Describes updates regarding sepsis

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°- 38.1°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.

15. SOFA…
SOFA score
0-6
7-9
10-12
13-14
mortality
< 10%
15-20%
40-50%
50-60%

16. SOFA…

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

30. Sepsis Bundles

32. EGDT
• During the first 6 hours of resuscitation, the goals
of initial resuscitation
• CVP 8–12 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 30 cm
H2O, over higher plateau pressure
• Higher PEEP
• Prone ventilation for greater than 12 hr. 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.

40. Monitoring Response
1.Clinical
2.Hemodynamic monitoring
•Dynamic
•Static
3.Laboratory
•Lactate clearance
•ABG

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
• Tintinalli’s Emergency Medicine A Comprehensive
Study Guide,9th edd.
• Uptodate ,2021

60. Thank
You