SEPSI

S
MODS
SEPTIC
DrA l i A h m e d S o h a i l
SHOCK
PGR Anesthesia
SEP S I S

Definition:

A life-threatening organ dysfunction

due to a dysregulated host response
to infection.
SIRS

SIRS req uires 2 or m ore of the fo llowing:

► Fever of more than 38°C (100.4°F) or less than 36°C

(96.8°F)
► Heart rate of more than 90 beats/minute
► Respiratory rate of more than 20 breaths/minute or
arterial carbon dioxide tension (PaCO 2 ) of less than 32
m m Hg
► Abnormal white blood cell count (>12,000/µL or
<4,000/µL or >10% immature b a n d forms)
► Sepsis is SIRS + confirmed or presumed
infections
► mortality: 10-15%
 MUlTI Organ Dysfunction
Syndrome (MODS)

► Subsequent failure of more than one organ

systems associated with sepsis
Septic Shock
► Septic shock is a subset of sepsis in which
underlying circulatory a nd cellular/metabolic
abnormalities are profound enough to substantially
increase mortality.

Septic shock clinical criteria:

► Sepsis a n d (despite a d eq u a te volume resuscitation)

both of:

❑ Persistent hypotension requiring vasopressors to maintain

MAP greater than or equal to 65 mm Hg
❑ Lactate greater than or equal to 2 mmol/L
Pathophysiology

► It c a n b e subdivided into

1. Sources of infection
2. Causative organisms
3. Effects on body a n d organs systems
1. Sources Of Infection

► Respiratory
► GIT
► Urinary
► CNS
► Ear/Nose
► Indwelling catheter
► Cutaneous/soft tissue infection
► Undetermined
2. Causative Organisms

► Gram-positive bacteria
► Gram-negative bacteria
► Fungal infections
► Anaerobes
► Uncommon causes:
✔ Seasonal influenza viruses
✔ Dengue viruses
✔ Avian and swine influenza
viruses
✔ Ebola
✔ Yellow fever viruses
3. Systemic Effects

Endocrine Dysfunction

HYPERGLYCEMIA

► Hyperglycemia due to decreased production of insulin,

increased production of stress hormones leading to
gluconeogenesis, increased resistance to insulin due to
impaired expression of GLUT-4

► Hyperglycemia leads to suppressed function of neutrophils

that decreases bactericidal activity
Adrenal Insufficiency

Initially increased surge of glucocorticoid due to stress

an d then adrenal insufficiency due to

► Depression of synthetic capacity of intact adrenal

gland
► Frank adrenal necrosis due to DIC

Decreased Vasopressin
Production (due to blunted
sympathetic response)
Increased serum lactate
level
► Inhibition of pyruvate dehydrogenase

► Diminished oxidative phosphorylation

► Increased level of pyruvate

► Pyruvate conversion to lactate by

anaerobic glycolysis
 Hemodynamic Effects

► Systemic vasodilation (both arteries a n d veins) that

decreases ventricular preload a n d after load. Impairment
of secretion of vasopressin so persistance of vasodilation.

► Cause: Increased production of endothelial NO

► Oxidative injury to vascular endothelium leading to fluid

extravasation a n d hypovolumia that adds to
decreased ventricular filling from venodilation
► Proinflammatory cytokines promote cardiac
dysfunction (both systolic a n d diastolic)

► Cardiac output is initially maintained due

to tachycardia a n d volume recussitation
Cardiovascular Effects

► Early stage:
low CVP or PCWP/high CO/low SVR

► Because of high cardiac output a n d peripheral

vasodilation, it is called hyperdynamic/warm
shock

► In later stages:
High CVP or PCWP/low CO/high SVR
Organ Dysfunction include

Lung: Decrease in arterial PO2, tachypnea, ARDS

Kidney: ARF a n d proteinuria.

Liver: Elevated levels of serum bilirubin a n d ALP; cholestatic jaundice.

GIT: Nausea, vomiting, diarrhea, an d ileus.

Heart: Cardiac output is initially normal or elevated. Later on,

impaired cardiac contractility occurs.

Brain: Confusion

Skin: Rash, petechiae, purpura, erythema a nd necrosis.

High Risk Groups
Signs a n d symptoms
 Scoring systems for
Sepsis
► qSOFA
► SOFA

SOFA score 5 of two points or more for patients in an ICU

while qSOFA score of two or more for patients outside of the
ICU, when there is p resum ed or susp ec ted infec tion
qSOF
A
qSOFA criteria specifically relate to the most likely
manifestations of organ dysfunction in e a c h of the main organ
systems:

Neurologic, Cardiovascular, a n d Respiratory

Two or more of the following constitutes

sepsis:

► Hypotension: SBP less tha n or eq ua l to 100

m m Hg
► Altered mental status (any GCS less than
SOFA SCORING SYSTEM

► Two or more of the following constitutes

sepsis:
Time course of disease

► Admission SOFA
► Daily SOFA
► Maximum SOFA
► Delta SOFA
► Discharge SOFA

A high total SOFA score (SOFA max) a n d a high delta

SOFA (the total maximum SOFA minus the admission total
SOFA) have been shown to b e related to a worse
outcome
INVESTIGATIONS
CBC: Increased TLC with neutrophilia. Low PLT count.

RFTs: Urea a n d raised Sodium more than creatinine

show dehydration. High creatinine shows renal failure.

Coagulation profile: Raised INR shows septic

coagulopathy.

ABGs: metabolic acidosis is common. There may b e compensatory

hyperventilation.

Serum lactate level

Chest radiograph: To see ARDS

MANAGEMENT OF SEPSIS
AND SEPTIC SHOCK

1. Control a n d eradication of source of infection

2.Maintenance of a de q u at e perfusion with i/v fluids
a n d vasopressors
3. Supportive treatment of complications of sepsis
One Hour Bundle
1. Initial Resuscitation

► IV crystalloids
► 30ml/kg
► Resuscitation GOALS:
. CVP 8-12 mmHg
. MAP > or = 65mmHg
.Urine output > or = 0.5 ml/kg/hr
. ScvO2 > or = 70%
. Mixed venous saturation > or = 65%
2. Obtain Cultures

► Get appropriate cultures (blood, CSF,

sputum, urine, wound) before starting
antibiotics

► Two or more sets of blood cultures from

different sites

► Approx. 20ml blood in e a c h culture

3. Start Antibiotic Therapy

► Start antibiotic therapy as early as sepsis diagnosed

(within first hour)

► Empiric broad spectrum antibiotics until culture a nd

sensitivity results are obtained

► Combination therapy for 3-5 days

► Duration: 7 to 10 days

► Reassess
4. Eradicate source of
infecion
► Identify source

► Drain abscess
► Debridement of wounds
► Remove infected foreign bodies
► Remove i/v or urinary catheters if source of infection
5. Fluid Therapy

► Crystalloids - fluid of choice in septic shock.

Balanced crystalloids are preferred

► Goal-directed fluid therapy for first 24

hours.

► Hematocrit above 30.

► Albumins
6. Vasopressors

► Start if hypotension (MAP less than

65mmHg) persists.

► Norepinephrine – first choice 2-20ug/min

► Epinephrine – 20-50ug/min
► Vasopressin – 0.03units/min (splanchnic
ischemia)

► Angiotensin-II - newest addition after

a d eq u a te volume resuscitation & use of
vasopressors.FDA approved in 2017
7. Role of I/V Steroid
therapy
► Indicated in septic shock not responding to fluid resuscitation

► Increase vasoconstrictor response to catecholamines according to

ACCCM use only in vasopressor dependant septic shock.wean when
vasopressor are not needed.

► Anti inflammatory activity

► IV Hydrocortisone is recommended

► Dose less than 300mg/day (limit risk of infection). Better to give in

infusion to prevent hyperglyycemia
► Surviving Sepsis Campaign guidelines emphasize that steroids
should
not b e administered to patients with septic shock unless
hemodynamic stability cannot b e achieved with fluid resuscitation
a nd vasopressor agents
8. Blood products

► Target Hb = 8g/dl. Once tissue hypoperfusion has

resolved a n d in the absence of extenuating
circumstances, such as myocardial ischemia,
severe hypoxemia, acute hemorrhage, or ischemic
heart disease,

► Platelets if less than 10000/mm3 with no bleeding .

(prophylactically)and 20000/mm3 if bleeding risk
present transfuse prophylactically.

► 3. Fresh frozen plasma not b e used to correct

laboratory clotting abnormalities in the absence of
bleeding or planned invasive procedures
9. Glycemic control

► Target blood glucose <180mg/dl

► IV insulin to control hyperglycemia, if neede d

► Monitor BSR every 1-2 hr initially, then 4-hrly

when stable.
► 10%moratality benefit with tight glycemic
control
11. Nutritional support

► Enteral route is p referred .

► Some suggestions for starting feed after 24 to

maximum 48 hours due to increased load on gut.

► Maintain normo-glycemia.
► Glutamine: decreases the adherence of bacteria
to gut wall a n d translocation
13.Dvt Prophylaxis

► In the absence of contraindications (eg, active

bleeding or thrombocytopenia), administer either
low-dose unfractionated heparin (UFH; 2 or 3
times daily) or low-molecular-weight heparin
(LMWH); LMWH may b e preferred in very high risk
patients (eg, patients with severe sepsis a n d
previous DVT, trauma, or orthopedic surgery)
►
If the patient’s creatinine clearance is less
than 30 mL/min, dalteparin may b e used
12. Treat complications of
sepsis
► ARF – hemodialysis

► DVT prophylaxis - compression stockings, heparin,

LMWH

► Stress ulcers - PPI or H2 antagonists. Prevent VAP and

GI bleed.

► ARDS -ventilator support. Avoid d e e p sedation and

NMB

► Anemia
► Hyperglycemia
► Lactic Acidosis
Anesthesia Considerations
For
Patients with Sepsis
► Surgical drainage of abscess, laparotomies, wound
debridement or amputation of limb may b e required.

► If surgery c a n b e delayed for an hour or so, delay it until

p a tient is resusc itated (ABC) a nd then c ontinue
m a na g e m ent intraop.

► Some patients require emergency surgeries like

necrotizing fasciitis.
Pre-operative preparation:

► Preop Assessment (History, Examination, Airway, Labs)

► Informed Consent.
► Sepsis/Septic Shock management continued side by side.
► Administer oxygen while preparing equipment/drugs.
► Obtain wide bore cannula, if not secured already.
► Pass NG a n d Foley catheter.
Intra-operative Considerations:

► RSI.
► Avoid Sux, if hyp erka lemia is
likely.
► Ketamine: increases contractility an d systemic vascular
resistance, assuming an intact sympathetic nervous system.
► Avoid etomidate in critically ill patient due to adrenocortical
supression
► Avoid Propofol: Augments hypotension. Prepared in emulsion
so c a n harbor pathogens.

► Short acting opiods i.e alfentanil cause significant

dose reduction in induction agent.
► The effect a nd duration of opiods other than ramifentanil will
b e increased by impaired hepatic a nd renal function.

► Avoid NSAIDS who are persistently hypotensive or septic.

NEURAXIAL
ANESTHESIA
• Use of EPIDURAL is controversial in sepsis although depending upon
circumstances some clinicians still consider benefits outweigh risk.

• A potential bacteremia is considered contraindication

• Coagulopathy may preclude insertion
• Hypotensive effects are likely to b e aggravated

• If insertion of epidural is not contraindicated by other factors

consider inserting catheter but waiting until patient is stable before
establishing the block.
Antibiotics

► Antimicrobial Stewardship

► Classifica tion (on basis of mode of

ac tion)

► Regimen/Activity
Antibiotics & their regimen
Aminoglycosides Gram Negative Aerobic Bacilli (including
Pseudomonas)

Carbapenams (Imipenam/ All bacterial pathogens (Pseudomonas,

Meropenam) Pneumococci, Methicillin-sensitive &
Coagulase-negative Staphylococci,
Anaerobes) except MRSA & VRE

Fluoroquinolones (Levo/ Methicillin-sensitive Bacilli, Streptococci

Moxi) (including Penicillin-resistant
Pneumococci), Atypical Organisms (such
as Mycoplasma & Heamophillus)

Penicillins (Amino, Carboxy, Aerobic Gram Negative Bacilli

Ureidopenicillins)

Vancomycin All strains of Staphyloccocus Aureus

(including MRSA), Aerobic & Anaerobic
Streptococci

Linezolid Same as of Vanco plus VRE

Cephalosporins