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KEY CONCEPTS

KEY CONCEPTS

  • imageGram-negative organisms are isolated in 44% to 59% in sepsis or septic shock, followed by gram-positive bacteria in 37% to 52%, and fungi in 4% to 10%. Candida albicans remains the most prevalent Candida species: however non-albicans Candida species collectively is more frequently isolated.

  • imagePathogenesis of sepsis is complex and multifactorial consisting of causative pathogen, host characteristics, and the inflammatory responses during which the interactions between pro- and anti-inflammatory cytokines, procoagulant state, and decreased fibrinolysis occur simultaneously.

  • imageThe highest mortality is reported in patients with complicated intra-abdominal infections, chronic kidney disease, renal replacement therapy, multiple organ dysfunction, candidemia, and septic shock.

  • imageInitial resuscitation from sepsis-induced hypoperfusion should begin with at least 30 mL/kg of IV crystalloid fluid. Dynamic fluid responsiveness assessment by examining cardiac output with fluid bolus is essential to avoid fluid overload.

  • imagePrompt initiation of empiric broad-spectrum IV antibiotics within 1 hour of recognition of sepsis or septic shock improves survival, and the regimen should be assessed daily for potential de-escalation.

  • imageNorepinephrine is the preferred vasopressor to achieve and maintain MAP goal of at least 65 mmHg in fluid-resuscitation refractory septic shock, and it should be titrated up carefully to an end point of adequate organ perfusion.

  • imageImplementation of a protocolized, performance improvement bundle including administration of fluid and broad-spectrum antibiotics and use of vasopressor agents improves patient outcomes. The updated Sepsis-3 guidelines recommend 1-hour care for start of immediate treatment and possibly faster transition to vasopressors to meet MAP goal.

  • imageIntravenous hydrocortisone is recommended for adult patients with septic shock who are hemodynamically unstable after initial resuscitation with IV fluids and vasopressors.

  • imageA blood glucose level less than 180 mg/dL (10.0 mmol/L) is recommended for critically ill patients to reduce potential hypoglycemia and mortality associated with tighter blood glucose control (ie, blood glucose goal of 81-108 mg/dL [4.5-6.0 mmol/L]).

PATIENT CARE PROCESS

Patient Care Process for Sepsis and Septic Shock

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Collect

  • Patient characteristics (eg, age, sex)

  • Patient medical history (including recent hospitalization and infection within last 6 months)

  • Social history (eg, tobacco/ethanol use/IVDA/place of residence)

  • Current medications (prescription and nonprescription; including recent history of antibiotic usage within last 6 months)

  • Subjective data (including general constitutional and infection-site specific, onset)

  • Objective data

    • Temperature, blood pressure (BP), heart rate, respiratory rate, mean arterial pressure (MAP), O2-saturation, height, and weight

    • Labs including white blood cell (WBC) count with differential, hemoglobin, platelet count, complete serum chemistry including serum creatinine, and bilirubin, lactate, procalcitonin (PCT), coagulation panel including prothrombin time and activated partial thromboplastin time, and arterial blood gas including pH, PaCO2, PaO2, and HCO3

    • Objective parameters for sequential organ failure assessment (see sequential organ failure assessment [SOFA]; Table 137-2)

    • Microbiology data (including gram stain, culture, rapid diagnostic testing)

Assess

  • Mental status

  • Systemic inflammatory response (SIRS) criteria (Table 137-1)

  • Hemodynamic stability (eg, systolic BP> 100 mmHg, MAP> 65 mmHg)

  • Presence of organ dysfunction ...

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