John Park, MD Assistant Professor of Medicine
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1 John Park, MD Assistant Professor of Medicine Faculty photo will be placed here 2015 MFMER
2 Sepsis Out with the Old, In with the New Mayo School of Continuous Professional Development 2nd Annual Inpatient Medicine for NPs & Pas: Hospital Care from Admission to Discharge Wednesday-Saturday, October 19-22, 2016 Sawgrass Marriott Hotel Ponte Vedra Beach, Florida 2015 MFMER
3 Disclosure I have no relevant financial conflicts to disclose 2016 MFMER
4 Objectives To be able to recognize sepsis Understand the importance of early intervention Implement treatment guidelines in management of sepsis 2016 MFMER
5 Case 1 A 78 year-old male with history of HTN presents with fever and dysuria for 3 days. VS in the ED: BP = 125/65 (MAP 85), RR = 28, HR = 120, Temp = 38.9⁰C. Urine shows many WBCs, nitrite positive. Blood and urine were sent for cultures. Does this person have sepsis? A. Yes B. No C. Maybe 2016 MFMER
6 Case 1 A 78 year-old male with history of HTN presents with fever and dysuria for 3 days. VS in the ED: BP = 125/65 (MAP 85), RR = 28, HR = 120, Temp = 38.9⁰C. Urine shows many WBCs, nitrite positive. Blood and urine were sent for cultures. Does this person have sepsis? A. Yes B. No C. Maybe 2016 MFMER
7 Case 2 78 year old male presents with cough and dyspnea for one week. His vitals: temp 37.9, HR 90, RR 15, BP 110/48 (MAP 69). You hear some crackles in the lung fields. Pertinent laboratory findings include WBC of 9 K and lactate of 1.0. Bilirubin is 1.8 (normal < 1.2)and creatinine is 2.0 (normal < 1.2). Chest x-ray shows an infiltrate in the right lower lobe. Does this person have sepsis? A. Yes B. No C. Maybe 2016 MFMER
8 Case 2 78 year old male presents with cough and dyspnea for one week. His vitals: temp 37.9, HR 90, RR 15, BP 110/48 (MAP 69). You hear some crackles in the lung fields. Pertinent laboratory findings include WBC of 9 K and lactate of 1.0. Bilirubin is 1.8 (normal < 1.2)and creatinine is 2.0 (normal < 1.2). Chest x-ray shows an infiltrate in the right lower lobe. Does this person have sepsis? A. Yes B. No C. Maybe 2016 MFMER
9 Sepsis SIRS + infection (known or suspected) Systemic inflammatory response syndrome Infection Non-infectious Pancreatitis Criteria Temp > 38.3ºC or < 36ºC HR > 90/minute RR > 20/minute WBC > 12,000 or < 4,000/mm 3, or > 10% bands 2016 MFMER
10 Crit Care CCM Med 2013;41: MFMER
11 In With the New 2016 MFMER
12 SEPSIS - 3 Life-threatening organ dysfunction caused by dysregulated host response to infection Organ dysfunction is identified by acute change in total SOFA (Sequential Organ Failure Assessment ) score of 2 points This criteria had in-hospital mortality risk of 10% Compared to 8.1% for STEMI JAMA 2016;315(8): MFMER
13 SOFA JAMA 2016;315(8): MFMER
14 Case 1 A 78 year-old male with history of HTN presents with fever and dysuria for 3 days. VS in the ED: BP = 125/65 (MAP 85), RR = 28, HR = 120, Temp = 38.9⁰C. Urine shows many WBCs, nitrite positive. Blood and urine were sent for cultures. Does this person have sepsis? A. Yes B. No C. Maybe 2016 MFMER
15 SEPSIS - 3 Severe Sepsis terminology is so yesterday! Septic shock: In those with sepsis, those needing vasopressors to maintain MAP 65 mmhg and lactate > 2 mmol/l (18 mg/dl) despite adequate volume resuscitation These patients have expected hospital mortality of 40%! JAMA 2016;315(8): MFMER
16 qsofa (Quick SOFA) Having 2 of 3 criteria in those with infection should alert clinicians to further investigate for potential sepsis, escalate care/therapy, and/or transfer to higher level of care Also, having these criteria in those not previously known to have infection, should prompt clinician to look for possible infection JAMA 2016;315(8): MFMER
17 Case 3 An 85 y/o nursing home resident is admitted to the floor for altered mental status. GCS = 14. He was recently treated for healthcare associated pneumonia with broad spectrum antibiotics. He has had diarrhea and decreased oral intake for 5 days. His BP is 92/50 mm Hg (MAP 64), RR 20/min, HR 120/min, T 37.6 ⁰ C. His C. diff toxin was negative. He has poor skin turgor, and dry skin and oral mucosa. His urine output has been 10 ml for the last 4 hours, and his Cr is 1.9. His serum lactate is 5 mmol/l. Does he have sepsis? A. Yes B. No 2016 MFMER
18 Case 3 An 85 y/o nursing home resident is admitted to the floor for altered mental status. GCS = 14. He was recently treated for healthcare associated pneumonia with broad spectrum antibiotics. He has had diarrhea and decreased oral intake for 5 days. His BP is 92/50 mm Hg (MAP 64), RR 20/min, HR 120/min, T 37.6 ⁰ C. His C. diff toxin was negative. He has poor skin turgor, and dry skin and oral mucosa. His urine output has been 10 ml for the last 4 hours, and his Cr is 1.9. His serum lactate is 5 mmol/l. Does he have sepsis? A. Yes B. No 2016 MFMER
19 Case 3 An 85 y/o nursing home resident is admitted to the floor for altered mental status. GCS = 14. He was recently treated for healthcare associated pneumonia with broad spectrum antibiotics. He has had diarrhea and decreased oral intake for 5 days. His BP is 92/50 mm Hg (MAP 64), RR 20/min, HR 120/min, T 37.6 ⁰ C. His C. diff toxin was negative. He has poor skin turgor, and dry skin and oral mucosa. His urine output has been 10 ml for the last 4 hours, and his Cr is 1.9. His serum lactate is 5 mmol/l. Does he have sepsis? A. Yes B. No 2016 MFMER
20 Case 3 An 85 y/o nursing home resident is admitted to the floor for altered mental status. GCS = 14. He was recently treated for healthcare associated pneumonia with broad spectrum antibiotics. He has had diarrhea and decreased oral intake for 5 days. His BP is 92/50 mm Hg (MAP 64), RR 20/min, HR 120/min, T 37.6 ⁰ C. His C. diff toxin was negative. He has poor skin turgor, and dry skin and oral mucosa. His urine output has been 10 ml for the last 4 hours, and his Cr is 1.9. His serum lactate is 5 mmol/l. Does he have sepsis? A. Yes B. No 2016 MFMER
21 Case 3 An 85 y/o nursing home resident is admitted to the floor for altered mental status. GCS = 14. He was recently treated for healthcare associated pneumonia with broad spectrum antibiotics. He has had diarrhea and decreased oral intake for 5 days. His BP is 92/50 mm Hg (MAP 64), RR 20/min, HR 120/min, T 37.6 ⁰ C. His C. diff toxin was negative. He has poor skin turgor, and dry skin and oral mucosa. His urine output has been 10 ml for the last 4 hours, and his Cr is 1.9. His serum lactate is 5 mmol/l. Does he have sepsis? A. Yes B. No 2016 MFMER
22 Sepsis Starts with infection, either suspected or documented Then look for any additional signs of organ dysfunction and hypoperfusion Need: ABG CBC Bilirubin Creatinine GCS assessment Lactate 2016 MFMER
23 Operationalization of Sepsis Identification JAMA 2016;315(8): MFMER
24 Importance of Early Intervention N = 9190 Each 10% increase in lactate was associated with 9.4% increase in odds of hospital death Each 7.5 ml/kg increase in fluids was associated with 1.3% decrease in lactate Ann Am Thorac Soc 2013;10: MFMER
25 Too Much of a Good Thing Ann Am Thorac Soc 2013;10: MFMER
26 Sepsis: Management Early appropriate antibiotics Crit Care Med 2006;34: MFMER
27 Sepsis Management Fluids If they are hypotensive, have elevated lactate, have reduced urine output Recall tachycardia may also be due to fever 250 ml is NOT a bolus Bolus is not 100 cc/hr Bolus is given within 15 minutes 500 to 1000 ml at a time 2016 MFMER
28 The Volume Properties of 1-L Fluid Infusion Fluid Volume (ml) Intracellular Extra-cellular Intravascular Interstitial D 5 W NS or LR % NaCl % Albumin Whole blood Courtesy: Dr. Afessa 2016 MFMER
29 Meta-analysis of Albumin in Sepsis Crit Care Med 2011;39: MFMER
30 Hydroxyethyl Starch (HES) NEJM 2012;367: MFMER
31 CRISTAL Trial JAMA 2013;310: MFMER
32 Albumin Supplementation: ALBIOS NEJM 2014;350: MFMER
33 Contents of Crystalloids and Colloid NS LR 5% Alb Na Cl Osm Lactate Potassium Calcium ph Cost MFMER
34 Type of fluid matters Balanced fluid (lactated ringer) appears to be better than normal saline Crit Care Med 2014;42: MFMER
35 Type of fluid matters Chloride restrictive fluids (LR or Plasma-Lyte) reduces renal injury JAMA 2012;308: MFMER
36 Amount of fluid matters Giving too much may be harmful Adjusted for age, APACHE II score, dose of norepinephrine Crit Care Med 2011;39: MFMER
37 Issues Regarding Fluids Watch out for hyperchloremic metabolic acidosis with too much NS Crystalloid should be the initial resuscitative fluid 5% albumin is iso-oncotic whereas 25% albumin is hyper-oncotic Chloride-restrictive fluid may have better outcomes Too much fluid may be harmful 2016 MFMER
38 Sepsis Management Early identification Initially based on suspicion, but adjust accordingly Procalcitonin Not for diagnosis of sepsis Misses fungal and possibly viral 2016 MFMER
39 Sepsis Management Early appropriate antibiotics Targeting suspecting organism Considering potential resistance Sufficient fluid administered Crystalloid first Consider chloride-restrictive or balanced fluid 2016 MFMER
40 What next? 2016 MFMER
41 Early Goal Directed Therapy NEJM 2001;345: MFMER
42 Surviving Sepsis Guideline Crit Care Med 2013;41: MFMER
43 CCM 2013;41: MFMER
44 Crit Care Med 2013;41: MFMER
45 ProCESS Trial NEJM 2014;370: MFMER
46 ARISE Trial NEJM 2014;371: MFMER
47 ProMISe Trial NEJM 2015;372: MFMER
48 Adapted from NEJM 2014;370: MFMER
49 Adapted from NEJM 2014;370: MFMER
50 Vasopressors Norepinephrine is the first line Vasopressin can be added 0.03 or 0.04 u/min NOT titrated If still hypotensive, add steroids Hydrocortisone 50 mg Q6 hr Next choice of pressors depends Inotrope Epinephrine Phenylephrine Dopamine has been associated with worse outcomes! 2016 MFMER
51 Vasopressors α - vasoconstriction β 1 increase HR and myocardial contractility β 2 - vasodilation Chest 2007;132: MFMER
52 Mayo MICU Sepsis Management Within the first 3 hours: Lactate POC in MICU. If elevated, repeat in 3 hours. If normal, no further testing Cultures before antibiotics Antibiotics 30 ml/kg IVF bolus Noticed: De-emphasized: CVP, SCVO 2, RBC transfusion! 2016 MFMER
53 CMS!!!!! 2016 MFMER
54 CMS!!!! 2016 MFMER
55 Sepsis - Summary Early identification Starts with infection suspected or documented! SOFA qsofa But for CMS SIRS 2016 MFMER
56 Sepsis - Summary Early management Lactate Make sure its repeated if > 2 mmol/l, within 6 hours Cultures before antibiotics Appropriate antibiotics Fluids 30 ml/kg crystalloid 2016 MFMER
57 Sepsis - Summary Crystalloids Balanced or chloride-restrictive fluid may be better 30 ml/kg Control the source of infection Repeat lactate, if initial was elevated, should guide 2016 MFMER
58 Sepsis - Summary Consider adjunctive therapies Vasopressors Hydrocortisone Consider cardiogenic issues Demand ischemia Stress cardiomyopathy Consider transfer to higher level of care Only if I am not covering the MICU! 2016 MFMER
59 Thanks for your attention 2016 MFMER
60 Questions & Discussion 2016 MFMER
61 GCS MFMER
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