Sepsis and Septic Shock

Strong Medicine

19 Nov 201917:21

EducationalLearning

32 Likes 10 Comments

TLDRIn this informative video, Dr. Eric Strong discusses sepsis, a severe clinical syndrome caused by an overactive immune response to infection. He explains the spectrum of sepsis, from mild symptoms like fever and rapid heart rate to life-threatening conditions like organ dysfunction and septic shock. The video outlines the evolution of sepsis definitions, moving from the systemic inflammatory response syndrome (SIRS) criteria to the Sequential Organ Failure Assessment (SOFA) score for identifying severe cases. Dr. Strong also covers the diagnostic process, emphasizing the importance of identifying the infection source and complications through physical exams, blood cultures, and imaging. Treatment priorities include maintaining vital functions, fluid resuscitation, and administering broad-spectrum antibiotics. The video also touches on the debate around lactate levels in sepsis and the potential role of high-dose vitamin C in treatment, although noting the latter remains experimental.

Takeaways

🚨 **Sepsis Definition**: Sepsis is a life-threatening clinical syndrome caused by a dysregulated host response to infection, leading to a range of physiologic and biochemical abnormalities.
🌡️ **Sepsis Spectrum**: Sepsis presents with a spectrum of severity, from mild signs like fever and tachycardia to severe conditions like hypotension and organ dysfunction.
📉 **Organ Dysfunction Signs**: Organ dysfunction in sepsis can manifest as low urine output, confusion, hypoxemic respiratory failure, liver failure, and more.
🏥 **Septic Shock**: Septic shock is a specific, severe form of sepsis characterized by hypotension that is unresponsive to IV fluids and an elevated serum lactate level.
🔄 **SIRS and Sepsis**: The systemic inflammatory response syndrome (SIRS) was a previous tool to identify high-risk sepsis patients but has been phased out in favor of a more simplified approach.
📊 **SOFA Score**: The Sequential Organ Failure Assessment (SOFA) score is used to identify patients at the greatest risk of death from sepsis by assessing six organ function domains.
🔍 **Diagnosis**: Diagnosing sepsis involves a thorough physical exam, blood cultures, and other relevant tests to identify the cause and complications.
💊 **Treatment Priorities**: The primary treatment for sepsis includes ensuring ABCs (Airway, Breathing, Circulation), restoring hemodynamics with IV fluids and pressors, and using broad-spectrum antibiotics.
🩸 **Fluid Resuscitation**: Adequate fluid resuscitation in sepsis is indicated by a mean arterial pressure of 65 or higher, urine output, normalized mental status, and improving lactate levels.
⚖️ **Antibiotic Timing**: While guidelines suggest administering antibiotics within an hour in sepsis, the reality may require a more prudent approach based on the patient's condition.
🚫 **Avoiding Certain Combinations**: Certain antibiotic combinations like vancomycin and piperacillin-tazobactam (Zosyn) should be avoided due to increased kidney injury risk.

Q & A

What is the current understanding of sepsis?
-Sepsis is a life-threatening clinical syndrome caused by a dysregulated host response to infection, leading to a characteristic constellation of physiologic and biochemical abnormalities.
What are the mild symptoms of sepsis?
-In its mildest form, sepsis can present with vital sign abnormalities such as fever, tachycardia, tachypnea, and leukocytosis.
What are the signs of organ dysfunction in sepsis?
-Signs of organ dysfunction in sepsis can include low urine output, increased creatinine, confusion or delirium, hypoxemic respiratory failure, liver failure, and ileus.
What is the current definition of septic shock?
-Septic shock is defined as hypotension that is resistant to IV fluids due to peripheral vasodilation and an elevation of serum lactate.
What was the purpose of introducing the systemic inflammatory response syndrome (SIRS)?
-SIRS was introduced in 1991 as a tool for clinicians to identify patients at the highest risk of death from sepsis.
What are the criteria for SIRS?
-SIRS is present if at least two of the following are present: temperature greater than 38°C or less than 36°C, pulse above 90, respiratory rate above 20 or pCO2 below 32, and either a white cell count above 12 or less than 4.
Why was the SIRS criteria problematic?
-The SIRS criteria were too inclusive, potentially misclassifying patients with conditions other than infection or inflammation as having SIRS.
What is the SOFA score and how is it used?
-The SOFA score stands for Sequential Organ Failure Assessment and is used to assess six domains of organ dysfunction (oxygenation, coagulation, liver function, blood pressure, level of consciousness, and renal function) to identify patients at the greatest risk of death from sepsis.
What are the three criteria of the quick SOFA score?
-The quick SOFA score has three criteria: respiratory rate of 22 or greater, systolic blood pressure of 100 or less, and any degree of altered mentation.
What are the priorities in treating sepsis?
-The priorities in treating sepsis are ensuring ABCs (Airway, Breathing, and Circulation), restoring hemodynamics through IV fluids and pressors, and treating the underlying infection with broad-spectrum antibiotics.
What is the recommended approach for fluid resuscitation in septic shock?
-The recommended approach is to use crystalloid fluid, with balanced solutions such as lactated ringers, and to infuse 30 milliliters per kilogram within the first three hours, adjusting based on the patient's needs.
What are the signs that a patient has received adequate fluid resuscitation?
-Signs include a mean arterial pressure of 65 or higher, urine output of at least 0.5 milliliters per kilogram per hour, normalized mental status, improving lactate levels, and for mechanically ventilated patients, dynamic measures of hemodynamics assessed by ultrasound.

Outlines

00:00

🚨 Understanding Sepsis: Definition and Clinical Presentation

The first paragraph introduces sepsis as a life-threatening clinical syndrome resulting from a dysregulated host response to infection. It outlines the spectrum of sepsis, from mild symptoms like fever and tachycardia to severe manifestations including hypotension, organ dysfunction, and septic shock. The paragraph also discusses the historical criteria for systemic inflammatory response syndrome (SIRS) and the evolution of sepsis definitions, leading to the current understanding that emphasizes organ dysfunction and the removal of SIRS from the diagnostic criteria.

05:00

📝 Identifying Sepsis: The SOFA Score and Clinical Assessment

The second paragraph delves into the Sequential Organ Failure Assessment (SOFA) score, which is used to identify the severity of sepsis by evaluating six organ systems. It contrasts the comprehensive SOFA score with the Quick SOFA (qSOFA), a simplified version that uses clinical signs to predict sepsis. The paragraph also emphasizes the importance of identifying the cause of sepsis through physical exams and various diagnostic tests, as well as recognizing complications through lab tests and imaging studies.

10:02

🩸 Sepsis Treatment: Hemodynamic Support and Antibiotics

The third paragraph focuses on the treatment priorities in sepsis, starting with the ABCs of life support and moving on to hemodynamic stabilization through IV fluids and pressors, with norepinephrine being the first-choice vasopressor. It discusses the use of broad-spectrum antibiotics and the importance of source control in managing the underlying infection. The paragraph also touches on the assessment of adequate fluid resuscitation and the considerations for additional treatments like steroids and red blood cell transfusions.

15:02

🧬 Controversies and Emerging Treatments in Sepsis Management

The fourth and final paragraph addresses two controversial topics in sepsis management: lactic acidosis and the role of vitamin C. It presents differing views on whether elevated lactate levels in sepsis are due to tissue hypoxia or are a marker of the body's stress response. Additionally, it mentions a study suggesting potential benefits of high-dose vitamin C, thiamine, and hydrocortisone in treating septic shock, but notes the need for further research before it can be recommended for routine use.

Mindmap

Keywords

💡Sepsis

Sepsis is a life-threatening clinical syndrome characterized by a dysregulated host response to infection, which leads to a range of physiological and biochemical abnormalities. In the video, sepsis is the central theme, with its spectrum of severity being discussed from mild cases with fever and tachycardia to severe cases that can lead to septic shock and death.

💡Systemic Inflammatory Response Syndrome (SIRS)

SIRS is a term introduced to identify patients at high risk of death from sepsis. It is diagnosed when a patient exhibits at least two of the following: high or low body temperature, high pulse rate, high or low respiratory rate, and abnormal white blood cell count. However, the video explains that SIRS has been phased out in favor of a more simplified approach to sepsis diagnosis.

💡Septic Shock

Septic shock is a severe form of sepsis characterized by hypotension that is resistant to IV fluids due to peripheral vasodilation and an elevation of serum lactate. It represents a critical stage in the progression of sepsis where the patient's condition is life-threatening and requires immediate medical intervention, as discussed in the video.

💡Sequential Organ Failure Assessment (SOFA)

SOFA is a scoring system used to identify patients at the greatest risk of death from sepsis by assessing six domains: oxygenation, coagulation, liver function, blood pressure, level of consciousness, and renal function. Each domain is scored, and the total score can range from 0 to 24, with higher scores indicating greater organ dysfunction and severity of sepsis.

💡Quick SOFA (qSOFA)

qSOFA is a simplified version of the SOFA score that can be assessed by physical exam alone. It includes three criteria: respiratory rate of 22 or greater, systolic blood pressure of 100 or less, and any degree of altered mentation. The presence of two or three of these criteria suggests a likelihood of sepsis, as mentioned in the video.

💡Blood Cultures

Blood cultures are a diagnostic tool used to identify the cause of sepsis by culturing blood samples to detect the presence of bacteria or other pathogens. The video emphasizes the importance of obtaining two sets of blood cultures as part of the workup for sepsis.

💡Lactate

Lactic acidosis, indicated by elevated serum lactate levels, can be a sign of systemic hypoperfusion and tissue hypoxia in sepsis. The video discusses the use of lactate levels in diagnosing septic shock and the debate around its role as a marker of the body's stress response versus a byproduct of anaerobic metabolism.

💡Antibiotics

The use of broad-spectrum antibiotics is a critical part of treating sepsis by targeting the underlying infection. The choice of antibiotics depends on the suspected infection, risk factors for antibiotic resistance, and the patient's overall condition. The video mentions the importance of administering antibiotics promptly, within an hour for sepsis patients, according to guidelines.

💡Source Control

Source control involves interventions to eliminate the source of infection, such as draining an abscess or removing an infected catheter. It is a crucial aspect of sepsis treatment, as discussed in the video, to prevent the spread of infection and reduce the body's inflammatory response.

💡Vasopressors

Vasopressors are medications used to increase blood pressure and improve hemodynamics in patients with septic shock. The video explains that norepinephrine is the first-choice vasopressor in septic shock, with other options available depending on the patient's specific conditions and response to treatment.

💡Early Goal-Directed Therapy (EGDT)

EGDT is a protocol-driven approach to sepsis management that targets specific hemodynamic goals. Initially shown to reduce mortality, more recent studies have not confirmed these benefits, as standard care has improved. The video notes that EGDT is no longer considered the standard of care for sepsis treatment.

Highlights

Sepsis is a life-threatening clinical syndrome caused by a dysregulated host response to infection.

Sepsis has a spectrum of severity, ranging from mild with fever and tachycardia to severe with hypotension and organ dysfunction.

Septic shock is characterized by hypotension resistant to IV fluids and elevated serum lactate.

The systemic inflammatory response syndrome (SIRS) was introduced in 1991 to identify patients at high risk of death from sepsis.

SIRS criteria were found to be too inclusive, leading to misdiagnosis and unnecessary treatment pathways.

The international consensus conference 'Sepsis-3' (2014-2016) simplified the sepsis paradigm by removing SIRS and severe sepsis categories.

The SOFA (Sequential Organ Failure Assessment) score was introduced to identify patients at the greatest risk of death from sepsis.

The qSOFA (quick SOFA) score is a simplified version of SOFA, assessing respiratory rate, systolic blood pressure, and altered mentation.

Diagnosis of sepsis now requires the presence of organ dysfunction, narrowing the spectrum compared to previous definitions.

Physical examination, blood cultures, and imaging are crucial for identifying the cause of sepsis.

Complications of sepsis can be identified through CBC, metabolic panels, lactate levels, and other diagnostic tests.

The priorities in treating sepsis are ensuring ABCs, restoring hemodynamics with IV fluids and pressors, and treating the underlying infection.

Norepinephrine is the first-choice vasopressor in septic shock, with other options depending on patient-specific conditions.

Broad-spectrum antibiotics should be used for sepsis treatment, with adjustments based on suspected infections and resistance factors.

Source control, such as draining abscesses or removing infected lines, is crucial in managing sepsis.

Adequate fluid resuscitation in sepsis is indicated by a mean arterial pressure of 65 or higher and improving lactate levels.

Combination of vancomycin and piperacillin-tazobactam (Zosyn) should be avoided due to the risk of kidney injury.

Empiric steroids may be considered in septic shock that is refractory to fluid and pressor treatment.

Early goal-directed therapy, once shown to reduce mortality, has not shown benefits in recent studies due to improvements in standard care.

Red cell transfusions should only be given when hemoglobin drops below 7 grams per deciliter, except in cases of hemorrhage or myocardial ischemia.

High-dose vitamin C treatment for septic shock remains investigative and is not recommended outside of clinical trials.

Transcripts

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Sepsis and Septic Shock

Takeaways

Q & A

What is the current understanding of sepsis?

What are the mild symptoms of sepsis?

What are the signs of organ dysfunction in sepsis?

What is the current definition of septic shock?

What was the purpose of introducing the systemic inflammatory response syndrome (SIRS)?

What are the criteria for SIRS?

Why was the SIRS criteria problematic?

What is the SOFA score and how is it used?

What are the three criteria of the quick SOFA score?

What are the priorities in treating sepsis?

What is the recommended approach for fluid resuscitation in septic shock?

What are the signs that a patient has received adequate fluid resuscitation?