SEPSIS INFO DUMP
SEPSIS A&P CONSIDERATIONS AND DATA
[REMOVE BELOW – DEFINITIONS]
SEPSIS = INFECTION + DYSREG HOST RESPONSE
= s/s (fever, leuk, tachyp) + SOFA 2 OR GREATER
SEPSIS-3 moved past SIRS b/c min sens/spec for actual sepsis
SEPTIC SHOCK = INFECTION + hypotension refractory to fluid resus (30cc/kg) + lactate >2 mmol/L (and/or SOFA 2 OR GREATER)
Multiple Organ Dysfunction Syndome Criteria (evidence of >2 organs failing)
[REMOVE ABOVE- DEFINITIONS]
# Sepsis
# Septic Shock (Sepsis with Hypotension, Severe Sepsis, Sepsis-Induced Hypotension)
– Ilnness w/ subj fever for ABCDE days, brought from nursing home w/ report of AMS. Patient presented with fever (), tachypnea (RR), tachycardia (HR). Blood pressures RANGE with MAPs of RANGE. On exam, patient demonstrated AMS (AO*2). Patient hemodynamically stable.
– Labs on admission: WBC elevated (ABCDE) w/ neutrophil predominance (ANC), lactate ABCDE), procalcitonin ABCDE. Imaging finding
– In the ER, patient r/c’d ceftriaxone + vancomycin and 2L IVF. BCx, UCx taken.
– Review of records revealed prior septic hospitalizations, most recently (ABCEDEFGH)
– Pt RFs for infection included comorbidities (T2DM) and age, indwelling lines, recent surgery, immunocompromise
– Scoring:
– qSOFA = [SCORE]: at least 2- 1. SBP ≤100 mmHg, 2. RR ≥22/min, 3. AMS.
– SOFA = [SCORE]: Scores 0-4 in 6 areas – Resp (PaO2/FiO2), CNS (GCS), Cardio (MAP/dopamine/dobutamine/epinephrine/norepinephrine), Liver (bilirubin), Coag (platelets), Renal (creatinine/urine output).
– Source of infection suspected to be: PNA, UTI, SSTI, intra-abd infection, primary bacteremia in I/C pt
PLAN
1. HEMODYNAMICS
[ICU]
– Fluid resus: 30 mL/kg crystalloid (LR/NS) for hypotension/lactate ≥4 mmol/L, monitor to avoid overload
– Vasopressors: Norepi 1st line, add Vasopressin or Epi prn. Target MAP ≥65 mmHg.
– Inotropes: Dobutamine for myocardial dysfunction
– Hydrocort 50 mg IV q6hr
– Hemodyn Targets
– MAP: Init >65 mmHg, consider >80 mmHg for chronic HTN/poor U/O, reduce goal to >60 mmHg post-resusc
– HR: ~140 b/m (switch to non-ß-agonist vasopressors)
[WORSENING]
– Fluid resus: 30 mL/kg crystalloid (LR/NS) for hypotension/lactate ≥4 mmol/L.
– Monitor fluid response, avoid overload.
– ICU team aware of pt requiring IVF to maintain MAPS > 65
[STABLE]
– Fluid- gentle IVF 75cc/hr in stable pt
– stable MAPs, no consideration for pressors or ICU elevation at time of assessment but will continue to monitor close (VS Q2hrs)
2. SOURCE CONTROL
– remove foley
– surgery eval for hardware rmvl, debridement pending
– surgery eval for possible NSTI
– abscess on CT, surgery eval for drain
3. EMPIRIC ABX
– ABx (empiric) admin <1hr pres
– Pip-tazo (Piperacillin-tazobactam) 4.5g IV Q6hrs for 7-14 days
– Meropenem 1g IV Q8hrs for 7-14 days
– Cefepime: 2g IV q8h for sepsis.
– Linezolid: 600mg IV q12h for sepsis.
– Vancomycin: Dosed based on actual body weight (15-20 mg/kg IV q8-12h, not to exceed 2g per dose), with trough levels targeted typically between 15-20 µg/mL for sepsis
– Metronidazole: 500mg IV q8h for sepsis.
– Renal dosing considerations [VANC + ZOSYN = BAD RENAL]
– Vanco: Adjust for CrCl <50 mL/min, initial dose based on ABW (15-20 mg/kg), then dose per levels.
– Linezolid: No adjustment needed for renal impairment.
– Ceftriaxone: No adjustment needed for mild-moderate renal impairment; for severe (CrCl <30 mL/min), 1-2g q24h.
– Cefepime: CrCl 30-60 mL/min 1g q12h; CrCl 11-29 mL/min 1g q24h; CrCl <10 mL/min 500mg q24h.
– Meropenem: CrCl 26-50 mL/min 500mg-1g q8h; CrCl 10-25 mL/min 500mg q12h; CrCl <10 mL/min 500mg q24h.
– Pip-tazo: CrCl 20-40 mL/min 2.25g q6h; CrCl 10-20 mL/min 2.25g q8h; CrCl <10 mL/min 2.25g q12h.
– Metronidazole: CrCl 30 or UFH)
glycemic control
sedation/analgesia prn.
– Follow-up: Reassess SOFA, review abx @ 48-72 hrs for de-escalation per cx results and clinical improvement.
[OTHER CONSIDERATIONS]
OBSOLETE: SIRS (2 or more = SIRS)
– T>100.4F
– HR >90
– RR > 20, PaCO2 12K, <4K, or 10% bands
Source dep abx: tick-borne (doxy), C. diff (PO vanco +/- IV metro)
NEPHROTOXICITY
– Piperacillin/tazobactam (particularly w/ vancomycin) and vancomycin show a higher association with nephrotoxicity compared to meropenem, cefepime, linezolid, ceftriaxone, and metronidazole.
– Linezolid is noted for its lack of nephrotoxicity
1. Pip-tazo (Piperacillin/tazobactam): Significantly incr AKI risk in combo with Vanco, 6.7 times more likely vs Vanco + Cefepime/Meropenem [PubMed].
2. Vanco (Vancomycin): incr AKI risk in monotherapy; 2-fold incr risk vs other single agents
3. Meropenem: Lower AKI risk vs Vanco, HRs below null
4. Cefepime: Lower AKI risk vs Vanco, HRs below null
5. Linezolid: No kidney tox, often used as comparator
6. Ceftriaxone and Metronidazole: Nephrotox less characterized, specific comparative data not found.
ADVERSE RXN ABX
– Vanco: AEs nephrotox, ototox;
CI in pts w/ known hypersens to vanco.
– Linezolid: AEs incl myelosupp (thrombocytopenia, anemia, leukopenia), neuropathy;
CI in uncontrolled HTN, pheochromocytoma, thyrotoxicosis, concurrent use of SSRIs.
– Ceftriaxone: AEs incl pseudomembranous colitis, hypersens;
CI in neonates w/ hyperbilirubinemia, cephalosporin allergy.
– Cefepime: AEs incl neurotox (encephalopathy, seizures), positive Coombs;
CI in cephalosporin allergy.
– Meropenem: AEs incl seizures in CNS disorders, GI issues; CI in carbapenem hypersens.
– Pip-tazo: AEs incl bleeding diathesis, hypersens reactions;
CI in severe penicillin/β-lactam allergy.
– Metronidazole: AEs incl neurotox (peripheral neuropathy, seizures), disulfiram-like rxn w/ alcohol;
CI in 1st trimester pregnancy, active CNS diseases.