From today’s resource:
Definitions and Scoring Systems
According to Sepsis-3, sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Clinically, this is defined as a SOFA score of 2 points or higher (see below for criteria). Septic shock is defined as the subset of sepsis in which there are more profound circulatory, cellular, and metabolic abnormalities. Clinically, this is defined by a vasopressor requirement to maintain MAPs > 65 or serum lactate > 2 in the absence of hypovolemia (Singer, 2016).
Today, I review, link to, and excerpt from The Curbsiders’ #419 Rapid Response Series: Sepsis with Dr. Mohleen Kang.*
*Trubitt M, Amin M, Evans S, Coleman C.“#419 Rapid Response Series: Sepsis with Dr. Mohleen Kang. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date December 4, 2023.
All that follows is from the above resource.
A shock to the system
Join us for an infectious conversation about sepsis as we learn about the recognition and initial management of sepsis on the wards. We are joined by Dr. Mohleen Kang (@KangMohleen, Emory University).
Sepsis Pearls
- Antibiotics and IV fluids (IVF) should be started within the first hour of onset of suspected sepsis.
- In cases of suspected sepsis, patients should receive 30mL/kg of IVF within the first three hours of identifying suspected sepsis.
- If a patient receives appropriate fluid resuscitation without response, consider transition or addition of vasopressors (even if administration is peripheral). Ideally, peripheral access should be placed above the antecubital vein.
- The CANDIDA score can be used to help determine if antifungal coverage should be added to a patient’s antibiotic regimen
- Goals of care conversations should take place early in a hospitalization given the difficulty of having such discussions during a rapid response.
Rapid Response Series: Sepsis – Show Notes
Tips and Tricks for Managing a Rapid Response
Team Roles and Responsibilities
During this episode we briefly discuss the ins and outs of the rapid response. Dr. Kang recommends knowing your hospital rapid response team and identifying team members’ roles and responsibilities early. Doing so can help minimize the number of people in the patient’s room during urgent or emergent situations. This varies across hospitals so she emphasizes the need to be aware of who is in this team at your local institution. Team members should have a role in direct care of the patient.. For example, this may include an ICU nurse who can assist with drawing blood and getting necessary access started on the patient, the patient’s day nurse who can provide history as to the events leading to the rapid response, and respiratory therapy for any airway needs. Additionally, the other roles to identify include those who will assist with hospital flow and logistics. This may be a charge nurse or nurse manager who will help ensure prioritization of beds for patients in the appropriately identified unit.
Access
Similar to identifying roles and responsibilities of the team, it is important to identify the best and fastest route for fluids, antibiotics, and potentially vasopressors. Ideally, this will be a peripheral IV (low gauge number) above the antecubital vein in the event pressors need to be started. If below the antecubital, providers should be more cautious with pressors for risk of extravasation. Dr. Kang reminds us that intraosseous lines (IOs) are an acceptable alternative if a good peripheral cannot be placed. While a central line may be necessary for a patient’s treatment plan in the ICU, it does not need to be placed emergently, as the vast majority of medications can be given peripherally during rapid response.
Sepsis
Definitions and Scoring Systems
According to Sepsis-3, sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Clinically, this is defined as a SOFA score of 2 points or higher (see below for criteria). Septic shock is defined as the subset of sepsis in which there are more profound circulatory, cellular, and metabolic abnormalities. Clinically, this is defined by a vasopressor requirement to maintain MAPs > 65 or serum lactate > 2 in the absence of hypovolemia (Singer, 2016).
There are numerous scoring systems which have been developed over the years to identify sepsis early in patients and to try to improve improve mortality. Below is a list of the scores and their associated criteria.
Systemic Inflammatory Response Score (SIRS) criteria includes:
- Temperature > 38 C or < 36C
- HR > 90
- RR > 20 or PaCO2 < 32
- WBC > 12 or < 4 or differential with > 10% bands
Sequential Organ Failure Assessment (SOFA) criteria includes:
- PaO2
- FiO2
- On mechanical ventilation
- Platelets
- Glasgow Coma Scale
- Bilirubin
- MAP or use of vasoactive agents
- Creatinine
Quick Sequential Organ Failure Assessment (qSOFA) criteria includes:
- Altered mental status
- Resp Rate ≥ 22
- Systolic BP ≤ 100
National Early Warning Score (NEWS) criteria include:
- Resp rate
- Oxygen saturations
- Any supplemental oxygen use
- Temperature
- Systolic BP
- Heart rate
- AVPU score
Modified Early Warning Score (MEWS) criteria include:
- Systolic BP
- Heart rate
- Resp rate
- Temperature
- AVPU score
SIRS was widely used until the Sepsis-3 definition was published in 2016. The downside to SIRS is that it is not specific for sepsis. The Sepsis-3 definition included qSOFA as a screening tool, making it more widely used; however, it has more recently fallen out of favor due to its poor sensitivity (although does have better specificity than SIRS). NEWS performed the best out of the scoring systems (Liu, 2020), but it is cumbersome to use so may not be the best urgent bedside tool. Furthermore, a pooled analysis of three RCTs did not demonstrate a mortality benefit of active screening in inpatient wards (Evans, 2021). Therefore, the scoring systems have noted limitations, and while no single scoring system is ideal for screening, NEWS is most likely the most comprehensive tool available with more evidence to support its use.
Diagnostic Testing*
It is necessary to obtain a complete work-up for the source of infection. This should start with a thorough history and physical for any localizing source of infection. In terms of diagnostic testing, this should include blood cultures, urinalysis/urine culture, chest x-ray, and a basic set of labs (CBC, BMP).
Based on the Surviving Sepsis Campaign (SSC) Guidelines, it is also recommended to get an initial lactate and to trend the lactate to resolution (Evans, 2021).
Lastly, Dr. Kang reminds us that it may be necessary to engage with surgical consultants early, if the source of infection may require surgical intervention.
*And consider obtaining CT scans of the head, neck, chest, abdomen, and pelvis to look for a source of the sepsis. And a diagnostic lumbar punture may be indicated if there is no evidence of increased intracranial pressure. [Tom Wade MD]
Antibiotics
Start here.
