Dr Faheem Guirgis, UF Health Jacksonville Emergency Medicine

1. Faheem Guirgis MD, FACEP
ED andTrauma Symposium – February 16th, 2017
Co-Chair Sepsis Committee
Assistant Professor of Emergency Medicine
Division of Research
Department of Emergency Medicine
UF Health Jacksonville

2.  K23GM115690 – National Institute of General
Medical Sciences
 Society of Critical Care MedicineWeil Grant
for Sepsis
 Dean’s Grants from UF

3.  Briefly discuss updated sepsis definitions
 Discuss principles of early severe sepsis
management
 Review pearls and tips for sepsis management
 Outline common pitfalls to avoid in sepsis
 Discuss the implications of recent literature
and potential future changes in sepsis care

5.  A. Under-recognized
 B. Under-treated
 C. Misunderstood (pathophysiology)
 D. All of the above
Sepsis 3?

8. OLD
NEW

9. Local Infection
Systemic signs?
Organ Dysfunction
(dysregulated response)
Shock

10. +

11. SOFA

13. 1. Figure it out EARLY Sepsis Screening
2. Fill theTank = Fluids IVC US, Dynamic
measures, PLR
3. Fight the Bugs Antibiotics
Source Control
4. Fix perfusion MAP Organ fx
Lactate Inotropes
The 4 F’s

14. Institution-Wide Multidisciplinary Approach
 Sepsis Screening/Early recognition protocol
(Automated)
 Early Management Bundle/Order set
 Continued Care Bundle
 Education + Re-education = Culture of change
 Chart dives
 Be Data-driven

16.  Echo/IVC Ultrasound
 Passive Leg Raise
 Pulse PressureVariation
 StrokeVolumeVariation

17. QUICK ESTIMATION OF EF – GOOD SQUEEZE OR POOR SQUEEZE

18. 1. Use Cardiac
Probe
2. Place probe in
the long axis,
SubX, just right
of midline
3. Find IVC and
measure 3 cm
distal to RA (at
or distal to HV)
4. Can use M-
mode
5. Have patient
sniff if
spontaneously
breathing

19.  IVC < 1 cm = give fluids
 IVC 1-2 cm w/ 50% collapse w/ inspiration=
give fluids
 IVC > 2 cm or w/o collapse = not fluid
responsive
 Pulmonary Hypertension/RHF may confound
your IVC US
 Patients on mechanical ventilation – look for
a 15-18% change in IVC diameter

20. 3 cm

22.  ICU population
 Vasopressor dependent septic shock
 All on mechanical ventilation
 Limited Echo (LE) performed w/in 24 hours of
ICU admission

23. 1. Systolic function:
normal, moderate, or
severely impaired
2. Assess for pericardial
effusion
3. IVC diameter
fluctuation < or > 15%
dIVC=[(dI−dE)/dE]×100
<15% dIVC with normal LV fx = stop
fluids
>15% dIVC w/ normal LV fx = 20 to 40
mL/kg fluids
>15% dIVC w/ mod to severe LV
dysfx = 10 to 20 mL/kg fluids and
dobutamine 5 mcg/kg
<15% dIVC w/ mod to severe LV
dysfx = dobutamine and no fluids

24. Passive leg raise.To perform a passive leg raise, a patient is
placed in a semi-recumbent position at 45°.The patient’s legs
are then elevated to 45° and the hemodynamic variable of
interest evaluated after 30−60 seconds.

25. 1. Is fluid resuscitation adequate?
- Heart, IVC collapse, PPV, SVV
2. Is MAP adequate?
- MAP > 65
3. Is Oxygen Delivery adequate?
- Lactate normalization vs Lactate clearance?
Now Go Back and Ask 3 Questions…
What about individual measures of organ function?

27.  Effective Abx within 1st hour for sepsis and
septic shock (2016)
 Every hour of delay in giving Abx is associated
with a measurable increase in mortality
(Kumar et al; Ferrer et al)
 Mortality significantly increased in patients
who received initial antibiotics after shock
recognition (n = 172 [59%]) compared with
before shock recognition (OR, 2.4; 1.1-4.5) –
Puskarich et al

28.  Gram + > Gram - > polymicrobial as the cause
of most septic shock
 Bolus drugs before infusion drugs
 Broad coverage guided by local prevalence
patterns
 All patients should receive a full loading dose
of antibiotics

29.  EmpiricTherapy – best guess, no bugs yet
 Broad SpectrumTherapy – broad spec abx to
cover multiple potential bugs
 CombinationTherapy – Using more than one
drug to cover the same bug (largely
unproven)

30.  Empiric combo therapy for initial
management of septic shock
 No Empiric combo therapy for regular sepsis
or bacteremia
 No combo therapy for neutropenic
sepsis/bacteremia
 If combo therapy is used – de-escalate in the
first few days if clinical improvement

31.  “Trauma is a compulsive search for injuries” –
Billy Mallon
 “Sepsis is a compulsive search for a source of
infection” – Me
 Treat the patient like a trauma – fully expose, etc
 The less the patient can tell you the more
compulsive the search
 And…the severity of the source should be
proportional to the severity of illness

32.  Source control as soon as possible (Rec 6-12
hrs from time of diagnosis)
 If intravascular device is a possible source, it
should be promptly removed after other
vascular access established
 Consider IR or Surgery

33.  Cultures of blood and other sites (urine, CSF,
wounds, respiratory secretions, etc) before
abx if possible
 Cultures from vascular access and peripheral
blood – 10 cc each
 If culture from vascular access is positive
earlier than peripheral blood then vascular
access = infectious source

34. DO NOT DELAY ANTIBIOTICS > 45 MIN
FOR BLOOD CULTURES

38.  Published in CCM in 2015
 Dopamine still a bad choice for SSh
 Greater hospital mortality – propensity-
matched scoring, n = 38,788; 25% vs 23.7%;
OR 1.08; 95% CI, 1.02-1.14)
 Most commonly used in the South!

39.  Norepinephrine 1st agent
 Vaso or Epi as 2nd agent
 Epi - especially if inotropy required
 Vaso – need alpha
 Phenylephrine if inotropy not needed
 Norepi causing arrhythmias
 CO is high and BP is low
 Salvage therapy
 Dobutamine – first choice inotrope

40.  Vaso +/- HC vs Norepi +/- HC for vasopressor
dependent septic shock
 Primary outcome – renal failure free days
 No difference
 Demonstrated thatVaso could be titrated up
to a dose of .06units/min

41.  Guide resuscitation to normalize lactate
 Lactate normalization (< 2)
 Clearance?

43.  Hydrocortisone 200 mg/day
 When starting your second pressor

45.  Management so far:
 Fluids
 Abx
 Source identified and controlled
 Pressors
 Lactate level

46. Prevalence Mortality
Lactate > 4
alone
5.4% 30% but
Perhaps 20%
Hypotension
alone
49.5% 36.7%
Lactate > 4 +
Hypotension
16.6% 46.1%

47.  1316 pts w/ sepsis w/in 4 hrs of ED arrival
 111 progressed to shock w/in 48 hrs (8.4%)
 Females (OR 1.59), nonpersistent hypotension
(OR 6.24), bandemia ≥ 10% (OR 2.6), lactate ≥ 4
(OR 5.3), PMH CAD (OR 2.01)

48. SEPSIS RECIDIVISM
 110 ED patients w/ SS/SSh
 28-90 days: 17% rate of
sepsis readmission
LONG-TERM MORTALITY
 Initial mortality 18% (90
survivors)
 3 year mortality 48% (only
53 survivors)
Chronic Critical Illness
Disease of the elderly who survive initial sepsis  dc LTAC, functionally dependent,
die outside of the hospital months to years later (Sepsis P50 – UF)

49.  Fiscal impact of 30 day sepsis readmission
Sepsis CHF Acute MI
Initial
Hospitalization
(2009-11)
240,198 193,153 105,684
Readmission rate 20.4% 23.6% 17.7%
Annual costs
(California)
$500
million/yr
$229
million/yr
$142
million/yr

51.  Improved sepsis diagnostics (biomarkers)
 Dys-HDL?
 Better understanding of pathophysiology
 CCI/PICS/CARS (thanks to UF G’ville – Moore, Moldawer,
Leeuwenburgh)
 Persistent/long-term organ dysfunction – who/why?
 Sepsis recidivism – why?
 Mitochondrial medicine?
 RACETrial - L-carnitine (increases cardiac mechanical
efficiency and facilitates mitochondria)
 Metabolic cocktails?
 Hypothermia?!
 ECMO?

52.  Old definitions
 SEVERE SEPSIS: SIRS + sepsis-induced organ dysfunction:
 SBP < 90 or MAP < 70 mm Hg
 Creatinine > 2.0 mg/dl or Urine Output < 0.5 ml/kg/hour for > 2
hours
 Bilirubin > 2 mg/dl (34.2 mmol/L)
 Platelet count < 100,000
 Coagulopathy (INR >1.5 or aPTT >60 secs)
 Lactate > 2 mmol/L
 SEPTIC SHOCK:
 Lactate > 4 mmol/L, OR
 SBP < 90 or MAP < 70 mm Hg, not responsive to fluids

53.  A. measure lactate level
 B. obtain blood cultures prior to antibiotics
 C. administer broad spectrum antibiotics
 D. administer 30 ml/kg crystalloid for hypotension or
lactate = 4 mmol/L
 E. apply vasopressors (for hypotension that does not
respond to initial fluid resuscitation to maintain a
mean arterial pressure = 65)
 F. in the event of persistent hypotension after initial
fluid administration (MAP < 65 mm Hg) or if initial
lactate was = 4 mmol/L, reassess volume status and
tissue perfusion and document findings.*

54.  2/4 of the following
 Measure CVP
 Measure ScvO2
 Bedside cardiovascular ultrasound
 Dynamic assessment of fluid responsiveness with
passive leg raise or fluid challenge
 OR Focused exam† including vital signs,
cardiopulmonary, capillary refill, pulse and skin
findings.
 Remeasure lactate if initial lactate is elevated

55.  But sadly, it’s the end of my lecture 
 Thank you!

59.  Fluids - 30 ml/kg in the first 3 hours, crystalloid first, then maybe
albumin, use dynamic markers and/or fluid challenges
 Goal MAP>65
 EGDT is no longer recommended
 Lactate - attempt to normalize lactate
 Blood Cultures - get them before antibiotics, if obtaining them will
not delay the provision of antibiotics
 Antibiotics -Within 1 hour of sepsis or septic shock
 Vasopressors - Norepi is the first choice, add in epi or vaso, Do not
use dopamine
 Steroids - 200 mg Hydrocortisone for patients who are still
unstable after fluids and vasopressors
 Blood - In most circumstances, use a trigger of <7.0 g/dL
 Glucose - goal is < 180 mg/dL
 Bicarb - Not recommended if pH is >7.15 (which in no way means it
is recommended for pHs less than that)