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Sepsis management

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Much, but not all of the content of this page is based on Surviving Sepsis Campaign guidelines

Resuscitation

Initial resuscitation

  • aggressive early resuscitation as soon as severe sepsis or septic shock diagnosed
  • do not wait for ICU admission before initiating resuscitation
  • targets (first 6 hours):
    • CVP: 8-12 mmHg
      • 12-15 mmHg in mechanically ventilated patients
    • MAP at least 65 mmHg
    • Urine output at least 0.5 ml/kg/h
  • if central or mixed venous oxygen saturation <70% despite reaching these targets:
    • transfuse packed red blood cells to achieve a haematocrit of at least 30% and/or
    • give dobutamine (up to 20 µg/kg/min)
  • recommendation based on Rivers E et al. N Engl J Med, 2001; 345:1368-1377
  • NB supranormalization in the later phase of resuscitation is not associated with benefit

Fluids

  • either colloids or crystalloids can be used
  • use fluid challenges of 300-500 ml of colloid or 500-1000 ml of crystalloid over 30 mins
    • repeat as necessary based on response (blood pressure, urine output) and tolerance (signs of intravascular volume overload)
  • fluid input-output balance of no value in assessing fluid requirements during first 24 h because of capillary leak

Vasopressors

  • if adequate fluid therapy does not restore adequate BP and organ perfusion start vasopressor
    • may also be required transiently before hypovolaemia has been completely corrected in patients who are severely hypotensive, in order to maintain life.
  • norepinephrine or dopamine are agents of choice
    • dopamine has a greater effect on cardiac output but also has greater chronotropic and pro-arrhythmic effects
  • low-dose dopamine for renal protection of no benefit and should not be used
  • vasopressin
    • consider in patients with refractory shock despite adequate fluid resuscitation and high dose conventional vasopressors
    • not recommended as first line therapy
    • dose: 0.01-0.04 units/min. Higher doses may be associated with myocardial ischaemia, decreased cardiac output and cardiac arrest

Inotropes

  • dobutamine first choice inotrope for patients with low cardiac output despite adequate fluid resuscitation
  • should be combined with a vasopressor in hypotensive patients

Diagnosis

  • blood cultures
    • before initiation of antibiotics
    • at least 2 sets
    • paired timed blood cultures may be useful in diagnosed intraluminal catheter related infection. If the set drawn through vascular access device is positive more than 2 hours before set taken percutaneously infection of the device is more likely
  • culture of urine and respiratory secretions
  • cultures from other sites as appropriate
  • CXR
  • imaging of other organs to determine source of sepsis as indicated by clinical features
  • click here for further details

Definitive therapy

Source control

  • assess every patient for a source of infection that may be amenable to source control such as:
    • drainage of abscess
      • percutaneous
      • surgical
    • debridement of infected necrotic tissue
    • removal of potentially infected device eg central venous catheter
    • definitive control of source of ongoing contamination
  • in general the intervention that accomplishes the objective of source control with the least physiological upset should be employed
  • source control measures should be instituted as soon as possible after initial resuscitation

Antimicrobials

  • should be started within the first hour after recognition of severe sepsis, after appropriate cultures have been taken
    • NB in certain conditions, eg community acquired meningitis in the non-immunocompromised patient, advantages of making a precise microbiological advantage are outweighed by the disadvantages of delaying antibiotic therapy. Similarly adminstration of antibiotics should not be delayed in order to obtain sputum samples in a non-intubated patient with community acquired pneumonia
  • initial choice of empirical antimicrobial regimen should have a broad enough spectrum to cover all likely pathogens and should be based on local flora and sensitivity patterns
  • antimicrobial regimes should be reassessed once microbiological results are available with the aim of using a narrower spectrum regime
  • in general courses of 7-10 days, guided by clinical response, should be adequate
  • in the absence of knowledge of local flora and sensitivities use recommended regimes for community acquired pneumonia, hospital acquired pneumonia, meningitis, complicated intra-abdominal infections and neutropaenic sepsis

Adjunctive therapy

Steroids

  • IV hydrocortisone 200-300 mg/day in 3-4 divided doses or by continuous infusion or patients with septic shock who require vasopressors despite adequate fluid therapy
  • the value of the short Synthacthen test and random cortisol measurements in this setting is doubtful due to the day to day variation in results

Recombinant human activated protein C

  • recommended in patients at high risk of death
    • APACHE II of at least 25
    • sepsis-induced multiorgan failure
    • septic shock
    • sepsis-induced ARDS
  • Contraindications:
    • active internal bleeding
    • haemorrhagic stroke in past 3 months
    • intracranial or intraspinal spinal surgery or severe head trauma in past 2 months
    • presence of an epidural catheter
    • intracranial neoplasm or mass or evidence of cerebral herniation
  • keep platelet count 30,000 or above during infusion of activated protein C
  • more recent data has cast some doubt on the efficacy of this treatment

Miscellaneous

Further reading

Dellinger RP et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med, 2004; 32(3):858-73 and Intesive Care Med, 2004; 30(4):536-55

Potential conflict of interest

The Dept of Anaesthesia & Intensive Care, Chinese University of Hong Kong has received educational, research or travel grants from Astra Zeneca, Daiichi Pharmaceuticals, Merck Sharp & Dohme, Pfizer and Wyeth.

Webpage created April 2004
Updated June 2006

 


İCharles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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