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Chapter 199. Sepsis

Nirav Mistry, MD; Adel Bassily-Marcus, MD, FCCP, FCCM

  • Systemic inflammatory response syndrome (SIRS): systemic response to any inflammatory/infectious etiology (see Table 199-1)

  • Sepsis: definite infectious etiology with a resultant systemic response (at least two or more SIRS criteria)
  • Severe sepsis → sepsis with acute organ dysfunction
  • Septic shock → sepsis-induced hypotension refractory to fluid resuscitation and evidence of end-organ damage including lactic acidosis, oliguria, or altered mental status
  • Mortality ranges from 28% to 50%

Table 199-1 SIRS Criteria (Need 2 out Of 4)
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Table 199-1 SIRS Criteria (Need 2 out Of 4)
  • WBC >12,000/mL, <4,000/mL, or >10% immature bands
  • HR >90/min
  • Temperature >38.5°C or <35°C
  • RR >20 breaths/min, or Paco2 <32 mm Hg
Figure 199-1. Diagnostic Workup of Sepsis
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Management of Severe Sepsis or Septic Shock
Initial resuscitation (first 6 h)
Patients with hypotension, lactic acid >4 mmol/L require immediate resuscitation
Goals
  • Mean arterial pressure ≥65 mm Hg
  • Urine output ≥0.5 mL/kg/h
  • Central venous pressure (CVP) 8–12 mm Hg (controversial benefit)
  • Central venous oxygen saturation ≥70% or mixed venous ≥65% (controversial benefit)
Crystalloids and colloids equally effective
  • Challenges of 1,000 mL of crystalloid or 300–500 mL of colloid over 30 min
  • May require larger volumes in patients with persistent hypotension with vasopressors
  • Bicarbonate therapy contraindicated in patients with hypoperfusion-induced lactic acidosis and pH ≥7.15
Blood product transfusion
  • Transfuse packed red blood cells to target Hb ≥7 (may require higher targets in patients with special circumstances [myocardial ischemia, etc.])
  • Avoid plasma or platelet administration unless active bleeding or planned procedure
Vasopressors
  • Start if shock persists despite fluid resuscitation (20–30 mL/kg) to keep MAP ≥60–65 mm Hg
  • Vasopressors, including norepinephrine and dopamine, should be administered via central venous catheter
  • Vasopressin (0.03 U/min), phenylephrine, or epinephrine may be added if shock unresponsive to initial vasoactive medications
  • Arterial catheter use recommended for hemodynamic monitoring
  • Dobutamine recommended in patients with myocardial dysfunction
Source control and antibiotics
  • Identify infectious etiology within 6 h of presentation
  • Evaluate and implement measures of source control (abscess drainage, tissue debridement, etc.)
  • Remove infected intravascular devices
  • Culture all available specimens
  • Start broad-spectrum antibiotics within the first hour as sepsis and septic shock recognized
    • Combination therapy should be used in patients with suspected Pseudomonas infection or who are otherwise immunocompromised
Mechanical ventilation in patients with ALI/ARDS
  • Tidal volume of 6 mL/kg (ideal body weight)
  • Maintain plateau pressures ≤30 cm H2O
  • Increase PEEP as needed to avoid lung collapse at end-expiration and to avoid oxygen toxicity with high FiO2 levels
  • Allow Paco2 to rise to minimize plateau pressures and tidal volumes
  • Keep head of bed elevated to at least 30° (30–45°), unless contraindicated
  • Institute weaning protocols and daily assessment for SBT to liberate patients from mechanical ventilation
  • Use conservative fluid strategy
  • Some advocate against PAC in patients with ALI/ARDS: no survival benefit, ...

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