Sepsis
                                ======
þ Septic shock: SAVE*
   S Suspicion
   A Act
   V Ventilation/Oxygenation
   E Expand differential - Evaluate goals
 - SEPSIS = SIRS + Infection process
 - SEVERE SEPSIS = SEPSIS + organ dysfunfunction, hypoperfusion, hypotension
 - SEPTIC SHOCK = SEPSIS + hypotension/hypoperfusion refractory to fluid
   resuscitation
 - Fill the tank
   Aggressive fluids, serial 500-1 000 ml NS boluses
   (50-60 mUkg often needed}
   Early Perfusion Goals:
  + MAP > 65 mmHg
  + UO > 0.5mUkg/hr
  + Cutaneous perfusion/mental status
 - When do you go to pressors? When tank is full
  + CVP 8-12 mmHg
  + US assessment of IVC
  + Goal:
   - MAP> 65
   - SCV02 > 70
   - Lactate clearance equivalent to SCV02
   - Clearance > 10% associated = increased survival
     [Jones AE, et al. Lactate clearance vs SCV02 as goals of early sepsis 
     therapy. JAMA, 2010.] 
 - Antibiotics
  + Recent study showed >50% increase in mortality when abx given > 1 hour 
    from identification of sepsis 
    [Gaieski, et al. Impact of time to antibiotics on survival in patients with 
    severe sepsis or septic shock.] 
    [Grit Care Med, 2010. Dellinger RP, et at. Surviving sepsis campaign: 
    Guidelines for the management of sepsis. Crit Care Med, 2008.]
  + 2-5 fold increase in mortality if inappropriate antibiotics selected
    [Mortality of Inappropriate vs appropriate abx in sepsis: Ibrahim, et al. 
    Chest 2000. 61.9% vs 28.4%.] 
    [Fraser etal. Am J Med 2006. 20.1% vs 11.8%]
    [Kumar et al. Chest 2009. 52% vs 10.3%]
  + Unknown source:
   - Vancomycin
     PLUS
   - Piperacillin-tazobactam (Zosyn) or ticarcillin-clavulanate (Timentin)
     OR ceftriaxone (Rocephin) or cefotaxime (Claforan)
     OR imipenem or meropenem
  + Unknown source, pseudomonas risk:
   - Vancomycin
     PLUS 2 of the following
     Piperaciflin-tazobactam (Zosyn) or ticarcillin-clavuranate (Timentin)
     OR ceftazidime (Fortaz) or cefepime (Maxipime)
     0R imipenem or meropenem
     OR ciproflxacin
     OR gentamicin
 - Ventilation:
  + High risk of ARDS (50%)
  + Ventilator settings reduce damage
   - Tidal volume 6cc/kg IBW
   - Plateau pressure < 30 em H20
   
þ Shock Index (SI)
 - Ratio of HR/Systolic BP
 - Normal 0.5- 0. 7
 - 1.0 or greater may predict uncompensated shock
   [Birkhahn RH, et al. Shock index in diagnosing early acute hypovolemia. 
   Am J Emerg Med, 2005.]

þ Systemic Inflammatory Response Syndrome (SIRS)
 - Two or more of the following:
    T: > 38°C or < 36°C
    HR: > 90 bpm
    RR: > 20 or PC02: < 32 mm Hg
    WBC: > 12,000 or < 4,000 or> 10% bands
 - Criteria for SIRS were established in 1992 as part of the American College of 
   Chest Physicians/Society of Critical Care Medicine Consensus Conference.[2] 
   The conference concluded that the manifestations of SIRS include, but are not 
   limited to
  * Body temperature less than 36°C or greater than 38°C
  * Heart rate greater than 90 beats per minute
  * Tachypnea (high respiratory rate), with greater than 20 breaths per 
    minute; or, an arterial partial pressure of carbon dioxide less than 4.3 kPa 
    (32 mmHg)
  * White blood cell count less than 4000 cells/mm³ (4 x 109 cells/L) or 
    greater than 12,000 cells/mm³ (12 x 109 cells/L); or the presence of greater 
    than 10% immature neutrophils (band forms)
 - SIRS can be diagnosed when two or more of these criteria are present.
 - In children, the SIRS criteria are modified in the following fashion:[8]
  * Heart rate > 2 standard deviations above normal for age in the absence of 
    stimuli such as pain and drug administration, OR unexplained persistent 
    elevation for greater than 30 minutes to 4 hours. In infants, also includes 
    Heart rate < 10th percentile for age in the absence of vagal stimuli, beta-
    blockers, or congenital heart disease OR unexplained persistent depression 
    for greater than 30 minutes.
  * Body temperature obtained orally, rectally, from Foley catheter probe, or 
    from central venous catheter probe < 36 °C or > 38.5 °C. Temperature must be 
    abnormal to qualify as SIRS in pediatric patients.
  * Respiratory rate > 2 standard deviations above normal for age OR the 
    requirement for mechanical ventilation not related to neuromuscular disease 
    or the administration of anesthesia.
  * White blood cell count elevated or depressed for age not related to 
    chemotherapy, or greater than 10% bands + other immature form
 - As an alternative, when two or more of the systemic inflammatory response 
   syndrome criteria are met without evidence of infection, patients may be 
   diagnosed simply with "SIRS." Patients with SIRS and acute organ dysfunction 
   may be termed "severe SIRS."
 - Much of the SIRS pathophysiology is related to the concept of "cytokine 
   storm"
   
þ Sepsis Treatment:
 - fluids, cultures, antibiotics
 - if BP <90 despite fluids, or lactate >4, start pressors