Lecture on Sepsis – an update

This is the screen cast of a lecture titled “Sepsis an update” given by Irfan Hafiz MD on June 21st 2013 at Centegra Woodstock Hospital.

Sepsis protocol

TO BE COMPLETED WITHIN 3 HOURS:

  1. Measure lactate level
  2. Obtain blood cultures prior to administration of antibiotics
  3. Administer broad spectrum antibiotics
  4. Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

  1. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg
  2. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL):
    1. Measure central venous pressure (CVP)*
    2. Measure central venous oxygen saturation (ScvO2)*
  3. Remeasure lactate if initial lactate was elevated*
  4. Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg; ScvO2 of ≥70%, and normalization of lactate.

Resuscitation Goals

  1. To achieve central venous pressure (CVP) of > 8 mm Hg
  2. To achieve central venous oxygen saturation (ScvO2) of > 70%
  3. To achieve MAP > 65mmHg and a urine output of >0.5mls/kg/hr
  4. The 24 hour SSC Management Bundle includes:
  5. Low-dose steroids administered for septic shock in accordance with a standardized ICU policy
  6. Glucose control maintained below upper limit of normal (8.3 mmol/L) with an insulin sliding scale regime (usually short-acting insulin such as Human Actrapid)
  7. Lung Protective Ventilator Strategy utilising 5–8 mls/kg tidal volumes for mechanically ventilated patients to avoid volutrauma and barotrauma.

References

  1. Surviving sepsis campaign
  2. History of sepsis
  3. Ingaz Semmelweis – reduced puerperal sepsis
  4. Louis Pasteur – founder of microbiology
  5. Joseph Lister – father of antisepsis
  6. Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis; N Engl J Med 2008; 358:125–139January 10, 2008DOI: 10.1056/NEJMoa070716
  7. RBC transfusion guidelines
  8. Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis; The Lancet Infectious Diseases, Volume 13, Issue 5, Pages 426 – 435, May 2013 doi:10.1016/S1473–3099(12)70323–7
  9. Understanding of the Efficiency and Effectiveness of the Health Care System – Dartmouthatlas.org
  10. The Quality of Health Care Delivered to Adults in the United States; N Engl J Med 2003; 348:2635–2645June 26, 2003DOI: 10.1056/NEJMsa022615
  11. Use of a Computer Decision Support System and Antimicrobial Therapy Appropriateness
    Infection Control and Hospital Epidemiology , Vol. 34, No. 6 (June 2013), pp. 558–565
    Article DOI: 10.1086/670627