INFECTIOUS DISEASE
SEPSIS
PromptHistory associated with high mortality in sepsis
ResponseAge (older)
Malignancy
Female gender
CCF
Recent admissions
Cirrhosis/dialysis
Ventilated patient
Malignancy
Female gender
CCF
Recent admissions
Cirrhosis/dialysis
Ventilated patient
PromptInvestigations associated with increased mortality in septic shock
ResponseLactate
Certain blood culture results (MRSA, Enterococcus, Pseudomonas, candida)
Renal failure/renal replacement therapy
MRSA
INR - High
Platelets - Low (ie: DIC bloods)
Bilirubin - High
Certain blood culture results (MRSA, Enterococcus, Pseudomonas, candida)
Renal failure/renal replacement therapy
MRSA
INR - High
Platelets - Low (ie: DIC bloods)
Bilirubin - High
PromptSick Sepsis intubation strategy
ResponsePreoxygenation 100% FiO2 5 minsBVM with PEEP - HFNP for apnoeic oxygenation, aim sats 100% - To prevent rapid deoxygenation given critical illness and existing hypoxia
Support circulation - IV fluids (1-2L hartmann’s stat) +/- Norad infusion (commencing 5-10 mics/min) then titrate aiming MAP >65 - likely required in addition to IV fluids due to sepsis and vascular collapse
Safe intubation dosing - Ketamine 0.5mg/kg + rocuronium 1.2-2mg/kg - avoid haemodynamic collapse with large doses of induction agent.
Support circulation - IV fluids (1-2L hartmann’s stat) +/- Norad infusion (commencing 5-10 mics/min) then titrate aiming MAP >65 - likely required in addition to IV fluids due to sepsis and vascular collapse
Safe intubation dosing - Ketamine 0.5mg/kg + rocuronium 1.2-2mg/kg - avoid haemodynamic collapse with large doses of induction agent.
PromptARISE Trial
ResponseBig australian study in lots of hospitals
Cricially ill patients presenting to the emergency department with early septic shock, early goal directed therapy did not reduce all cause mortality at 90 days.
Benefit from early antibiotics
Cricially ill patients presenting to the emergency department with early septic shock, early goal directed therapy did not reduce all cause mortality at 90 days.
Benefit from early antibiotics
PromptQSOFA
Response
PromptList 3 components of the qSOFA score
ResponseRR>22
SBP <100
Altered GCS
0 - Mortality <1%
1 - Mortality 2-3%
3 - Mortality >10%
SBP <100
Altered GCS
0 - Mortality <1%
1 - Mortality 2-3%
3 - Mortality >10%
PromptChanges to international sepsis guidelines 2017
ResponseTime to antibiotcs for pts with Sepsis (SOFA 2 or more)
Lactate - measurments, treatment targeted at reducing lactate
Cultures before antibiotics
Emperic broad spectrum antibiotics for all sepsis patients
Procalcitonin
Fluid challenge for fluid resuscitation up to 30 mL/kg- crystaloid (not coloid)
No routine steroids unless specifically indicated
Inotropes (Norad >> vasopressin >> Dobutamine/Adrenaline)
Lactate - measurments, treatment targeted at reducing lactate
Cultures before antibiotics
Emperic broad spectrum antibiotics for all sepsis patients
Procalcitonin
Fluid challenge for fluid resuscitation up to 30 mL/kg- crystaloid (not coloid)
No routine steroids unless specifically indicated
Inotropes (Norad >> vasopressin >> Dobutamine/Adrenaline)
PromptProlactin
ResponseUsually produced by the thyroid
In sepsis is produced in inflamed tissue
Lag time 2-4 hours, peak 24-48 horus
Normal <0.1 ng/mL
Uses:
Identify occult infection
Rule out bacterial infection
Duration of antibiotic therapy
Predicts fatal outcome in critically ill
In sepsis is produced in inflamed tissue
Lag time 2-4 hours, peak 24-48 horus
Normal <0.1 ng/mL
Uses:
Identify occult infection
Rule out bacterial infection
Duration of antibiotic therapy
Predicts fatal outcome in critically ill
PromptDifferentials of very high lactate
ResponseGIT ischaemia
Hepatic failure
Sepdeis
Seizure
Poisoning
Metformin
Poor perfusion
Hepatic failure
Sepdeis
Seizure
Poisoning
Metformin
Poor perfusion