Day 1 - Sepsis

Identification

Several scoring mechanisms exist, but above all it is key to have a high index of suspicion

  1. Systemic Inflammatory Response Syndrome (SIRS)

    1. Sensitive but not specific, several potential mimickers ie. pancreatitis

    2. Should raise your suspicion for infection, but does not rule it in

  2. quick Sequential Organ Failure Assessment (qSOFA)

    1. Specific but not sensitive, not intended as a screening tool for sepsis

    2. Best used to risk stratify patients with respect to sepsis-related mortality

  3. While not captured in these scoring systems, always assess for other evidence of organ dysfunction (decreased urine output, hepatic dysfunction, coagulopathy)

Upfront Management

  1. Obtain adequate IV access - at least 1, ideally 2 large bore (18G) IVs

  2. Draw 2 sets of blood cultures

  3. Administer empiric broad spectrum antibiotics

    1. Should be done ideally within 1hr

    2. Guided based on clinical suspicion of site of infection and previous sensitivities

    3. Start broad and narrow later once stabilized and cause identified

  4. Fluid resuscitate

    1. Initially 30mL/kg bolus within 3 hours (majority should be given within first 30 minutes)

What should guide decisions on further volume administration?

  1. Favour dynamic over static measures, although there is no single perfect tool

    1. Look at blood pressure response to previous boluses, metrics of cardiac output such as urine output, lactate levels

    2. Ultrasound can assist with assessment but again, not perfect

      1. Look at IVC compressibility (valuable if very collapsed)

      2. Echo for hyperdynamic or underfilled LV

      3. Passive leg raise as a trial fluid bolus

  2. Switch to vasoactive agents early if clinical picture does not suggest they are fluid responsive any longer

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Anything else I shouldn’t miss?

  1. Never forget source control!

    1. Involve colleagues from surgery, interventional radiology, etc, early when needed

  2. Narrow and de-escalate antibiotics when appropriate and you know what you are targeting

The Intern at Work -