SEPSIS
Definitions:
SIRS: Two or more of the following: T>38.5°C or <35.0°c;>90 beats/min; RR >20 breaths/min or PaCO2 of <32>12,000 cells/mL, <4000>10 percent immature (band) forms.
Sepsis: SIRS secondary to an infection
MANAGEMENT:
Early goal directed therapy for sepsis is now the standard of care. A trial showing improved mortality using an early goal directed approach to sepsis can be found here, this trial is frequently referred to in the ICU as the Rivers' protocol.
Aimed at maintaining tissue perfusion:
1) Ensure adequate airway/breathing - intubate if necessary. Provide supplemental oxygen
2) Evaluate for signs of poor perfusion - frequent BP monitoring (consider art line - NEJM video on insertion here), LOC, Urine output, lactic acidosis, shock liver, etc.
3) Improve perfusion - FLUIDS!!!!!. Crystalloids (NS or Ringer's) are currently used as the first line resuscitation fluid. Patients often need >6L in the early stages of sepsis - be sure to monitor for signs of fluid overload, especially in those with renal or heart failure. Consider placing a central venous catheter - this provides secure venous access, can allow infusion of inotropes/pressors and can be used to monitor central venous oxygen saturatino and CVP.
4) Monitoring/"Advanced measures" - Involve the ICU/CCRT team. Activated Protein C (Xigris) and/or steroids should be considered in the right clinical context. Steroids are generally used now when shock persists despite adequate fluids and inotrope administration, or in patients on chronic steroids.
5) TREAT THE SOURCE - Identify and treat the cause of infection. In a large retrospective study, antimicrobial administration within the first hour of hypotension was associated with increased survival to hospital discharge in patients with septic shock. Culture potential sources and use appropriate broad spectrum antibiotics based on the suspected source and patient characteristics. Surgical evaluation and debridement should be rapdily arranged if necessary.
