Bootcamp - SepsisAdam Manko, M.D.

PGY-3 Internal MedicineUniversity Hospitals Case Medical Center

Sepsis – Definition Initial Management Medications Mechanical Ventilation - Briefly What Your Senior Expects From You Summary

Goals

69 y/o Male presented to ER with shortness of breath.

VS 38.3 88/46 114 28 86%

He is placed onto 50% ventimask, but continues to have low oxygen saturation and is intubated in the ER.

He is given 2L of NS and repeat BP is 92/44

Case

The Patient arrives in the MICU…..what do you do next?

Sepsis is a continuum….. SIRS Sepsis Severe Sepsis Septic Shock Refractory Septic Shock Multi-Organ Dysfunction Syndrome (MODS)

Defining Sepsis 1

SIRS Criteria◦ Temperature >38.3 (or >38.0 for 1 hour) or <36.0◦ WBC >12k or <4k, or >10% bandemia◦ RR >20, or paCO2 <32mmHg◦ HR >90

Defining Sepsis 2

Sepsis = SIRS + suspected infection◦ Does not have to be culture proven infection to

begin treatment for Sepsis

Defining Sepsis 3

Severe sepsis = sepsis + and signs of at least one organ dysfunction thought to be from tissue hypoperfusion◦ Hypotension◦ Elevated lactate◦ Urine output <0.5ml/kg◦ Acute Lung Injury with PaO2/FiO2 ratio of <250◦ ARDS◦ Acute Renal Failure◦ Elevated bilirubin◦ Platelet Count <100,000◦ Coagulopathy with INR >1.5◦ Altered Mental Status◦ Abnormal EEG findings◦ Cardiac Dysfunction

Defining Sepsis 4

“Early Goal Directed Therapy”◦ Goal SBP >90◦ Goal MAP >65◦ Goal Hemoglobin 7-9◦ Goal urine output >0.5ml/kg/hr◦ Goal normalized serum lactate◦ Goal Mixed Venous >70%◦ Central Venous >65%

Initial Management

Goal SBP >90, MAP >65, Hgb 7-9 IVF bolus with NS What if you give IVF and remains

hypotensive?◦ Need to check a CVP!!!

Hypotension

CVP ◦ = Central Venous Pressure

What is the utility of a CVP◦ Estimates the Right Atrial Pressure◦ What is a Normal Right Atrial Pressure

<6

What is a CVP

Place a CVC = Central Venous Catheter Locations include

◦ Internal Jugular◦ Subclavian

What do you need for a CVP?

CVP >8 If intubated, CVP >12

What if still hypotensive but at goal CVP?

Goal CVP

Norepinephrine◦ First Line pressor (preferred agent over dopamine

(NEJM 2010 Comparison of Dopamine and Norepinephrine in the Treatment of Shock)

◦ Mainly A1, some B1◦ Dosing in mcg/min

Typically uptitrate to max of ~30 mcg/min Vasopressin

◦ Second line pressor◦ Entirely V1

Can be titrated, however we typically turn it “on or off” at dose of 0.04 U/min

Pressors

Phenylephrine◦ Weaker pressor, A1 activity◦ Less arrhythmogenic

Dopamine◦ Dose dependent◦ Low dose 1-3mcg/kg/min = “renal” dosing, almost

all D1◦ Medium dose 3-10mcg/kg/min = B1 and D1◦ High Dose >10mcg/kg/min = “pressor” dosing

Pressors - 2

Epinephrine◦ “king of pressors”◦ Used as last line pressor at our institution◦ Side effect includes increased risk of intestinal

ischemia

Pressors - 3

Pressor photo

Mixed Venous >70◦ Mixed venous taken from a swan-ganz catheter

Central Venous >65%◦ Taken from Central Line in the SVC

Mixed Venous and Central Venous Saturations

High Venous saturation with unclear utility Low Venous saturation means increased

extraction peripherally

How to increase mixed venous saturation, you have 2 option◦ Increase hematocrit◦ Increase cardiac output

Dobutamine

Venous Saturation

Consider when refractory hypotension◦ when you are adding 2nd pressor, think of adding

steroids!! No longer recommended to do ACTH stim or

random cortisol Empirically add hydrocortisone, dose 50mg

q6h

Corticosteroids

Antibiotics within 1 hour Typically vancomycin and zosyn are first line

agents if unclear of source Start broad and narrow when source

identified

Antibiotics

ABX photo from UH guide

Maintain tight blood glucose control with goal 140-180

If unable to manage easily (you get 2 tries with SQ insulin) then start on insulin gtt

Protocol driven by nursing◦ FYI this is different than the DKA protocol◦ (2010 NEJM – Glycemic Control in the ICU)

Glycemic Control

DVT◦ If no contra-indications….

Heparin SQ preferred agent◦ If contraindications

SCDs and TED hose

Stress Ulcer◦ PPI or H2 blocker

Prophylaxis

Protective Lung Ventilation Strategy ARDSnet protocol

◦ Low tidal volumes 6ml/kg of IBW

◦ PEEP◦ Goal plateau pressure <30

(2007 NEJM - Low Tidal Volume Ventilation in the Acute Respiratory Distress Syndrome) (2000 NEJM – Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute

Lung Injury and the Acute Respiratory Distress Syndrome)

Mechanical Ventilation

ARDS NET photo

RRT = Renal Replacement Therapy◦ HD = Hemodialysis◦ UF = Ultrafiltration

CRRT = Continuous Renal Replacement Therapy◦ CVVH = Continuous veno-venous hemofiltration◦ CVVHD = Continuous veno-venous hemodialysis

RRT, HD, UF, CRRT,CVVH, CVVHD…..What?

A◦ Acidosis

E◦ Electrolyte imbalance

I◦ Intoxication

O◦ Fluid Overload

U◦ Uremia

Indications for RRT

Sedation◦ Versed for anxiety◦ Fentanyl for pain◦ Haldol for agitation◦ Propofyl◦ Precedex

Miscellaneous

Assess the patient!!(Go into room, not look in EMR first)

Labs◦ CBC◦ RFP◦ LFTs◦ Coag◦ Type and Screen◦ Lactate!!!◦ In the right setting

Troponin, amylase, lipase, etc

Microbiology◦ Blood cultures x2◦ UA and culture◦ +/- sputum culture

Imaging◦ CXR, +/- KUB◦ CT in right setting

What Your Senior Expects From You

Check for Access◦ Prep for CVC

If hypotensive, need invasive hemodynamic monitoring◦ Central Line (CVC)◦ Arterial Line

Other◦ HD Catheter?◦ Introducer (Cordis)?

What Your Senior Expects From You

Get us if you are uncomfortable in a situation, aka the patient is very sick and crashing!!

STAY CALM!!! Nurses are your friend or worst enemy, the

choice is yours!!◦ They have taken care of more patients than you,

they often know what the next step is, use them as a resource!!

What Your Senior Expects From You

In Summary, the Goals of Sepsis are……

Our ICU Algorithm for Sepsis

69 y/o Male presented to ER with shortness of breath.

VS 38.3 88/46 114 28 86%

He is placed onto 50% ventimask, but continues to have low oxygen saturation and is intubated in the ER.

He is given 2L of NS and repeat BP is 92/44

Case

The Patient arrives in the MICU…..what do you do next?

Identify Severe Sepsis and Septic Shock Early

IVF Early invasive hemodynamic monitoring Goal endpoints

◦ Urine output, SBP, MAP, lactate, central venous sat, CVP <8 or 12

◦ Pressors and Steroids Cultures and ABX

Summary

Thank you!!!

Questions?