Sepsis

Luis D. Pacheco MD
Maternal Fetal Medicine
Surgical Critical Care
University of Texas Medical
Branch

1
 Objectives

l Know the latest therapeutic interventions

in the management of severe sepsis

l Acknowledge the applications and

limitations of such therapies in the
pregnant patient

2
3
 Introduction
l Sepsis continues to be the most frequent
cause of death in ICU’s

l Mortality as high as 40-50% for septic

shock

4
Definitions

5
6
 New Definition
l Severe sepsis is not used anymore

l Septic shock includes need of a pressor

plus lactate > 2 mmol/L (mortality>40%)

JAMA 2016;315(8):801-810

7
8
 Cytokines Endothelial Injury Third spacing,
hypovolemia

MACROCIRCULATION Increased NO,

Inhibit cardiac Low SVR
vasodilation
contractility

Tissue Factor
Systolic expression Diffuse
and clotting
diastolic
DIC
dysfunction
Multi organ
MICROCIRCULATION failure (Brain,
(LACTATE, ScVO2) lung,
heart,bowel, liver,
kidney, bone
marrow)
9
10
 BP = CO x SVR
May increase with May increase with
fluid or with vasopressors such as
inotropes norepinephrine or
(dobutamine or vasopressin
milrinone)

11
12
13
14
15
 Empiric initial antibiotic regimens

l Ampicillin Gentamicin Clindamycin

l Meropenem Vancomycin

l Cefepime Vancomycin Metronidazole

l Levofloxacin Metronidazole

16

Obstet Gynecol 2021;138(3):459-465

17
 Fluids and pressors
l Albumin vs saline?

NO benefit of adding albumin to crystalloids

Balanced solutions may be ideal (LR, Plasmalyte)

NEJM 2014;370:1412-1421
Crit Care Med 2014;42(7):1585-1591
18
 Crystalloids
Normal Saline (0.9%) Crystalloid with 154 meq of Na and
154 meq of Cl-. Increased incidence
of hyperchloremic metabolic
acidosis and acute kidney injury.
AVOID in ICU patients

Lactated Ringers “Balanced solution” with 109 meq of

Cl- and 28 meq of lactate
Plasmalyte “Balance solution” with 98 meq of Cl-
and 27 meq of acetate with 23 meq of
gluconate

19
 Colloids
Albumin May be 25% (100cc) or 5% (250-500
cc). Theoretical advantages of anti
inflammatory and anti oxidant
activity with NO scavenger role
Hydroxyethylstarch (Hespan) Increased risk of acute kidney injury
(osmotic nephrosis) and mortality in
sepsis. DO NOT use in ICU patients

20
21
22
Only 50% of hemodynamically
unstable patients in the ICU will
be fluid responsive

23
24
25
 Original Article

Hydrocortisone plus Fludrocortisone

for Adults with Septic Shock
D. Annane, A. Renault, C. Brun-Buisson, B. Megarbane, J.-P. Quenot, S. Siami,
A. Cariou, X. Forceville, C. Schwebel, C. Martin, J.-F. Timsit, B. Misset,
M. Ali Benali, G. Colin, B. Souweine, K. Asehnoune, E. Mercier, L. Chimot,
C. Charpentier, B. François, T. Boulain, F. Petitpas, J.-M. Constantin,
G. Dhonneur, F. Baudin, A. Combes, J. Bohé, J.-F. Loriferne, R. Amathieu,
F. Cook, M. Slama, O. Leroy, G. Capellier, A. Dargent, T. Hissem, V. Maxime,
and E. Bellissant, for the CRICS-TRIGGERSEP Network*

ABSTR ACT

BACKGROUND 26

Septic shock is characterized by dysregulation of the host response to infection, with The au
27
 Sepsis in pregnancy
l Use steroids for lung maturity as needed

l Individualize delivery

28
DVT prophylaxis is mandatory during
pregnancy in setting of severe sepsis

29
30
31
THANK YOU

32