EGDTGordon Finlayson

Case

•45 year old male

•AML

•Febrile, tachycardic, tachypneic, hypotensive

•Diarrhea last 24 hours

Case

•1st Priority: Early Identification of Sepsis

•Next Priorities: Identification of Source; Quantify Severity

Your JOB

Definitions of systemic inflammatory response syndrome (SIRS) and different degrees of severity of sepsisCondition

Description

Systemic inflammatory response syndromeTwo or more of the following conditions: temperature >38.5°C or <35.0°C; heart rate of >90 beats/min; respiratory rate of >20 breaths/min or PaCO 2 of <32 mm Hg; and WBC count of >12,000 cells/mL, <4000 cells/mL, or >10 percent immature (band) forms

SepsisSIRS in response to documented infection (culture or Gram stain of blood, sputum, urine, or normally sterile body fluid positive for pathogenic microorganism; or focus of infection identified by visual inspection, eg, ruptured bowel with free air or bowel contents found in abdomen at surgery, wound with purulent discharge)

Severe sepsisSepsis and at least one of the following signs of organ hypoperfusion or organ dysfunction: areas of mottled skin; capillary refilling of ≥3 s; urinary output of <0.5 mL/kg for at least 1 h or renal replacement therapy; lactate >2 mmol/L; abrupt change in mental status or abnormal EEG findings; platelet count of <100,000 cells/mL or disseminated intravascular coagulation; acute lung injury/ARDS; and cardiac dysfunction (echocardiography)

Septic shockSevere sepsis and one of the following conditions: systemic mean BP of <60 mm Hg (<80 mm Hg if previous hypertension) after 20 to 30 mL/kg starch or 40 to 60 mL/kg saline solution, or PCWP between 12 and 20 mm Hg; and need for dopamine of >5 mcg/kg/min, or norepinephrine or epinephrine of <0.25 mcg/kg/min to maintain mean BP at >60 mm Hg (80 mm Hg if previous hypertension)

Refractory septic shockNeed for dopamine at >15 mcg/kg/min, or norepinephrine or epinephrine at >0.25 mcg/kg/min to maintain mean BP at >60 mm Hg (80 mm Hg if previous hypertension)WBC count: white blood cell count; BP: blood pressure.Data from: Annane, D, Bellissant, E, Cavaillon, JM. Septic shock. Lancet 2005; 365:63.

Identification of Sepsis

•Unexplained tachpnea/tachycardia

•Respiratory Alkalosis

•Confusion/Delirium

Quantifying Severity

•Compensated Vs Decompensated Shock

•Clincial/Lab marker of inadequate perfusion

•Identifying End-organ dysfunction

Source Idenfication

•Surgical Vs Non-surgical

Antibiotic Timeliness

Time to Source Control

Resuscitation

Fluid Type

Preload Responsiveness

Preload Responsiveness

Adjuvants

•Low Vt Ventilation

•APC

•Steroids

•Glycemic Control

Glycemic Control

APC

?things don’t fit

•High CVP

•Narrowed pulse pressure

•Exaggerated systolic pressure variation/pulsus paradoxus

•high vasopressor requirements

things don’t fit

•Consider mixed shock/extra diagnosis

•?Inadequate source control

Summary•Identify sepsis early

•Antibiotics and source identification/control

•early, aggressive resuscitation -- defined end-points (lactate clearance/svo2)

•consider APC, steroids

•if failing ? mixed shock/inadequate source control