Sepsis and septic shock:

Guideline-based management

Corina Fiqilyin
 Sepsis is a life-threatening
organ dysfunction that results
from the body’s response to
infection.

It requires prompt recognition,

appropriate antibiotics, careful
hemodynamic support, and
control of the source of infection.

Universitas Muhammadiyah Surakarta 2

 best practice statements ICON Add an image ICON diagnostic criteria

controversies in definitions ICON ICON management

This article reviews guidance on the diagnosis and management of sepsis and
septic shock :

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 COMMON AND LIFE-THREATENING

1 Sepsis affects 750,000 patients each year in the United States

2 Killing more than 210,000 people every year

About 15% of patients with sepsis go into septic shock, which accounts for about 10% of admissions
3 to intensive care units (ICUs)

4 Has a death rate of more than 50%

5 The incidence of sepsis doubled in the United States between 2000 and 2008

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 DEFINITIONS HAVE EVOLVED
In 1991

1 Temperature below 36°C or above 38°C

Sepsis was first defined as a
systemic inflammatory response
syndrome (SIRS) due to a 2 Heart rate greater than 90/minute

suspected or confirmed infection

with 2 or more of the following 3 Respiratory rate above 20/minute
criteria:
White blood cell count less than 4 × 109/L or greater than 12 × 109/L,
4 or more than 10% bands

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 DEFINITIONS HAVE EVOLVED
In 1991
Severe sepsis
Defined as the progression of
sepsis to organ dysfunction, tissue
hypoper-fusion, or hypotension.
Septic shock
Described as hypotension and
organ dysfunction that persisted
despite volume resuscitation,
necessitating vasoactive
medication, and with 2 or more of
the SIRS criteria listed above.
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 DEFINITIONS HAVE EVOLVED

In 2001
Definitions were updated with clinical and laboratory variables.

In 2004
The US Centers for Medicare and Medicaid Services (CMS) defining sepsis as the presence of at least 2 SIRS criteria
plus infec-tion; severe sepsis as sepsis with organ dysfunction (including serum lactate > 2 mmol/L); and septic
shock as fluid-resistant hypotension requiring vasopressors, or a lactate level of at least 4 mmol/L

In 2016
The Sepsis-3 committee issued the following new definitions:
• Sepsis—A life-threatening condition caused by a dysregulated host response to infection, resulting in organ
dysfunction
• Septic shock—Circulatory, cellular, and metabolic abnormalities in septic patients, presenting as fluid-refractory
hypotension requiring vasopressor therapy with asso-ciated tissue hypoperfusion (lactate > 2 mmol/L)
• The classification of severe sepsis was eliminated The Power of PowerPoint | thepopp.com 7
 Multiple definitions create confusion

The CMC:
Sepsis-3 use:
Definition continues to recommend SIRS for
sepsis identification. Sequential organ failure assessment (SOFA) or
the quick version (qSOFA) to define sepsis.

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 TOOLS FOR IDENTIFYING HIGH RISK: SOFA AND qSOFA

 
SOFA is cumbersome qSOFA is simpler…
SOFA is an objective scoring system to determine  Respiratory rate at least 22 breaths/minute
major organ dysfunction based on :
 Systolic blood pressure 100 mm Hg or lower
 oxygen levels
 Altered mental status (Glasgow Coma Scale
 platelet count score < 15).
 Glasgow Coma Scale score A qSOFA score of 2 or more with a sus-pected or
confirmed infection was proposed as a trigger
 bilirubin level
for aggressive treatment, includ-ing frequent
 creatinine level monitoring and ICU admission.
 and mean arterial pressure

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 …but has limitations
qSOFA

4 1
ICON ICON
Studies have suggested that: needs careful interpretation for defining
sepsis
the SIRS criteria be used to detect sepsis,
while qSOFA should be used only as a
triaging tool.

3 2
ICON ICON
preexisting chronic diseases may influence less sensitive than SIRS for diagnosing early
accurate qSOFA and SOFA measurement. sepsis

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 ANTIMICROBIAL THERAPY

1. 2. 3.

Prompt, broad-spectrum antibiotics De-escalation and early cessation

 Delay in giving appropriate antibiotics
 mortality rate
 Broad-spectrum
 If a nosocomial source  sepsis, anti-
MRSA agents are recommended
 Appropriate dosing
Consider antifungals
 Antifungals should be considered for
patients at risk
 Azoles are considered appropriate for
hemodynami-cally stable patients
 A robust de-escalation strategy is
needed to balance an initial broad-
spectrum approach
 A rapid nasal polymerase chain
reaction test  shown to be safe and
to significantly  reduce empiric use
of vancomycin and linezolid

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 FLUID RESUSCITATION

1 Rescue

• The goals of resuscitation in sepsis and septic

shock are to restore intravascular volume,
increase oxygen delivery to tissues, and 2 Optimization

reverse organ dysfunc-tion.

• A crystalloid bolus of 30 mL/kg is recom-
3 Stabilization
mended within 3 hours of detecting severe
sepsis or septic shock  controversion

4 De-escalation

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EARLY SOURCE CONTROL

 Examination
 Appropriate imaging studies
 If appropriate  6 to 12 hours of diagnosis, once initial
resuscitation is completed

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 RESTORING BLOOD PRESSURE
The recommended initial goal is 65 mmHg (80-85 mmHg)

Norepinephrine is the first-line

vasopressor Adding a second vasopressor or inotrope

Norepinephrine has shown survival benefit with Vasopressin or epinephrine can be used to
lower risk of arrhythmia than dopamine either
achieve target mean arterial pressures or
decrease the norepinephrine requiremen

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ROLE OF CORTICOSTEROIDS IS QUESTIONED

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 BIOMARKERS

Icon Icon Icon Icon

C-reactive protein Procalcitonin Galactomannan and Cytokines

and erythrocyte beta-D-glucan
sedimentation rate

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USUAL CARE VS PROTOCOLIZED INITIAL RESUSCITATION

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 1 Sepsis is a multifaceted disease, and its management is complex

Simplified guidelines and quality measures based on sound evidence are

2 needed

A call to refine guidance Electronic medical record systems show promise for assisting with early and
3 accurate detection of sepsis

The success of optimal care initiatives requires sustained, collaborative

4 quality improvement across different specialties in medicine, nursing,
and hospital administration

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REFERENSI

Universitas Muhammadiyah Surakarta 21

Terima Kasih