Sepsis

 

Definitions:

Sepsis

·      Life-threatening organ dysfunction caused by a dysregulated host response to suspected or confirmed infection

Septic shock

·      Sepsis

·      mAP <65

·      Lactate >2

·      Despite adequate volume resuscitation

 

Classification: SOFA Score (Scale 0-4 for each)

CVS

·      mAP

·      Pressor requirement

Resp

·      P/F ratio

CNS

·      GCS

Kidney

·      Creatinine

·      Urine output

Liver

·      Bilirubin

Coag

·      Platelet

(Quick Sofa: worry if any of a) RR >22 b) SBP <100 c) GCS <15)

 

Pathophysiology:

Inflammation

·      Not as simple as pro-inflammatory (i.e. glucocorticoids don’t help)

·      Early severe inflammation can kill

·      Late immune suppression can kill

·      Genomics may reveal different response phenotypes

Coagulation

·      Coagulants upregulated

·      Anticoagulants consumed and downregulated

·      Microvascular thrombosis contributes to multi-organ dysfunction

·      Consumption may lead to DIC

Endothelial injury

·      Vasodilation

·      Disrupted glycocalyx -> exudate (e.g. ARDS)

Microcirculatory dysfunction

·      Heterogenous dysregulated expression of iNOS

o  A ‘steal’ phenomenon

o  Hyperperfusion if iNOS excess

o  Hypoperfusion of iNOS-deficient

·      Might be the reason for AKI

 

Treatment:

Main things

·      Antimicrobial ASAP

·      Blood cultures beforehand

Fluids

·      EGDT doesn’t help

·      Crystalloid is good enough for most

·      Albumin might be better in severe sepsis

·      Starches cause renal failure and death

·      Hb 70 is sufficient (TRISS)

Vasoactives

Vasopressors:

·      1st line: noradrenaline

·      2nd line: vasopressin (better for kidneys than ↑↑norad)

Inotropes:

·      Dobutamine is safest

Other:

·      Adrenaline is as good as noradrenaline but ↑HR, ↑lactate, ↑bsl

·      Dopamine causes arryhthmias

·      Role of inodilators is unclear

Immunotherapy

Glucocorticoids:

·      Reduce pressor requirement

·      Improves outcomes

·      Multiple adverse effects

Other:

·      Trials ++

Anticoagulation

·      Safe

·      Makes no overall difference

 

 

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