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Sepsis and Septic Shock

title: Sepsis and Septic Shock tags: #FFICM notebook: 🌑-FFICM type: inprogress

category: [[Infections And Immune Disorders]]

Sources:

  • [[MCQs and SBAs in Intensive Care Medicine (Oxford Higher Special Training)]]
  • Singer M, et al. The third international consensus definition for sepsis and septic shock. Journal of the American Medical Association 2016;15:801–10
  • https://zentensivist.com/2021/08/29/resuscitation-endpoints-in-septic-shock/

Flashcard type:cloze
The {{c1::2016::year}} definition of {{c2::Sepsis::condition}} is that it is {{c3::life-threatening organ dysfunction::state}} caused by a {{c4::dysregulated host response to infection::cause}}.
The 2016 definition of organ dysfunction in sepsis was a change of total {{c1::SOFA score::system}} by {{c1::2+}} points
The 2016 definition of {{c1::multi-organ dysfunction syndrome}} was {{c2::progressive organ dysfunction to the point that life could not be sustained without life suppport}}

Resuscitation Endpoints:

First broad brush strokes

  1. Macrocirculation - Think MAP
  2. Microcirculation - Think Lactate

But theres loads more, that you could split into:

  1. Flow - Cardiac Output
  2. Tone - Vascular Tone
  3. Filling - Filling Pressures (Adequacy/Not Over Doing It)

Where to start

Mental Framework used in the ANDROMEDA Shock trial:

Bayesian analysis of the ANDROMEDA SHOCK trial seems to indicate that cap refill should be used more in assessing someone in shock, even if main trial didn't support that.

Step One:

  • Assess perfusion, either with lactate or capillary refill

Step Two:

  • Do they have adequate cardiac output? (Majority in septic shock should do, even low)
  • Would they be fluid responsive
    • But later in disease process they prob wont be
  • Would it be safe to give further fluid
    • You could use CVP? Maybe, more to see if too much fluid, rather than space for more
    • "Central venous pressure is a stopping rule, not a target of fluid resuscitation" an editorial to look at. A rough guide would be CVP more than 8
    • Another thing to be would be severe abnormality in a VEXUS Score

Step Three:

  • What should the MAP goals be?

  • Somewhere around 65, but maybe higher if hypertensive.

What is the cardiac output?

  • One measure that might be useful is the veno-arterial CO2 difference.
  • The logic here being that the higher the difference (Venous - Arterial), the lower the cardiac output. As more time for co2 to accumulate in venous blood, with poor cardiac output.

[Infections And Immune Disorders]: "Infections And Immune Disorders"