Patient will present as → a patient with severe pancreatitis is experiencing new-onset changes in mental status. Vitals are BP 70/50 mm Hg, HR 132/min, RR 24/min, temp 103°F, sat 94%. Laboratory values reveal a WBC count of 28,000 and a serum lactate level of 17.3 mmol/L (normal: 0.5–2.2 mmol/L).
SEPSIS 3 Guidelines
Sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection
Septic shock is defined as sepsis with circulatory, cellular, and metabolic dysfunction that is associated with a higher risk of mortality
- Previously, septic shock was identified by the presence of hypotension. It is now recognized that hypotension can be a late manifestation, and tissue hypoperfusion proceeds hypotension
- Lactate level is an indirect marker of tissue perfusion
Etiology: Respiratory, gastrointestinal, genitourinary, and skin and soft tissue infections are the most common sources
- Pneumonia is the most common cause of sepsis
- Fever is the most common manifestation, however, an absence of fever does not exclude sepsis
SIRS Criteria: The systemic inflammatory response syndrome (SIRS) criteria are no longer part of the new sepsis guidelines (Sepsis-3). However, still have a role in the identification of acute infections
- Systemic inflammatory response syndrome (SIRS) requires at least 2 of the 4 following criteria be met (no longer used, important to be aware of)
- Body temperature less than 36 deg C or greater than 38 deg C
- HR > 90 bpm
- Respiratory rate greater than 20/min
- WBC count less than 4,000 or greater than 12,000 OR greater than 10% bands
The two most commonly used scores are the quick Sequential (Sepsis-related) Organ Failure Assessment score (qSOFA) score and the National Early Warning Score (NEWS) score.
Quick SOFA (qSOFA) and SOFA - replaced the SIRS scoring system. Use to predict mortality, NOT to diagnose sepsis, per Surviving Sepsis Guidelines ⇒ qSOFA is used outside ICU, while the full SOFA is used in the ICU.
- Sepsis should be suspected in patients meeting at least two of the following three qSOFA criteria
- New or worsened mentation
- Respiratory rate greater than or equal to 22/min
- Systolic blood pressure less than or equal to 100 mmHg
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
The aggregate score represents the risk of death from sepsis and indicates the urgency of the response:
- 0 to 4 – low risk (a score of 3 in any individual parameter is low-medium)
- 5 to 6 – medium risk
- 7 or more – high risk
Gram-positive shock results from exotoxins leading to fluid loss - common etiologies are staph and strep
Gram-negative shock is caused by endotoxin by bacteria - such as E. Coli, Klebsiella, Proteus, Pseudomonas
Group associations:
- Neonates: Group B Strep, E. coli, Klebsiella
- Children: H. influenzae, pneumococcus, meningococcus
- Adults: Gram-positive cocci, aerobic bacilli, anaerobes
- IV drug: users S. aureus
- Asplenic patients: Pneumococcus, H. influenzae, meningococcus
- Line-associated infections: Skin flora (e.g., coagulase-negative staph)
Initial evaluation of patients with suspected sepsis includes basic laboratory tests, cultures, imaging studies as indicated, and sepsis biomarkers such as procalcitonin and lactate levels
- CBC with diff; BMP; LFTs; urinalysis
- Neutropenia or neutrophilia with increased bands
- Thrombocytopenia occurs in 50% of the cases
- Sepsis biomarkers lactate and procalcitonin
- Procalcitonin levels rise within four hours after the onset of infection and peak at 12-48 hours
- Lactate levels rise secondary to tissue hypoxia ⇒ levels > 18 are diagnostic of septic shock
- Arterial or venous blood sampling can determine the degree of acid-base abnormalities
- Respiratory alkalosis with a metabolic acidosis
- Two sets of peripheral blood cultures including a set from the central venous catheter, as well as cultures of urine, stool, sputum, and skin and soft tissue
- CSF, joint, or pleural, and peritoneal fluid cultures as needed
- Coagulation studies and +/- DIC panel
- Imaging should include CXR, with additional studies as indicated
Any neonate with a temperature of 100.4 deg F or higher should receive a full workup:
- Blood and urine culture, UA, CBC, LP
Identify and remove the cause of infection - patients often require ICU admission
- Fluid resuscitation is the priority in early management, including administering an IV crystalloid at 30 mL per kg within the first three hours
- Empiric antibiotics within one hour
- Vasopressor therapy is indicated if hypotension persists despite fluid administration
- Norepinephrine is the first-line vasopressor agent for patients if initial fluid resuscitation fails to restore MAP to > 65 mm HG
- Send blood cultures (draw blood cultures before initiating antibiotics)
- Remove all existing catheters, IV lines, central lines
Sepsis is a systemic inflammatory response to an infection and it is classified as severe sepsis when organ dysfunction is involved. Septic shock is the occurrence of sepsis with hypotension despite adequate fluid resuscitation. In response, several pathological mechanisms occur in the body including excessive vasodilation, increased microvascular permeability, excessive cellular activation, and increased coagulation. This results in the maldistribution of blood leading to inadequate tissue perfusion and subsequently tissue hypoxia.
Play Video + QuizSepsis Assessment
Sepsis is a systemic infection that triggers a systemic inflammatory response syndrome (SIRS) in the body in response to toxins. The initiating event may result from an infection, major surgery, trauma, burns, or acute pancreatitis. Common symptoms include fever, hypotension from systemic vasodilation, an increase in white blood cell count, change in LOC, tachycardia, and tachypnea. Some patients may also present with significant edema due to fluid shift, along with elevated blood glucose levels. Factors placing the patient at increased risk for developing this condition include increased aged, immunosuppressed individuals, and prolonged hospitalization.
DIC
DIC is a secondary disease that results from the abnormal widespread over-activation of the coagulation cascade (either the intrinsic or extrinsic pathway). This results in thrombi formation in the microcirculation and subsequent tissue hypoxia and infarction and microangiopathic hemolytic anemia.
Play Video + QuizTypes of Shock
Shock is a condition characterized by decreased tissue perfusion and impaired cellular metabolism. The four main types of shock classified by either the functional impairment or the site of origin and are known as hypovolemic, cardiogenic, obstructive, and distributive. More than one type of shock can be present at the same time.
Play Video + QuizQuestion 1 |
Genitourinary tract infection Hint: See D for explanation | |
Infection-related to an indwelling device Hint: Skin and soft tissue infection | |
Skin and soft tissue infection Hint: Skin and soft tissue infection | |
Pneumonia |
Question 2 |
Albumin is the fluid of choice, if available Hint: See B for explanation | |
30 mL per kg of an intravenous crystalloid, such as saline, should be administered within the first three hours of presentation | |
A 1-L bolus of saline should be administered every hour until blood pressure normalizes Hint: See B for explanation | |
Administration of vasopressor therapy via peripheral administration is preferred over a central venous catheter Hint: See B for explanation |
Question 3 |
Epinephrine Hint: See B for explanation | |
Norepinephrine | |
Vasopressin Hint: See B for explanation | |
Vasopressin plus epinephrine Hint: See B for explanation |
List |
References: Merck Manual · UpToDate