1. Wes Theurer, DO

2.  Recognize sepsis early  Understand therapeutic principles  Cultures before antibiotics  Crystalloid fluid resuscitation  Antimicrobials  Vasopressor agents  Role of imaging and other cultures

3.  Sepsis:  suspected infection + systemic manifestations ▪ See Table 1

4.  Severe Sepsis: acute organ dysfunction secondary to documented or suspected infection  Septic Shock: severe sepsis not reversed with fluid resuscitation

5.  Sepsis-induced hypotension  systolic blood pressure (SBP) 40mm Hg or less than two standard deviations below normal for age in the absence of other causes of hypotension.  Sepsis-induced tissue hypoperfusion  infection-induced hypotension that persists after fluid challenge, elevated lactate, or oliguria.

8.  How many?  Two (1 or 2 percutaneous, one from every pre- existing line)  Do it before IV Antimicrobials  Draw a lactate while you’re at it

9.  Crystalloid (1B) – 30mL/kg (or more) (1C)  Albumin for those who continue to require lots of crystalloid (2C)  DON’T use hetastarch (1C)  If not responsive to fluids  vasopressors

10.  Antimicrobials within one hour!  Which ones?  Many options – probably need combination

11. 1. Gram positive bacteria 2. Gram negative bacteria 3. Mixed bacterial organisms Viral and fungal are not as common but should be considered.

12.  Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrug- resistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B).  For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B).  A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B).?

13.  Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).  Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, un-drainable foci of infection, bacteremia with S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia (grade 2C).  Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).  Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause (UG).

14. 1. Norepinephrine – 1 st choice vasopressor (to MAP >65 mm HG) (1B) 2. Epinephrine – 2 nd line/additional agent (2B) 3. Vasopressin (0.03 U/min) can be added (UB)

15.  Dopamine is not recommended (highly select circumstances) (2C)  Dobutamine if myocardial dysfunction (low filling pressures/ cardiac output) (1C)  IV Hydrocortisone – don’t use if fluids and vasopressor therapy work (2C)

16.  Prompt imaging studies (to confirm source)  Cultures of other sites if doing so does not cause significant delay in antibiotic administration (grade 1C).

18.  Rapid Recognition  Treatment  ABC’s  IV, O2, Monitor  Crystalloid resuscitation  Blood Cultures, Lactate  Broad spectrum antimicrobials  Imaging and other cultures judiciously  Vasopressors if not responsive to crystalloid  Early consultation

19.  Recognize sepsis early  Understand therapeutic principles  Cultures before antibiotics  Crystalloid fluid resuscitation (30mL/kg)  Broad spectrum antimicrobials within 1 hour  Vasopressor agents when crystalloid not enough  Image to confirm infection source  Other cultures if no delay for antibiotics

20.  Early quantitative resuscitation within 6 hrs of recognition  Blood cultures before antibiotics (1C)  Prompt imaging studies (to confirm source)  Broad spectrum antibiotics within 1 hour of recognition (1B)  Goal: severe sepsis without septic shock  Crystalloid (initial fluid) (1B) – 30mL/kg (or more) (1C)  Albumin for those who continue to require lots of crystalloid (2C)  DON’T use hetastarch (1C)  Norepinephrine – 1 st choice vasopressor (to MAP >65 mm HG) (1B)  Epinephrine – 2 nd line/additional agent (2B)  Vasopressin (0.03 U/min) can be added last (UB)  Dopamine is not recommended (highly select circumstances) (2C)  Dobutamine if myocardial dysfunction (low filling pressures/ cardiac output) (1C)  IV Hyxrocortisone – don’t use if fluids and vasopressor therapy work (2C)  Hemoglobin goal: 7-9 g/dL (unless other complication (1B)

21.  Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012  Critical Care Medicine  February 2013. Vol. 41. No.2