Sepsis and Septic Shock: Treatment

00:01 So what are we gonna do for our septic patients? I already alluded to source control in order to control the source you need to know what the source is, so if it’s a simple source like pneumonia or a urinary tract infection just antibiotics are gonna be enough to take care of it, whereas if it’s an abscess, if it’s a surgical process, if it’s in an enclosed space that antibiotics can't reach like a septic joint, you might need more aggressive treatment to control that source.

00:31 We're gonna always use antibiotics in sepsis management because we wanna make sure that we are addressing any infections that are amenable to antibiotic treatment and we're gonna go for broad spectrum antibiotics until we know what the culprit bacteria is and we know what it’s sensitivity pattern is.

00:47 Every patient with sepsis is gonna get some degree of fluid resuscitation again based on their degree of physiologic derangement and their comorbidities.

00:57 We're often gonna need vasopressors for patients who are not responsive to fluid and we're always gonna keep super close tabs on the patient’s vital signs, their blood pressure, their lactate level, all of the things that give us information about how successful we're being in reversing that tissue level hypoperfusion that is creating the problem for them in the first place.

01:22 So again, broad spectrum antibiotic coverage is what we wanna do when we prescribed the antibiotics.

01:28 We wanna tailor that coverage to the most likely pathogens so clearly if a patient has pneumonia we wanna cover a streptococcus pneumoniae and any other respiratory flora that we might be concerned about, whereas if they have a urinary tract infection we're gonna wanna make sure we cover e. coli and other GU and GI pathogens.

01:50 We’re gonna always tailor antibiotics to local microbial resistance patterns so different communities are exposed to different antibiotics and therefore will have different types of resistance among bacteria, so you wanna know what's going on in your community and what bacteria are most likely to be susceptible to.

02:09 And we always wanna give antibiotics quickly so as soon as we're thinking sepsis we should really be reaching for antibiotics because this is a major determinant of morbidity and mortality in sepsis so the international standard is within one hour of arrival in the ED, patient should receive broad spectrum antibiotics ideally sooner if you can.

02:32 Regarding fluids, I mentioned before that 30cc/kilo is our general standard of care for patients in need of volume resuscitation.

02:42 Now again, you might decide that your patient needs more than that especially if their history suggests that they're likely to be significantly dehydrated maybe their sepsis started off with a GI infection and they’ve had copious diarrhea, maybe they haven’t been able to eat or drink, maybe they’ve been vomiting extensively, these are patients who might need more than the 30cc/kilo, but that’s sort of the minimum you wanna get in within the first three hour of their arrival.

03:09 You can give more than 30cc based on their volume status and how they're responding to fluid.

03:14 We always wanna start with isotonic crystalloids so either normal saline or lactated ringer’s and we can consider albumin in patients who needs large volume resuscitation just because it stays in the vasculature a little bit better and might be more useful for expanding their blood volume.

03:32 If our patients are significantly anemic or may become significantly anemic through dilution over the course of volume resuscitation, we can think about using blood for them as well.

03:43 Remember hemoglobin concentration is one of the determinants of arterial oxygen delivery so if your patient got a hemoglobin of less than 7, you wanna think about bringing it up to a more physiologic level in order to optimize delivery of oxygen to tissues.

03:59 When do we use vasopressors? Well, very simply ones we've had adequately expanded the patient’s blood volume and we feel they’re euvolemic, if they still have a mean arterial pressure of less than 65, we need to use medications to support their blood pressure and that’s gonna be in the form of vasopressors.

04:19 Norepinephrine is the most common one that we use and it is considered to be the first line agent but for patients who don’t respond appropriately to norepinephrine, you can add epinephrine or vasopressin if indicated to support the blood pressure.

04:34 Any patient who’s getting vasopressors we’re generally gonna wanna place an arterial line for continuous monitoring of blood pressure and we're gonna wanna titrate their infusion to get their mean arterial pressure up above 65.

04:47 There is no one best way to monitoring how well your patient response to treatment and guidelines actually recommend that we use multiple different methods rather than relying on just one physiologic parameter.

05:01 So of course, our clinical exam is gonna give us a lot of useful information.

05:05 We wanna know what their vital signs are, we wanna know if their blood pressure is adequate, if their tachycardia’s resolving, if their lungs are clear, if their capillary refill is brisk - these are all indicators that can help us understand our patient’s perfusion status.

05:20 In some centers, central venous pressure is measured.

05:24 Now, that’s an invasive measurement, it requires placement of the central line and use of a manometer to measure the hydrostatic pressure inside of the central venous vasculature, the goal is 8 - 12 cm of water so that’s something that you can do if your patient has a central line in place.

05:41 Central venous oxygen saturation can also be used to monitor response to treatment and we really wanna see an SpO2 of under 70%.

05:52 Another technique that’s not used all that commonly but is actually recently helpful is the passive leg raise.

05:58 So if you're trying to figure out whether you should go from fluids to pressors, one thing you can do is lay your patient flat, put their feet up at about a 30 to 45 degree angle and if their pulse pressure increases by 10% or more without maneuver, that indicates that there's still hypovolemic and they might benefit from additional volume resuscitation, whereas if they don’t respond to that maneuver, you might think about moving on to vasoconstrictors because you've probably already achieved your volume goals.

06:30 Ultrasound is another technique that you could use to monitor your patients volume status in shock so cardiac ultrasound is commonly used to assess contractility.

06:41 You wanna know if the heart’s beating really rigorously or if you've got significant impairment of myocardial function because that’s gonna help you understand what's going on with your patient physiologically.

06:52 Another tool that’s really great is IVC ultrasound.

06:55 This is a surrogate measure of intravascular volume status and basically what you do is you identify the inferior vena cava and you measure how big it is.

07:07 If the IV is big and distended, that suggests that they are already volume overloaded and you're not gonna benefit from giving them additional fluids, where if their IVC is really tiny that suggests that they're hypovolemic and you probably do wanna continue to give fluids.

07:23 The other thing you can look at is the collapsibility of the IVC.

07:27 So in a hypovolemic patient, when they breathe in deeply their IVCs gonna collapse down to nothing whereas a euvolemic patient, if they breathe deeply, their IVC should collapse significantly less.

07:39 So these are all indicators that you can use to get a feel for what your patients’ volume status is whether you should continue to give volume or move on to vasopressors to support their perfusion needs.

07:52 So I just wanna give you an overview about the national consensus or I should say, International Consensus Guidelines for Sepsis, within one hour of arrival to the ED, it is mandatory for septic patients that we complete blood cultures, that we measure the lactate and provide broad spectrum antibiotics.

08:10 We've got three hours to get 30cc/kilo of IV fluid into the patient and again you might give more depending on the patient’s physiologic status and you might give less in some cases if they have really severe comorbidities such as end-stage cardiomyopathy, or a dialysis dependent renal disease and you're concerned that they won't tolerate that much fluid.

08:35 You have 6 hours to identify whether they have a response to fluid and initiate vasoconstrictors in the event that they're not responding appropriately to fluid.

08:46 So take home points on sepsis are one, you wanna look for physiologic dysfunction in every patient with infection, that’s gonna allow you to separate patients who have simple infections from those who have sepsis and we can use the qSOFA Criteria to do that.

09:03 If you do decide that your patient is septic you always wanna look for the etiology of their sepsis and control that source if it’s necessary.

09:11 You wanna always check the lactate and recheck it if it’s elevated on the initial check, provide broad spectrum antibiotics, adequate fluid resuscitation which is gonna be 30cc/kilo or more and consider vasopressors for anybody who doesn’t respond to fluid and remains hypotensive despite achieving a euvolemic state.

09:34 And that’s what I have to tell you about sepsis.

09:37 Thank you very much.