Tachypnoea is the earliest indicator of a deteriorating patient. Look at the respiratory rate: measure it accurately, and watch for a change over time. Also consider the patient’s sensorium, CRT, HR, U/O, and BP.
Rx.
- Oxygen
- Crystalloid IV (Hartmann’s/Ringer’s Lactate or Normal Saline)
- Adult: 30 mL/kg (1-2 L) statim
- Child: 20 mL/kg bolus ± repeat
- Antibiotics
Clinical presentation and local antibiotic resistance patterns guide your empirical choice of antibiotic. (In severe cases, or where the source of infection is unknown, use broad spectrum cover, as per the ‘SSC’ below). Do not delay giving antibiotic therapy. E. coli, as an example, has a doubling time of 20 minutes!
Monitor the patient’s response to the fluid challenge.
[CRT=capillary refill time ≤ 2 sec; U/O=urine output ≥ 0.5 mL/kg per hour]
A couple of predictive rules to keep in the back of your mind (or the front of your smartphone):
Systemic Inflammatory Response Syndrome (SIRS)
• BT < 36°C or > 38°C
• RR > 20 bpm (or PaCO2 < 32 mm Hg)
• HR > 90 bpm
• WCC < 4 or > 12 (or > 10% bands)
[Note that 36°C = 96.8°F and 38°C = 100.4°F]
SIRS can be incited by ischemia, inflammation, trauma, infection or a combination of insults (i.e. it is a stress response syndrome). SIRS is not always associated with infection.
If someone is tachypnoeic and tachycardic, they have a problem. If they are also febrile, then they are likely septic:
quick-SOFA (qSOFA)
• SBP ≤ 100 mm Hg
• GCS < 15
• RR ≥ 22
[qSOFA is more specific (than SIRS) for infection but it is less sensitive.]
Lactate and Venous Blood Gas (VBG)
A lactate > 2 is one of the ‘Sepsis 6’. Again, it is not necessarily specific for sepsis. A venous blood gas (VBG) will give a good (and less painful) guide to any metabolic derangement. Monitor the trend in the lactate as a very good guide to patient progress.
Surviving Sepsis Campaign care bundles:
Sepsis 3 — to be completed within 3 hours
- Measure Lactate level
- Blood cultures (prior to administration of antibiotics)
- Broad spectrum antibiotics
- 30 ml/kg crystalloid for hypotension or lactate ≥ 4mmol/L
[Time of presentation is the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.]
Sepsis 6 — to be completed within 6 hours
Hypotension (MAP < 65) or Lactate ≥ 4 after initial fluid resuscitation
5. Vasopressors → MAP ≥ 65 mm Hg
6. Reassess volume status and tissue perfusion and document findings
7. Remeasure lactate (if initial lactate elevated)
References
- Induction podcast on Sepsis. The St. Emlyn’s Virtual Hospital Podcast. Mar 24, 2016.
- Surviving Sepsis. Society of Critical Care Medicine.
Further Reading
- VBG versus ABG. LITFL
- Understanding lactate in sepsis & Using it to our advantage. PulmCrit (EMCrit)
