sepsis and the bedside clinician needs to understand the limitations of each.
Cont. Only 24% of infected patients had a qSOFA score 2 or 3, but these patients accounted for 70% of poor outcomes Similar findings in the National Early warning Score (NEWS) and the Modified Early warning Score (MEWS)
SOFA score Used to predict mortality during ICU stay. Score is calculated after 24 hrs. then Q48hrs until discharge.
皆或酷粥 SOFA score 0-6 7-9 10-12 13-14 mortality < 10% 15-20% 40-50% 50-60%
皆或酷粥
Cont. The systemic inflammatory response syndrome response is not a diagnosis or a good indicator of outcome
Cont. Recommendation - is against using qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock
Lactate lactate alone is neither sensitive nor specific enough to rule-in or rule-out the diagnosis on its own. adjunctive test to sepsis diagnosis guides rescestation Lactate testing may not be readily available in many resource-limited settings
Cont. In approximately one-half of cases of sepsis, an organism is not identified (culture negative sepsis)
Diagnosis Since there is no gold standard test to diagnose sepsis A constellation of clinical, laboratory, radiologic, physiologic, and microbiologic data is typically required for the diagnosis of sepsis and septic shock.
Cont. Neither the qSOFA nor the full SOFA should completely replace clinical judgment about presence of sepsis or its severity
Continuum of Severity 1, Early Sepsis Infection bacteremia There is no formal definition of early sepsis. 2,Sepsis 3,Septic shock 4,MODs
Identification of early sepsis (qSOFA, NEWS) The qSOFA score is easy to calculate since it only has three components each of which are readily identifiable at the bedside are allocated one point: Respiratory rate 22/minute Altered mentation Systolic blood pressure 100 mmHg.
qSOFA To predict death/poor outcome and prolonged ICU stay in patients with known or suspected sepsis,not as a screening tool. When any two of these variables are present simultaneously the patient is considered to be qSOFA positive.
Cont. qSOFA score has been proposed by the SCCM/ESICM as a tool to help identify patients with early sepsis outside of the ICU.
Cont. NEWS is an aggregate scoring system derived from six physiologic parameters. Respiration rate Oxygen saturation Systolic blood pressure Pulse rate Level of consciousness or new confusion Temperature
Cont. The aggregate score represents the risk of death from sepsis and indicates the urgency of the response: 0 to 4 low risk 5 to 6 medium risk 7 or more high risk
Standard operating procedures - Usual care 1.Early identification 2. Sepsis bundles 1. Lactate measurement 2. Blood and other cultures prior to antibiotic administration 3. Antibiotic therapy directed at specific source or broadly 4.Source control 5. Initial fluid therapy with 30 mL/kg of crystalloid 6. Initiation of vasopressor for persistent hypotension 7. Reassessment and documentation
Sepsis Bundles
Peculiar features in sepsis.pptx
EGDT During the first 6 hours of resuscitation, the goals of initial resuscitation CVP 812 mm Hg MAP 65 mm Hg Urine output 0.5mL/kg/hr. Scvo2 70%.
TREATEMENT Fluid=>crystalloids vs. balanced crystalloids Antibiotics=>Empiric antimicrobials with MRSA coverage Vasopressors=>Norepinephrine ( 1st line) =>Vasopressin( 2nd line) =>Adrenaline(2nd line) =>Dopamine(2nd line)
Cont. Albumin in patients who received large volumes of crystalloids
Cont. Sepsis-induced hypoxemic respiratory failure: -the use of high flow nasal oxygen over noninvasive ventilation is recommended
Cont. Low tidal volume Upper limit goal for plateau pressures of 30cm H2O, over higher plateau pressure Higher PEEP Prone ventilation for greater than 12hr. daily.
Cont. Restrictive (over liberal) transfusion strategy(Hgb<7mg)
Cont. Sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements Metabolic academia (pH 7.2) Acute kidney injury (AKIN score 2 or 3)
Cont. Source control Ongoing requirement for vasopressor therapy we suggest using IV corticosteroids. => Dose of norepinephrine or epinephrine 0.25 mcg/kg/min at least 4 hours after initiation.
Monitoring Response 1.Clinical 2.Hemodynamic monitoring Dynamic Static 3.Laboratory Lactate clearance ABG
Cont. A .Clinical 1. mean arterial pressure (MAP) 2. urine output 3. heart rate 4. respiratory rate 5. skin color 6. Temperature 7. pulse oximetry 8. mental status.
Cont. Target MAP of 65 to 70 mmHg (low target MAP) VS Target MAP 80 to 85 mmHg (high target MAP) Patients with a higher MAP had a greater incidence of atrial fibrillation (7 versus 3 percent). => suggesting that targeting a MAP >80 mmHg is potentially harmful.
Cont. B. Hemodynamic predictors of fluid responsiveness 1. Static 2. Dynamic they are more accurate than static measures (eg, CVP) at predicting fluid responsiveness.
Dynamic Dynamic Respiratory changes in the IVC collapsibility radial artery pulse pressure variability(PPV) Stroke volume variability(SVV) Fluid challenge PLR
Cont. Pulse pressure variation (PPV) PPV = 100 x (PPmax PPmin)/PPmean
Stroke volume variation (SVV) Analogous to PPV SVV is typically defined as : SVV = 100 x (SVmax - SVmin)/SVmean
Cont. Normal PPV & SVV <10- 15% If variability is high fluid responsive =>needs more fluids. Limitations Arrhythmias Increased abdominal pressure Open chest
Static Traditional -CVP at a target of 8 to 12 mmHg -ScvO2 70 % -PAWP - LVEDA - GEDV
Laboratory Lactate clearance follow serum lactate ( every six hours) in patients with sepsis until the lactate value has clearly fallen.
Cont. The lactate clearance is defined by the equation [(initial lactate lactate >2 hours later)/initial lactate] x 100. Improvement of 10% or more is associated with improved clinical outcomes = SCVO2 70%
Cont. Arterial blood gases Pao2/FiO2 severity and type of acidosis, resolution of metabolic acidosis.
ROSE concept of fluid management
Resuscitation phase (R) The goal is early adequate goal-directed fluid Management. Fluid balance must be positive suggested resuscitation targets are: -MAP>65 mmHg, -cardiac index (CI) >2.5 L/min/m2 -pulse pressure variation (PPV) <12%
Optimization phase (O) Occurs within hours the phase of ischemia and reperfusion. Positive fluid balance seen during this phase The goal is to ensure adequate tissue perfusion with titration of fluids to maintain a neutral fluid balance: Targets: MAP >65 mmHg CI >2.5 L/min/m2 PPV<14%,
Stabilization phase (S) This phase evolves over days Fluid is needed for maintenance and replacement of normal losses: Monitor daily body weight, fluid balance and organ function =>Targets: Neutral or negative fluid balance .
Evacuation phase (E) Late goal directed fluid removal De-resuscitation to achieve negative fluid balance: Need to avoid over- fluid removal resulting in hypovolemia Diuretics or renal replacement therapy Albumin can be used to mobilize fluids in haemodynamically stable patient.
Prognosis Mortality is 10 percent for sepsis and 40 percent when shock is present
Poor prognostic factors include inability to mount a fever leukopenia age >40 years comorbidities (eg, AIDS, hepatic failure, cirrhosis, cancer, alcohol dependence, immunosuppression) inappropriate or late antibiotic coverage.
REFERECES Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 Tintinallis Emergency Medicine A Comprehensive Study Guide,9th edd. Uptodate ,2021
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Peculiar features in sepsis.pptx

  • 1. Update on Sepsis and Septic shock By Mekonnen A.(ECCMR1) Moderator- Dr. Berihu(ECCMR3)
  • 2. CASE PRESENTATION A 74-year-old woman presents to the ED complaining of fever of 3 days duration Other histories - flank pain and dysuria and change in mentation of similar duration. NO Past medical history. P /E Irritable T属- 38.1属c, RR 20 ,BP 120/70,PR 120 CVA tenderness GCS- 14/15 WBC 8000, Neut, 65% UA- many wbc, leucocyte +2
  • 3. Out lines Introduction Definition of sepsis Sepsis screening tools Management Monitoring
  • 4. Specific Objectives Define Sepsis Identify Screening Tools Describe The Managements Of Sepsis And Septic Shock Explain How To Monitor Sepsis And Septic Shock
  • 5. Introduction Incidence increasing Reasons for a possible increased rate of sepsis include - advancing age - immunosuppression - multidrug-resistant infections -It may also be due to the increased detection of early sepsis from aggressive sepsis education and awareness campaigns
  • 6. Definition Sepsis is a clinical syndrome that has physiologic, biologic, and biochemical abnormalities caused by a dysregulated host response to infection.
  • 7. Cont. Sepsis A 2016 SCCM/ESICM task force has defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection (Sepsis-3)
  • 8. Cont. Organ dysfunction Organ dysfunction is defined by the 2016 SCCM/ESICM task force as an increase of two or more points in the SOFA score.
  • 9. Septic Shock who fulfill the criteria for sepsis , despite adequate fluid resuscitation, require vasopressors to maintain a mean arterial pressure (MAP) 65 mmHg and have a lactate >2 mmol/L (>18 mg/dL)
  • 10. Old terms The term severe sepsis, and the term systemic inflammatory response syndrome are no longer used since the 2016 sepsis and septic shock
  • 11. Sepsis screening tools SIRS qSOFA NEWS MEWS Lactate => Sepsis screening tools are designed to promote early identification of sepsis.
  • 12. Cont. qSOFA is more specific but less sensitive than having two of four SIRS criteria for early identification of infection induced organ dysfunction Neither SIRS nor qSOFA are ideal screening tools for sepsis and the bedside clinician needs to understand the limitations of each.
  • 13. Cont. Only 24% of infected patients had a qSOFA score 2 or 3, but these patients accounted for 70% of poor outcomes Similar findings in the National Early warning Score (NEWS) and the Modified Early warning Score (MEWS)
  • 14. SOFA score Used to predict mortality during ICU stay. Score is calculated after 24 hrs. then Q48hrs until discharge.
  • 17. Cont. The systemic inflammatory response syndrome response is not a diagnosis or a good indicator of outcome
  • 18. Cont. Recommendation - is against using qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock
  • 19. Lactate lactate alone is neither sensitive nor specific enough to rule-in or rule-out the diagnosis on its own. adjunctive test to sepsis diagnosis guides rescestation Lactate testing may not be readily available in many resource-limited settings
  • 20. Cont. In approximately one-half of cases of sepsis, an organism is not identified (culture negative sepsis)
  • 21. Diagnosis Since there is no gold standard test to diagnose sepsis A constellation of clinical, laboratory, radiologic, physiologic, and microbiologic data is typically required for the diagnosis of sepsis and septic shock.
  • 22. Cont. Neither the qSOFA nor the full SOFA should completely replace clinical judgment about presence of sepsis or its severity
  • 23. Continuum of Severity 1, Early Sepsis Infection bacteremia There is no formal definition of early sepsis. 2,Sepsis 3,Septic shock 4,MODs
  • 24. Identification of early sepsis (qSOFA, NEWS) The qSOFA score is easy to calculate since it only has three components each of which are readily identifiable at the bedside are allocated one point: Respiratory rate 22/minute Altered mentation Systolic blood pressure 100 mmHg.
  • 25. qSOFA To predict death/poor outcome and prolonged ICU stay in patients with known or suspected sepsis,not as a screening tool. When any two of these variables are present simultaneously the patient is considered to be qSOFA positive.
  • 26. Cont. qSOFA score has been proposed by the SCCM/ESICM as a tool to help identify patients with early sepsis outside of the ICU.
  • 27. Cont. NEWS is an aggregate scoring system derived from six physiologic parameters. Respiration rate Oxygen saturation Systolic blood pressure Pulse rate Level of consciousness or new confusion Temperature
  • 28. Cont. The aggregate score represents the risk of death from sepsis and indicates the urgency of the response: 0 to 4 low risk 5 to 6 medium risk 7 or more high risk
  • 29. Standard operating procedures - Usual care 1.Early identification 2. Sepsis bundles 1. Lactate measurement 2. Blood and other cultures prior to antibiotic administration 3. Antibiotic therapy directed at specific source or broadly 4.Source control 5. Initial fluid therapy with 30 mL/kg of crystalloid 6. Initiation of vasopressor for persistent hypotension 7. Reassessment and documentation
  • 32. EGDT During the first 6 hours of resuscitation, the goals of initial resuscitation CVP 812 mm Hg MAP 65 mm Hg Urine output 0.5mL/kg/hr. Scvo2 70%.
  • 33. TREATEMENT Fluid=>crystalloids vs. balanced crystalloids Antibiotics=>Empiric antimicrobials with MRSA coverage Vasopressors=>Norepinephrine ( 1st line) =>Vasopressin( 2nd line) =>Adrenaline(2nd line) =>Dopamine(2nd line)
  • 34. Cont. Albumin in patients who received large volumes of crystalloids
  • 35. Cont. Sepsis-induced hypoxemic respiratory failure: -the use of high flow nasal oxygen over noninvasive ventilation is recommended
  • 36. Cont. Low tidal volume Upper limit goal for plateau pressures of 30cm H2O, over higher plateau pressure Higher PEEP Prone ventilation for greater than 12hr. daily.
  • 37. Cont. Restrictive (over liberal) transfusion strategy(Hgb<7mg)
  • 38. Cont. Sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements Metabolic academia (pH 7.2) Acute kidney injury (AKIN score 2 or 3)
  • 39. Cont. Source control Ongoing requirement for vasopressor therapy we suggest using IV corticosteroids. => Dose of norepinephrine or epinephrine 0.25 mcg/kg/min at least 4 hours after initiation.
  • 41. Cont. A .Clinical 1. mean arterial pressure (MAP) 2. urine output 3. heart rate 4. respiratory rate 5. skin color 6. Temperature 7. pulse oximetry 8. mental status.
  • 42. Cont. Target MAP of 65 to 70 mmHg (low target MAP) VS Target MAP 80 to 85 mmHg (high target MAP) Patients with a higher MAP had a greater incidence of atrial fibrillation (7 versus 3 percent). => suggesting that targeting a MAP >80 mmHg is potentially harmful.
  • 43. Cont. B. Hemodynamic predictors of fluid responsiveness 1. Static 2. Dynamic they are more accurate than static measures (eg, CVP) at predicting fluid responsiveness.
  • 44. Dynamic Dynamic Respiratory changes in the IVC collapsibility radial artery pulse pressure variability(PPV) Stroke volume variability(SVV) Fluid challenge PLR
  • 45. Cont. Pulse pressure variation (PPV) PPV = 100 x (PPmax PPmin)/PPmean
  • 46. Stroke volume variation (SVV) Analogous to PPV SVV is typically defined as : SVV = 100 x (SVmax - SVmin)/SVmean
  • 47. Cont. Normal PPV & SVV <10- 15% If variability is high fluid responsive =>needs more fluids. Limitations Arrhythmias Increased abdominal pressure Open chest
  • 48. Static Traditional -CVP at a target of 8 to 12 mmHg -ScvO2 70 % -PAWP - LVEDA - GEDV
  • 49. Laboratory Lactate clearance follow serum lactate ( every six hours) in patients with sepsis until the lactate value has clearly fallen.
  • 50. Cont. The lactate clearance is defined by the equation [(initial lactate lactate >2 hours later)/initial lactate] x 100. Improvement of 10% or more is associated with improved clinical outcomes = SCVO2 70%
  • 51. Cont. Arterial blood gases Pao2/FiO2 severity and type of acidosis, resolution of metabolic acidosis.
  • 52. ROSE concept of fluid management
  • 53. Resuscitation phase (R) The goal is early adequate goal-directed fluid Management. Fluid balance must be positive suggested resuscitation targets are: -MAP>65 mmHg, -cardiac index (CI) >2.5 L/min/m2 -pulse pressure variation (PPV) <12%
  • 54. Optimization phase (O) Occurs within hours the phase of ischemia and reperfusion. Positive fluid balance seen during this phase The goal is to ensure adequate tissue perfusion with titration of fluids to maintain a neutral fluid balance: Targets: MAP >65 mmHg CI >2.5 L/min/m2 PPV<14%,
  • 55. Stabilization phase (S) This phase evolves over days Fluid is needed for maintenance and replacement of normal losses: Monitor daily body weight, fluid balance and organ function =>Targets: Neutral or negative fluid balance .
  • 56. Evacuation phase (E) Late goal directed fluid removal De-resuscitation to achieve negative fluid balance: Need to avoid over- fluid removal resulting in hypovolemia Diuretics or renal replacement therapy Albumin can be used to mobilize fluids in haemodynamically stable patient.
  • 57. Prognosis Mortality is 10 percent for sepsis and 40 percent when shock is present
  • 58. Poor prognostic factors include inability to mount a fever leukopenia age >40 years comorbidities (eg, AIDS, hepatic failure, cirrhosis, cancer, alcohol dependence, immunosuppression) inappropriate or late antibiotic coverage.
  • 59. REFERECES Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 Tintinallis Emergency Medicine A Comprehensive Study Guide,9th edd. Uptodate ,2021