Perioperative Management of Sepsis:

A Paradigm Shift

Nay Myo Htun M.B.,B.S, M.Med.Sc, D.A

Anaesthesiologist
1000-Bedded General Hospital
Naypyidaw
 Outline of Presentation
Definition of Sepsis

Overview of Pathophysiology

Initial resuscitation of patients with sepsis

undergoing surgical intervention

Surviving Sepsis Campaing Guideline

Perioperative Issues

Conclusion
 The Impact of Sepsis

Sepsis and septic shock are major healthcare problem

Accounts for as much as 2 5% of intensive care unit (ICU) bed

utilization

Common in elderly, immunocompromised and critically ill patients

Mortality from septic shock remain high (30-50%)

 The Impact on Our OR/ICU ?

Generalized Peritonitis
Bowel perforation

Bowel obstruction

Wound Infections

ICU – CAP, HAP, VAP

 Definitions
The Third International Consensus Definitions (Sepsis-3)
Life-threatening organ dysfunction caused by
Sepsis a dysregulated
y g host response
p to infection

Organ Increase in the Sequential (Sepsis-related) Organ

Failure Assessment (SOFA) score of 2 points or
Dysfunction more
In ED and general ward settings, at least 2
quickSOFA (qSOFA):
RR of 22/min or greater, altered mentation
(GCS< 13/15) or SBP of 100 mmHg or less.

Septic Vasopressor requirement to maintain a MAP of

≥ 65 mmHg and serum lactate >2 mmol/L
Shock (18mg/dL) in the absence of hypovolemia
Mervyn et al, SEPSIS-3 :JAMA. 2016;315(8):801-810
Sequential [Sepsis-Related] Organ Failure Assessment Score

Vincent JL, Moreno R, Takala J, et The SOFA score to describe organ dysfunction/failure
Intensive Care Med. 1996;22(7):707-710.
 The Process of Sepsis Definitions by Task Force

1992

2001 International Sepsis Definitions Conference

2016
SEPSIS-3
Mitchell et al(2003) International Sepsis Definitions Conference:
Intensive Care Med 29:530–538.
 Why SOFA score ???
SOFA score of 2 or greater identified a 2- to 25-fold
increased risk of dying compared with patients with a SOFA
score less than 2
SOFA score is not intended to be used as a tool for patient
management but as a means to clinically characterize a
septic patient

SIRS Criteria
The task force wishes to stress that SIRS criteria may
still remain useful for the identification of
infection.
 Overview of Pathophysiology
SIRS
Endotoxin (LPS)

LBP on CD 14
Macrophage, Endothelial

Intrcellular Signal Transduction via TLR

Complex Endothelial-Leucocyte Interaction

Increased TF and PAI O2 radical, Cytokine, Completement, Lipid mediators

Procoagulant Capillary Leak, Vasodilatation

Microvascular MODF
CVS instability
occlusion

Proinflammatory Vs
Dysregulated Immune Response
Anti-inflammatory
 Perioperative Management of Sepsis

Early recognition and treatment of sepsis is important.

Not all septic patients have self-evident septic focus
Initial assessment followed by secondary assessment
a. State of IV Volume status
b. The need and Adequacy of resuscitation
c. Severity of Organs dysfuctions
d. Presence of Comorbid conditions
Early haemodynamic optimization can reduce mortality

Adequate Early IV Source

resuscitations Antibiotics Control

Reduce Mortality and

Morbidity

Martijn P et al (2005) Meta-analysis of hemodynamic optimization: relationship to

methodological quality: Critical Care 2005, 9:R771-R779
 Initial Assessment and Management

A brief history taking with limited examination (eSOFA)

 Recovery position, oro/ or nasopharyngeal airway

 Appropriate Oxygen therapy
 Early intubation

 Signs of respiratory failure

 Head up position
 Assisted by Ambu bag/Waters to and fro
 NIV Vs Intubation and Mechanical Ventilation

Rapid assessment (HR. BP, Capillary refill etc)

Fluid resuscitation – 20-30 ml/kg

Kate Stephens (2012) Management of sepsis with limited resources: Update in Anaesthesia;
Volume 28: 145-155
 Surviving Sepsis Campaing Guidelines
Circulation Early Goal Directed Therapy (EGDT)

Fluid Resuscitation

How much ? Types

How Fast? When to stop?

 How Much ???
At least 30 ml/kg

How Fast ???

Within first 3 hours
 Fluid of Choices ????
Crystalloids Vs Colloids
Crystalloids as the fluid of choice for initial resuscitation
and subsequent intravascular volume replacement

Balanced Salt Solution Vs 0.9% Normal Saline

Either is acceptable
Close monitoring of serum Cl- to avoid hyperchloraemic
metabolic acidosis
Suggest using Albumin in addition to crystalloids for
initial resuscitation and subsequent intravascular volume
replacement

A trend toward reduced 90-day mortality was observed in severe

sepsis patients resuscitated with albumin compared with
crystalloid and saline
 Role of Synthetic Colloids
Recommend Against using Hydroxyethyl Starches
(HES) for intravascular volume replacement

HES 130/0.38-0.45 increased the use of RRT, RBC

transfusion and resulted in more serious adverse events
 Role of Synthetic Colloids (Gelatins)
Gelatin use in critically ill adult patients did not increase
mortality or acute kidney injury compared to albumin or
crystalloid

SSC suggest using Crystalloids over Gelatins

when resuscitating patients with sepsis or septic
shock
 What are GOALS for EGDT???
2012 Dynamic over static variables
MAP > 65 mmHg
Urine Output CVP and ScvO2 : Not reliable
>0.5 ml/kg/hr and fail to show improve
Capillary Refill < outcome
2 sec
MAP 65 Vs 85 mmHg : No
CVP 8-12 mmHg difference outcome
ScvO2 > 70% Serum lactate guided
Serum Lactate < 4 resuscitation : Significant
mmol/L
reductin in Mortality
 VASOACTIVE MEDICATIONS
Norepinephrine as the first-choice vasopressor

Adding Epinephrine (20-50 mcg/min)/Vasopressin

(upto 0.03 U/min)

Dopamine only in selected cases (risk of arrythmia)

Dobutamine for hypoperfusion with fluid &

vasopressor agents

Phenylepherine : Still controversial !!!

 Dose of Norepinephrine
The mean dose of norepinephrine ranges from 0.2 to 1.3
mcg/kg/min with a maximum dosage of 3.3 mcg/kg/min
When to consider adding another vasopressor ????

Potential benefit in the population requiring

≥ 15 μg/min of norepinephrine
 Corticosteroids
Against using IV hydrocortisone to treat septic shock patients
if adequate fluid resuscitation and vasopressor therapy are
able to restore hemodynamic stability

When to Start and How much ??

Only if Adequate fluid therapy and vasopressor fail to

achieve target MAP
IV hydrocortisone at a dose of 200 mg per day
Use continuous flow
 Blood Products

RBC transfusion only when hemoglobin concentration

decreases to < 7.0 g/dL in adults in the absence of
extenuating circumstances, such as myocardial ischemia,
severe hypoxemia, or acute hemorrhage

Against the use of erythropoietin for

treatment of anaemia associated with
sepsis
 Blood Products cont:
Against the use of fresh frozen plasma to correct clotting
abnormalities in the absence of bleeding or planned invasive
procedures

Prophylactic platelet transfusion when counts are < 10,000

/mm3 (10 × 109/L) in the absence of apparent bleeding and
when counts are < 20,000/mm3 (20 × 109/L) if the patient
has a significant risk of bleeding

Higher platelet counts (≥ 50,000/mm3 [50 × 109/L]) are

advised for active bleeding, surgery, or invasive procedures

Giancarlo et al (2009) Italian Society of Transfusion Medicine and

Immunohaematology (SIMTI) Working Party: Blood Transfus 2009; 7: 132-150
 SSC Guidelines Against

Use of IV immunoglobulins

Use of blood purification techniques (CPFA,

Hemoadsorption etc)

Use of Antithrombin
No recommendation regarding the use of
thrombomodulin or heparin
 Blood Culture

Appropriate routine microbiologic cultures

(including blood) be obtained before starting
antimicrobial therapy

Appropriate routine microbiologic cultures always

include at least two sets of blood cultures (aerobic and
anaerobic)
 Antibiotic Therapy
Administration of IV antimicrobials should be
initiated as soon as possible after recognition and
within one hour
Empiric broad-spectrum therapy with one or more
Daily
antimicrobials for Assessment
patients presenting with sepsis or
septic shock to cover all likely pathogens
Antibiotic de-escalation should be done within first
few days depending on clinical improvements and/or
evidence of infection resolution
 Antibiotic Therapy
Antimicrobial treatment duration of 7 to 10 days is
adequate for most serious infections

Longer Duration : Only for poor clinical resolution

Recommend against sustained systemic anti-

microbial prophylaxis in patients with severe
inflammatory states of noninfectious origin (e.g.,
severe pancreatitis, burn injury )
 BICARBONATE THERAPY

Against the use of sodium bicarbonate therapy to

improve hemodynamics or to reduce vasopressor
requirements in patients with hypoperfusion-induced
lactic acidemia with pH ≥ 7.15
 Sepsis Bundles

WITHIN 3 HOURS
WITHIN 6 HOURS
1. Measure lactate level
2. Obtain blood cultures 1. Apply vasopressors
3. I.V broad spectrum (MAP ≥65mmHg)
antibiotics 2. Re-assess volume status
4. I.V 30ml/kg crystalloid and tissue perfusion
for hypotension or 3. Re-measure lactate
lactate ≥4mmol/L

Initial Assessment and Resuscitation should be followed

Secondary Assessment
 Preoperative Assessment

Detailed History & Examination + Airway Assessment

Investigations
 Full blood count /BUN/ Creatinine/Electrolyte/Coagulation
profile/Blood Glucose
 CXR /EKG
 Imaging studies – May be helpful for decision of source control
procedure

Diagnosis and the clinical course Timing and Degree of Surgery

!!! Immediate goal !!!

Aequate source control with the least physiological embarrassment
Communication with Surgical Team is crtitically important
 Preoperative Preparation
Optimize patient using SSC guidelines (Bundles)
 Heamodynamic stability
 Correction of coagulopathy
 Aspiration prophylaxis
 Blood glucose control (≤ 180 mg%)
Prepare for Post-operative plan (ICU or HDU)

Explain the possible risks and outcome after anesthesia and

surgery with patients and family
 Choice of Anesthetic Technique
Nature and extent Expertise of
Severity of Sepsis
of surgical anesthesiologist on
(esp CVS stability)
procedure sepcific technique

Pheripheral nerve
Neuraxial Anesthesia General Anesthesia
block
•Relative • CVS instability • Can avoid systemic
contraindication • Need for RSI effects of IV or
•Exaggerated • Easily desaturate inhalational agents
physiological response • Can provide high • CVS stability
•Coagulopathy FiO2 • Pharmacokinetic of LA
•Epidural abscess, • Lungs protective on acidic envinr-
epidural haematoma ventilation onment
 Intraoperative Management
Emergency medications/ anesthetic machine/
Before airway and resuscitation equipment
Induction Prepare for i.v lines (16 – 14 G)

EKG, SpO2, NIBP, EtCO2, Temperature, Urine

Output
Monitoring Other monitoring (IBP, CVP, ScVO2, lactate, CO
monitoring, TEE only if available)

RSI is the usual technique of choice

Preoxygenation with 100% O2
Induction
Step-wise process, Small doses of i.v agents,
Titrated to clinical response
The CARE how anesthetic agents are
administered
 Choosing an Induction Agent
Etomidate (0.2 to 0.3 mg/kg) Midazolam (0.1-0.3 mg/kg)
Rapid onset and short DOA  Rapid onset, short DOA
CVS stability  Directly relax laryngeal muscle
Issue of Adrenal insufficiency  Decrease in BP (approx 10%)
Current literature doesn’t support  Reflex increase in HR
absolute mortality effect  Cardiac index is well maintained

Ketamine Increase in myocardial O2 demand

I.V 1-2 mg/kg Maintain airway reflexes and increase
Rapid onset and short DOA secretion
Increase in HR, BP,SVR Useful for septic shock
 Choosing an Induction Agent Continue…

Propofol (1.5 – 2 mg/kg) Thiopentone (3-5mg/kg)

Rapid onset, short DOA Rapid onset
Inhibit airway reflexes Short DOA
Reduce BP, SVR (30% from Decrease SVR, Increase HR
base line) Direct Myocardial depression
Impaired baroreceptor reflex Immunosuppressive action
Inhibitory effect on Neutrophil Inhibition of granulocyte
Do not affect by renal recruitment and phagocytosis
y
dysfunction

Marie Mullen(2012) Induction Agents for Endotracheal Intubation in Severe Sepsis and Septic
Shock: Sepsis - An Ongoing and Significant Challenge : InTech Publish ;P 391-410
 Role of Opioids
Can enable to reduce dose of I.V agents.
Can avoid decrease in SVR
DOA may be increased by impaired hepatic and renal function
Fentany/Alfentanil/Remifentanil : NO MORPHINE
Bradycardia (Most are already tachycardiac)

Muscle Relaxants
 DNMBA can be used for RSI (hyperkalaemia)
 For maintenance, cis-atracurium or atracurium has organ
independent metabolism.
 Vecuronium is devoid of CVS insults (biliary and renal
metabolism)
 Perioperative Issues
• Continue EGDT
• Accessed by by CVP, Capillary refill,
Fluid Urine Output etc.
• Global O2 Delivery : Serum lactate -2
mmol/L and ScvO2 >70%

• Keep Hb% 7-9 g/dl

Blood • FFP and Platelet concentrate depending
Components on amount of blood loss and presence of
coagulopathy

• Keep Normothermia
Others • Blood glucose level < 180 mg/dL
• Proper Timing of I.V Antibiotic
 • SpO2 >90% with pH >7.2 (permissive
Target
hypercapnia: PaCO2 < 10 kPa)

• Adjusted with target SpO2 (usually

FiO2
within 0.5-0.6 )

Tidal Volume • 6-8 ml/kg

Plateau pressures • 30cmH20

• Recruitment manoeuvres
Other

• Failed oxygenation with lungs protective

PC-IRV
ventilation strategy
 Postoperative Management
 The Rate of blood loss should be minimal

 Decision to extubate depend on

Severity of Sepsis (Hemodynamic Instability)

Presence of comorbid diseases

Extensiveness of surgical procedures

 Monitoring should be continued at PACU / Pain Control

 Safe transfer of the patient to the ICU/HDU is essential

 A focused hand-over report is helpful for the ICU colleagues

 Pre-resuscitation measurements should be used to calculate the ICU

APACHE score
 Conclusion
A major healthcare issue with a high mortality

Definitions has been changed recently

Fluid resuscitation with vasopressors to

optimize CVS parameter is critically
important
Timely intervention to complete sepsis bundles
can improve outcome
 Conclusion
I.V Antibiotic should be started ASAP &
Continued intraoperatively if required

Decision for source control with appropriate

surgical intervention always depend on sincere
communication between surgical and
anaesthesia teams

If intubation is decided in ER, always consider

appropriate anaesthetic agents depending on
pharmacodynamic/kinetics in relation to sepsis
Thank You for Attention