University:
West Coast University
Course:
PHAR 837 | IPC Infectious Diseases I
Academic year:

2024
Views:

149

Pages:

27
Author:

Asal A.

3 Sepsis and Septic Shock PHAR 837 Infectious Diseases I Marc Salvatus, PharmD, BCPS West Coast University, School of Pharmacy September 27, 2024 Definitions & Scoring Systems6-7 • Sepsis-3 Guideline (2016): Life-threatening organ dysfunction caused by a dysregulated host response to infection • Organ dysfunction: Increase in baseline Sequential Organ Failure Assessment (SOFA) score of >2 points ◦ Baseline SOFA score = 0 in patients without pre-existing organ dysfunction ◦ Increase in SOFA score of >2 = >10% mortality risk ◦ Superior predictive validity than SIRS for in-hospital mortality 7 8 IsthescoreofSOFABooBadSignmoremortality What is the baseline SOFA score in a patient with the following? 3g PaO2/FiO2 350 Plt 208 Bilirubin 0.9 MAP 60 Glasgow Coma Scale 15 SCr 1.3 9 Definitions & Scoring Systems6 Quick SOFA (qSOFA): modified SOFA • Identifies patients with suspected infection who are likely to have prolonged ICU stay or die in the hospital top • Positive score (>2) associated with 3- to 14-fold increase in risk of in-hospital mortality • Easily performed at bedside; repeatable • Purpose: prompt clinicians to adjust care as appropriate; not to be used as a single screening tool qSOFA Respiratory rate >22/min Altered mentation SBP <100 mmHg of Loosystolic the Bp TOP 10 stay Systemic Inflammatory Response Syndrome (SIRS)8 Sepsis-2 Guideline (2012): Sepsis = >2 SIRS criteria + confirmed/suspected infection SIRS Criteria a Temperature >100.4°F or <96.8°F (>38°C or <36°C) 2 Heart rate >90 beats/min 3 Respiratory rate >20 breaths/min or PaCO2 <32 mmHg U WBC (x 103 μL) >12, <4, or >10% bands 11 Clinical Presentation9-10 Laboratory Signs a Hyperglycemia (>140 mg/dL) in the absence of diabetes output Madrone Acute oliguria (urine output <0.5 mL/kg/hr for >2 hours despite adequate fluid resuscitation) SCr increase of >0.5 mg/dL Coagulation abnormalities Total bilirubin >4 mg/dL Electrolyte abnormalities (e.g., ↓Na, ↑K) Elevated serum lactate Elevated serum procalcitonin as liver 13 Septic Shock6 a • Shock: state of cellular and tissue hypoxia NEED oxygen enough Not • Types of shock: distributive, cardiogenic, hypovolemic, obstructive A shock: distributive (vasodilatory); subset of sepsis with >40% mortality risk • Septic • Septic patients with serum lactate >2 mmol/L AND require vasopressors to maintain mean arterial pressure (MAP) >65 mmHg despite adequate fluid resuscitation ◦ Normal serum lactate is 0.5 to 1.5 mmol/L x • Causes: gram-positive bacteria, antibiotic-resistant organisms, gram-negative organisms, fungi 14 REEK100 3 qSOFA = ? Patient SR SIRS = ? Ig Chief Complaint i 59 y/o female admitted to your hospital for dyspnea, respiratory acidosis, and hypotension. Unable to provide any history. According to their medical record, recent hospital stay earlier this month for a fall. After initial management in the ED, they were admitted to the ICU. Allergies: NKDA Objective Weight 120 kg, Height 5’8”, Temp 98.5°F, Pulse 104 bpm, RR 24 breaths/min, BP 88/43 mm Hg WBC 19.3 x 109/L, SCr 1.4 mg/dL, CrCl 46 mL/min, lactic acid 1.6 mmol/L Diagnostics/Microbiology Urinalysis: Trace leukocyte esterase, WBC 13/hpf lowamountof NB PMH: Morbid obesity, HTN, hyperlipidemia IMI ten Borg 15 BB Sepsis Bundle 1. Measure lactate level i. it Eton.IM Remeasure lactate if initial lactate is elevated (>2 mmol/L) 2. Obtain blood cultures before administering antibiotics (usually >2 sets) 3. Administer broad-spectrum antibiotics for adults with possible septic shock or a high likelihood for sepsis 4. Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate >4 mmol/L 5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure >65 mm Hg optional 16 30m41sangst Evaluation of Infectious Source12-13 Lupo 74 Sepsis mortality rates: ● Unknown source: 50-55% ● Pulmonary source: 50-55% ● Urinary source: 30% CDC Vital Signs, 2016 17 combat Evaluation of Infectious Source12-13 • Target empiric antibiotics at the suspected source of infection Suspected Site Initial Microbiologic Evaluation Common Pathogens Lung Culture of sputum or bronchoalveolar lavage (BAL), rapid influenza testing S. pneumoniae, H. influenzae, S. aureus, E. coli, P. aeruginosa Urinary tract Urine culture, urinalysis E. coli, Klebsiella, Enterococcus, Enterobacter, P. aeruginosa Catheter-related Culture of blood (from site of catheter) or catheter tip S. aureus, S. epidermidis, E. coli, Klebsiella, Pseudomonas, Candida* Skin Gram stain and culture of draining pus S. pyogenes, Clostridium, S. aureus, P. aeruginosa, fungi* *Anti-fungal therapy not usually indicated in non-neutropenic patients 18 comebad Sample Empiric Antimicrobial Regimens in Sepsis* Antimicrobial Regimen Infection (Site or Type) Community-Acquired Hospital-Acquired Urinary tract Ceftriaxone Ceftriaxone/ceftazidime Respiratory tract Levofloxacin/moxifloxacin or ceftriaxone + azithromycin Piperacillin/tazobactam or ceftazidime or cefepime + vancomycin or linezolid Intra-abdominal (Ciprofloxacin/levofloxacin + metronidazole) or (ceftriaxone + metronidazole) Piperacillin/tazobactam or (ceftazidime/cefepime + metronidazole) Skin/soft tissue Vancomycin or linezolid or daptomycin Vancomycin + piperacillin/tazobactam Unknown Piperacillin/tazobactam *Not all-inclusive. Selection depends on patient factors (e.g. co-morbidities, organ dysfunction, risk factors for multidrug-resistant pathogens), trends of antibiotic use, institutional antibiogram, etc. 19 Initial Resuscitative Therapy16 • Rapid restoration of perfusion • Aggressive administration of intravenous fluids ◦ 30 mL/kg (ideal body weight) ◦ Started by 1 hour of presentation ◦ Fully infused within first 3 hours of presentation • Choice of fluid: Balanced crystalloids suggested over normal saline (NS) ◦ Mortality benefit ◦ Examples: Lactated Ringer’s solution, Plasma-Lyte ◦ Potential for hyperchloremic metabolic acidosis with NS ◦ Albumin solution – high cost • Common therapeutic targets: MAP >65 mmHg, urine output >0.5 mL/kg/hr 20 Vasopressors17 • • • Indication: refractory hypotension despite adequate fluid resuscitation Goal: improve tissue perfusion Common therapeutic target: MAP >65 mmHg Receptor Location Agonist Effect ɑ1 Vascular smooth muscle cells Vasoconstriction, ↑BP ꞵ1 Heart ↑ Inotropy, chronotropy, cardiac output, HR ꞵ2 Vascular smooth muscle cells Vasodilation Vasopressin Vascular smooth muscle cells Vasoconstriction Dopamine Renal, splanchnic, coronary, cerebral vascular beds Vasodilation 22 Vasopressor Initial Dose ɑ1 ꞵ1 ꞵ2 DA Comments Norepinephrine (NE) 5-15 mcg/min ++++ +++ 0 0 1st-line single agent Epinephrine 1-15 mcg/min +++ +++ ++ 0 May add to or replace NE Vasopressin <0.03 units/min 0 0 0 0 May add on to NE Acts only on vasopressin receptors Phenylephrine 0.5-8 mcg/kg/min ++++ 0 0 0 Minimal effect on HR 1-3 mcg/kg/min +/- ++ +/- ++++ 3-10 mcg/kg/min ++ +++ + ++ 10-20 mcg/kg/min ++++ +++ 0 + bestie Dopamine Dose-dependent receptor stimulation 23 Vasopressors • May be started peripherally for short period of time (<6 hours) until central venous access is established • au include extravasation, local tissue Risks of peripheral administration injury, ischemia 8130,4 Levophed® (Norepinephrine) • First-choice vasopressor in septic shock • Potent vasoconstrictive effects and less effect on the heart (i.e. tachycardia) compared to other vasopressors • Reduced stability when exposed to light • Compatible in either dextrose 5% in water (D5W) or NS 24 Hour-1 Bundle Hour-1 Bundle Elements Patient SR Time Initiated (Admitted 1/6 at 12:46) Measure lactate level (re-measure if initial level >2 mmol/L) 1.6 mmol/L 13:25 Obtain blood cultures before administering antibiotics 2 sets of blood cultures obtained 1st set: 13:25 2nd set: 13:40 Administer broad-spectrum antibiotics Ceftriaxone, piperacillin/tazobactam, vancomycin administered after obtaining blood cultures Ceftriaxone 1 g IV q24h: 13:50 Piperacillin/tazobactam 4.5 g IV q8h: 15:42 Vancomycin 2.5 g IV x1: 16:15 Rapid administration of 30 mL/kg crystalloid for hypotension or lactate >4 mmol/L 1365 mL NS over 1 hour (~21mL/kg) 13:50 Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP >65 mmHg Levophed initiated BP range prior: 66-138/14-98 mmHg Average MAP prior: 63 mmHg 20:59 30 j Adjuvant Therapy and Supportive Care GLUCOCORTICOIDS · VTE PROPHYLAXIS · STRESS ULCER PROPHYLAXIS · GLUCOSE CONTROL 31 p Glucocorticoid Therapy in Septic Shock18-19 • • Suggested for adults with septic shock and an ongoing need for vasopressor therapy oil• my Accelerates resolution of shock • Increase in vasopressor-free days • Restore balance to the hypothalamic-pituitary-adrenal (HPA) axis Rationale: critical illnessasks induces a state of adrenal insufficiency that may contribute to shock • Not recommended as early therapy for septic shock (no mortality benefit) • Agent of choice: hydrocortisone IV ◦ ◦ SCCM/EISCM 2017: <400 mg/day for >3 days 200 mg/day in divided doses (e.g., 50 mg IV q6h) 32 Eon P Venous Thromboembolism (VTE) Prophylaxis • ICU patients are at risk for VTE ◦ ◦ • DVT: <10% incidence PE: 2-4% incidence Agents of choice • Unfractionated heparin (UFH) ◦ • 5000 units SQ q8-12h Low-molecular-weight heparin (Enoxaparin/Lovenox®) ◦ ◦ ◦ Preferred due to cost savings, ease of administration, reduction in incidence of PE and heparin-induced thrombocytopenia (HIT) 40 mg SQ daily CrCl <30 mL/min: 30 mg SQ daily, or heparin preferred 33 3 Stress Ulcer Prophylaxis • • 83105 Stress ulcers develop in the GI tract of critically ill patients  may result in hemorrhage ◦ Associated with significant morbidity and mortality ◦ Increased risk: mechanical ventilation >48 hours, coagulopathy, pre-existing liver disease, need for renal replacement therapy, higher organ failure scores Choice of agent • Dependent on patient characteristics, GI bleed risk, local incidence of C. difficile infections • Proton pump inhibitor (PPI) preferred ◦ Oral route preferred in patients able to receive enteral medications ◦ Pantoprazole, omeprazole • Histamine-2 receptor antagonist (H2RA) ◦ Famotidine (renally dose adjust as necessary) IMSIBID 34 U Glucose Control • Hyperglycemia associated with critical illness  multifactorial • Associated with poor outcomes • Increased mortality, hospital/ICU length of stay, nosocomial infection • Initiate insulin therapy at a glucose level of >180 mg/dL • Target glucose level: <180 mg/dL ◦ ◦ ◦ • Recommendations based on the NICE-SUGAR trial No difference between glucose targets of 140-180 mg/dL and 110-140 mg/dL Goal: Avoid hyperglycemia, hypoglycemia, and wide swings in glucose levels Monitor glucose every 1-2h until stable 35 Additional Supportive Therapies • Blood product infusion • Nutrition support • Neuromuscular blocking agents • External cooling or antipyretics • Mechanical ventilation, sedation, weaning • A it big and emotional problems Assessment and follow-up for physical,apt cognitive, after hospital discharge i 36 Response to Therapy20-21 Resolution of Sepsis • Response to initial fluid therapy may take hours to days • • Blood test Reduce fluid administration rate, wean off of vasopressor support, administer diuretics if needed Clinical/laboratory parameters ◦ MAP >65 mmHg ◦ Urine output >0.5 mL/kg/hr ◦ Vital signs (Temperature, HR, RR) ◦ Serum lactate ◦ Arterial blood gases ◦ CMP, CBC I 37 Response to Therapy20-21 i De-escalation and Duration of Antibiotics • Narrow after culture and susceptibility results return and/or after clinical improvement • No pathogen is identified in ~50% of patients • Duration should be individualized (e.g., until sepsis resolution) • Longer courses (e.g., 7-10 days) appropriate in patients with slow clinical response 38 Summary • Sepsis Definitions • Scoring Systems: qSOFA, SIRS • Hour-1 Bundle • Adjuvant Therapy and Supportive Care • Sepsis Resolution 40

Sepsis and Septic Shock

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