Pocket ObGyn – Sepsis

Pocket ObGyn – Sepsis
See Abbreviations

Definitions (Crit Care Med 2003;31(4):1250)

• SIRS: 2+ of the following: (1) temp >38 OR <36°C, (2) HR >90 bpm, (3) RR >24/min or arterial CO₂ <32 mm Hg or mechanical vent, (4) WBC >12 K/mm³ or <4 K/mm³or >10% immature forms
• Sepsis: SIRS + documented infxn
• Sev sepsis: Sepsis + sign(s) of organ hypoperfusion/dysfxn including oliguria, metabolic acidosis, abrupt AMS, thrombocytopenia or DIC, cardiac dysfxn, acute lung injury
• Septic shock: Sev sepsis w/ HoTN despite adequate fluid resusc or need for vasopressors to maintain

Epidemiology (NEJM 2003 348:16)

• Incid: 240 cases per 100000, 9% annual ­ from 1979–2000
• Rate of sev postop sepsis 9%, mortality 34% (Anesthesiology 2010;112:917)
• Sepsis: Amplified, uncontrolled, self-sustaining intravascular inflamm response

Bact wall components (endotoxin, LPS) & products (exotoxins) activate host defense Initial excessive resp of inflamm mediators (TNFa & IL-1). Activation of coagula-

tion cascade & enhanced formation of microvascular thrombi. Impaired tissue oxygenation & tissue damage. Late shift to anti-inflammatory immunosuppressive state ® inability to clear infxn.

Clinical Manifestations

• HoTN, initial ­ cardiac output, but eventual systolic & diastolic failure
• AMS (encephalopathy): Agitation, confusion, obtundation
• Acute renal failure due to hypoperfusion/hypoxia: Oliguria, electrolyte abnormalities
• Pulm edema ® V/Q mismatch ® hypoxemia ® ARDS

Workup

• Obtain appropriate cx (eg, bld, urine, wound, catheter tip)
• CXR to assess acute lung injury & ARDS (diffuse bilateral infiltrates)
• Imaging studies (eg, CT) to confirm infxn site & sample poss source

Management (Crit Care Med 2008;36:296; see also www.survivingsepsis.org)

• Identify infectious source
• Early respiratory stabilization: Pulse oximetry, mechanical ventilation as needed
• Adequate access: CVC if sev sepsis or shock
• Aggressive fluid resusc: Crystalloid or colloid, necessary to prevent organ dysfxn

Goals: CVP ³8 mm Hg (12 mm Hg if ventilated), MAP ³65% mm Hg, UOP ³5 mL/kg/h

• IV Abx: Begin as soon as poss after cx are Broad spectrum: Directed at most likely pathogens of presumed source.
• Vasopressors: If BP not responsive to IV fluid administration, use to maintain MAP

>65 mm Hg (norepinephrine generally 1st line. Alternatives include phenylephrine, epinephrine, vasopressin, dopamine)

• Corticosteroids: Consider hydrocortisone IV (for adrenal insufficiency) if BPs unresponsive to fluid

•   Sepsis bundles:

Initial resusc bundle: All w/i 6 h of identification of sev sepsis Measure serum lactate

Obtain bld cx prior to Abx (2 sets of bld cxs, other indicated site) Broad-spectrum Abx w/i 1 h

If HoTN &/or lactate >4 mmol/L ® fluids + vasopressors to goal MAP >65 mm Hg If persistent HoTN despite fluid resusc (septic shock) ® maintain CVP ³8 mm

Hg & ScvO₂ ³70% or SvO₂ ³65%

Subseq mgmt bundle: W/i 24 h includes ventilator mgmt of ARDS, bld prod- ucts, steroids, vasopressors, sedation, maintaining euglycemia, renal replacement therapy, & mgmt of multiorgan dysfxn

See Abbreviations