Sepsis and Septic Shock

exp date isn't null, but text field is

Septicaemia (Sepsis) is defined as life-threatening organ dysfunction caused by a dysregulated host  response to bacterial infection (commonly) and fungal or viral infections (leastly).  Organ dysfunction  can  be  represented  by  an  increase  in  the  Sequential  [Sepsis-related]  Organ  Failure  Assessment  (SOFA) score of 2 points or more, with an in-hospital mortality greater than 10%.   

Septic Shock is defined as a subset of sepsis in which particularly profound circulatory, cellular, and  metabolic abnormalities are associated with a greater risk of mortality than 40%. 

Clinical presentation 

  • Temperature  of  >38oC  or  <36oC;  Heart  rate  of  >90/min;  Respiratory  rate  of  >20/min  or PaCO2 <32 mm Hg
  • Above  features  plus  evidence  of  organ  dysfunction  (hypotension,  jaundice,  oliguria,  or altered state of consciousness from altered sensorium like drowsiness/lethargy)

Note 

  • Septicaemia and septic shock are invariably fatal unless timely investigated and promptly managed using specific antimicrobial therapies and other supportive management.
  • Identification of the primary source/focus of infection is mandatory to eliminate the infection and ensure favorable treatment outcomes. Neonates may present atypically with inability to feed, respiratory distress/cyanosis or abdominal distension.

Investigations 

Blood  gases  analysis,  Bedside  ultrasound -  accessing  the  inferior  vena cava  and  the  lungs,  POC  ECG,  Urine  dipstick,  Chest  Xray -  if  suspecting  pneumonia,  Complete  blood  count,  Qualitative  or  quantitative  CRP  or  Procalcitonin  in  centres  available,  Serum  Electrolytes,  Creatinine  and  Urea,  Liver  function  tests -  liver  enzymes,  bilirubin,  clotting  time,  Blood  culture  and  antimicrobial  susceptibility testing. Primary source of infection’s clinical sample culture (e.g. urine, pus, sputum, CSF etc) and antimicrobial susceptibility testing and/or RNA/DNA PCR for viral pathogens (where indicated) 

Diagnostic criteria 

Sepsis: Q-SOFA in settings with limited laboratory infrastructures: two or more SOFA score namely:  Respiratory rate ≥22/min, Altered mentation and Systolic blood pressure ≥100 mm Hg) ± bacteria or  fungal  proven  blood  culture  and  susceptibility  testing  are  recommended  to  make  a  definitive  diagnosis.  

Septic shock: Sepsis diagnostic criteria above and vasopressor therapy needed to elevate MAP ≥65  mmHg and lactate >2 mmol/L (18 mg/dL) despite adequate fluid resuscitation. 

Non-pharmacological Treatment 

  • Nutritional support
  • Control measures focused to the primary focus of infection
  • Perform primary and secondary assessment and provide necessary interventions
  • Ensure patency of the airway and give oxygen if hypoxic or increased work of breathing
  • Connect the patient to the cardiac monitor and obtain vital signs

Pharmacological Treatments 

A: 0.9% sodium chloride (IV) (ADULT: 2litres; CHILD: 20mls/kg) 

OR  

A: compound sodium lactate (IV): Adult 2litres; paediatrics 20mls/kg in 20minutes as first bolus followed by second bolus of 2litres/20mls/kg (use small boluses in CCF)

OR   

S: dobutamine (IV) 2-20mcg/kg/min can be given for patients in shock not responding to fluids or when there is poor cardiac output

OR 

S: noradrenaline (IV) 5-20mcg/min for patients in septic shock not responding after 4litres of IVF to maintain the mean arterial pressure (MAP) of ≥ 65mm Hg  

AND   

A: hydrocortisone (IV) 200mg stat

Note: Transfuse blood  (if hemoglobin is < 7g/dl) 

Antimicrobial therapies (broad spectrum antibiotics must be started within the first hour): 

A: ampicillin (IV) 150-200mg/kg/day divided 6hourly a day 

AND  

B: cloxacillin (IV) 50-100mg/kg/day 6hourly a day 

AND 

A: gentamicin (IV) or (IM) 120mg [For children 7.5mg/kg] 24hourly for 5 days

If no improvement in vital signs within 24 hours (Temp, HR, RR and altered state of consciousness),  give: 

B: ceftriaxone (IV) 1 gm [For children 100 mg/kg (IV) or (IM)] 24hourly for 4-14 days 

AND 

A: gentamicin (IV) or (IM) 120mg [For children 7.5mg/kg] 24hourly for 5 days 

Refer immediately.

D:  ceftriaxone + salbactum (FDC) (IV) or (IM) 75-120 mg/kg 24hourly for 4-14 days 

AND  

A: gentamicin (IV) or (IM) 120mg [For children 7.5mg/kg] 24hourly for 5days 

OR 

S**: piperacillin + tazobactum (FDC) (IV) (4g+0.5g) administered 8hourly [For children 100 mg Piperacillin + 12.5mg Tazobactam per kg body weight 8hourly] for 7-10days 

AND  

A: gentamicin (IV) or (IM) 120mg [For children 7.5mg/kg] 24hourly for 5 days

Alternatively, (for patients who have evidence of not improving on the treatment above and referred  to  a  zonal/tertiary  hospital  with  judicious  decision  from  a  medical  specialist  or  medical  super-specialist): 

S**: meropenem 2g (IV) 8hourly in adults and adolescents [40 mg/kg 8hourly in children]  for 7-14 days 

OR 

S**: vancomycin (IV) 15 to 20 mg/kg body weight 8 - 12hourly (not to exceed 2 g per dose) for 7-14 days.  

Note: In renal insufficiency vancomycin can be adjusted for dose and dose interval. These antimicrobial  agents  are  usually  reserved  for  Gram  negative  and  Gram  positive  pathogen(s),  respectively  supported by culture and antimicrobial susceptibility testing 

For suspected co-existing anaerobic infections, an additional to all regimes above of  

B: metronidazole (IV) 500mg 8hourly [In children 7.5 mg/kg 8hourly] for 7 days  

OR 

S:  clindamycin  600mg - 1.2g/day  diluted  infusion  in  two  or  three  doses  [In  children  15-25mg/kg/day in three equal doses] for 7-10days is recommended

For  the  rare  cases  of  sepsis  or  septic  shock  due  to  carbapenem-resistant  Gram  negative  bacteria or vancomycin-resistant Gram positive bacteria, give: 

S**: colistin (IV) 2.5-5mg/kg/day 8-12 hourly for 5days  

AND  

S**: linezolid (PO/IV) 400-600mg 12hourly for 10-14 days respectively or other non-beta lactam  antibiotics  may  be  considered  based  on  culture  and  antimicrobial  susceptibility  testing results

In  case  there  is/are  risk  factors  for  invasive  Candida  infections  like  in  immunocompromised  states, prolonged invasive vascular, necrotizing pancreatitis, then antifungal therapies should  be added. 

C: fluconazole (IV) 800mg 24hourly on the first day then 400mg 24hourly for 14days [In  children 6-12mg/kg/day for 14days]