Term
| Defined as life-threatening organ dysfunction caused by a dysregulated host response to infection |
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Definition
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Term
| Can be identified as an acute change in total SOFA score by 2 points consequent to the infection |
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Definition
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Term
• A subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality
• Patients with septic shock by persisting hypotension requiring vasopressors to maintain MAP > 65mmHg and having a serum lactate level >2 mmol/L (18mg/dL) despite adequate volume resuscitation
• With these criteria, hospital mortality is in excess of 40% |
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Definition
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Term
• The baseline SOFA score can be assumed to be zero in patients not known to have preexisting organ dysfunction.
• A SOFA score of 2 reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection.
• Even patients presenting with modest dysfunction can deteriorate further, emphasizing the seriousness of this condition and the need for prompt and appropriate intervention, if not already being instituted.
• Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside with qSOFA:
• Alteration in mental status
• Systolic blood pressure < 100mmHg
• Respiratory rate > 22/min |
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Definition
| SOFA (Sequential Organ Failure Assessment Score) |
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Term
• Endothelial cell dysfunction
• Vasoparalysis
• Vasodilation
• Arteriolar resistance
• Venous capitance
• Vasoconstriction
• Inflammation
• Ischemia-reperfusion injury
• Thrombosis
• Loss of volume from vascular space
• Altered permeability
• Altered interstitium |
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Definition
| Attack on Microcirculation |
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Term
• Sepsis associated encephalopathy (SAE)
• Early manifestation
• Pathophysiology
• Endothelial activation
• Blood-brain barrier leakage
• Inflammatory cell migration
• Neuronal loss
• Neurotransmitter imbalance
• Severity correlates with prognosis
• May worsen rapidly
• Ability to protect airway compromised |
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Definition
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Term
• SpectrumofARDS
• Hypoxemia with “clear CXR” • SevereARDS
• Compromised respiratory mm function • Hypoxemia
• Hypotension • Acidosis
• RespiratoryarrestnotslowABGdeterioration |
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Definition
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Term
• Cannot assume good cardiac function
• Bi-ventricular dysfunction
• Greater than 1/3 of patients have decreased cardiac index
• Increased TNI and BNP
• Altered P-V relationship
• Dysrhythmias |
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Definition
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Term
• Hemodynamic • Renal
• Systemic
• Dependent upon cardiac output • Multiple mechanisms |
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Definition
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Term
• Glucose intolerance
• Euthyroid sick syndrome
• Relative adrenal insufficiency
• Critical illness-related corticosteroid
insufficiency (CIRCI)
• Vasopressin deficiency |
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Definition
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Term
• Increase or decrease WBC • Anemia
• Multifactorial
• Coagulation system
• Microvascular thrombosis • Laboratory abnormalities • Clinical DIC is rare |
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Definition
| Hematopoietic Dysfunction |
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Term
• Prevention
• Early recognition
• Initial resuscitation
• Therapy to eradicate inciting event • Definitive resuscitation
• Modulate inflammatory response |
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Definition
| Treatment of Sepsis and Septic Shock |
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Term
• Key element
• Improved outcome with less severe illness
• Sepsis and septic shock are medical emergencies; treatment and resuscitation should begin immediately |
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Definition
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Term
• Appropriate routine microbiology cultures, including blood cultures
• At least two sets of blood cultures, aerobic and anaerobic
• Obtain before starting antibiotics
• As long as it does not result in a substantial delay in the start of antibiotics
• Procalcitonin
• Recommend daily assessment for de-escalation of antibiotic therapy in patients with sepsis and septic shock
• Levels can be used to support shortening the duration of antibiotic therapy in sepsis patients
• Levels can be used to support the discontinuation of empiric antibiotics in patients who initially appeared to have sepsis, but subsequently have limited clinical evidence of infection |
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Definition
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Term
• Possibility of infection
• qSOFA
• Alteration in mental status
• Systolic blood pressure less than 100 mm Hg • Respiratory rate greater than 22/minute
• SOFA |
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Definition
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Term
• Airway
• Intubate early
• Protect from respiratory arrest and aspiration
• Breathing
• Conventional mode of ventilation
• Provide a high degree of ventilatory support
• IV fluids
• Establish adequate IV access • Appropriate fluid therapy |
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Definition
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Term
• Recommend fluid challenge technique be applied in which fluid administration is continued as long as hemodynamic factors continue to improve
• Recommend crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock
• Suggest using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock
• Suggest using albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock when patients require substantial amounts of crystalloids
• Recommend against using hydroxyethyl starches (HESs) for intravascular volume replacement in patients with sepsis or septic shock |
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Definition
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Term
• Adequate cardio-cerebral perfusion pressure
• MAP≥65
• Fluids
• Vasopressor • Inotrope
• BP is not final endpoint of resuscitation |
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Definition
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Term
• Antimicrobials
• Recommend that administration of IV antimicrobials be initiated
as soon as possible after recognition and within one hour
for both sepsis and septic shock
• Recommend empiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens (including bacterial and potentially fungal or viral coverage)
• Recommend that empiric antimicrobial therapy be narrowed once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted (BPS)
• Remove potential sources
• Surgical drainage and excision of necrotic tissue |
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Definition
| Therapy to Eradicate Inciting Event |
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Term
• Rapidly and completely restore tissue perfusion
• Hydrostatic pulmonary edema • Myocardial ischemia
• Acceptable MAP (65–70 mm Hg)
• Recommend that, in the resuscitation from sepsis-induced hypoperfusion, at least 30mL/kg of IV crystalloid fluid be given within the first 3 hours
• Recommend that, following initial fluid resuscitation, additional fluids be guided by frequent reassessment of hemodynamic status
• Recommend further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock if the clinical examination does not lead to a clear diagnosis |
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Definition
| Ongoing Resuscitation—Endpoints |
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Term
• Base deficit and lactate
• TTE and TEE
• Minimally invasive hemodynamic monitoring
• Pulmonary artery catheter
• Serial physical examination
• Invasive arterial monitoring
• Oscillometric devices inaccurate
• Site may be important
• Dynamic parameters
• Passive leg raising
• SBP variation
• PP variation
• Stroke volume variation
• VTI variability |
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Definition
| Definitive Resuscitation Monitoring— Adequacy of Perfusion |
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Term
• Persisting hypotension requiring vasopressors to maintain MAP > 65mmHg
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• Serum lactate level >2 mmol/L (18mg/dL) despite adequate volume resuscitation
• Suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion |
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Definition
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Term
• Recommend norepinephrine as the first-choice vasopressor
• Suggest adding either vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine with the intent of raising MAP to target, or adding vasopressin (up to 0.03 U/min) to decrease norepinephrine dosage
• Suggest using dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia)
• Recommend against using low-dose dopamine for renal protection
• Suggest using dobutamine in patients who show evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents
• Remarks: If initiated, vasopressor dosing should be titrated to an end point reflecting perfusion, and the agent reduced or discontinued in the face of worsening hypotension or arrhythmias.
• Suggest that all patients requiring vasopressors have an arterial catheter placed as soon as practical if resources are available |
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Definition
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Term
• High incidence of adrenal insufficiency
• No definite impact on mortality
• Decreases duration of vasopressor use
• SuggestagainstusingIVhydrocortisonetotreat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability
• If this is not achievable, suggest IV hydrocortisone at a dose of 200mg per day |
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Definition
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Term
• Sepsis is the primary cause of death from infection, especially if not recognized and treated promptly.
• Its recognition mandates urgent attention.
• Sepsis is a syndrome shaped by pathogen and host factors, with characteristics that evolve over time.
• Factors include sex, race, age, genetic determinations, comorbid conditions, and environment.
• What differentiates sepsis from infection is an aberrant or dysregulated host response and the presence of organ dysfunction.
• Sepsis-induced organ dysfunction may be occult.
• Should consider in any patient presenting with infection |
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Definition
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