Sepsis

Front 1

infx

Back 1

-localized process

Front 2

bacteremia

Back 2

-bacteria in the blood

Front 3

systemic inflammatory response syndrome (SIRS)

Back 3

-An inflammatory response to a variety of clinical insults.

Front 4

SEPSIS

Back 4

-SIRS CAUSED BY A KNOWN OR SUSPECTED INFX
-Does not require positive blood cultures!

Front 5

severe sepsis

Back 5

-sepsis plus hypotension OR hypoperfusion OR organ dysfunction

Front 6

shock

Back 6

-A syndrome of impaired tissue oxygenation and perfusion

Front 7

septic shock

Back 7

-A progression of severe sepsis with hypotension despite adequate fluid resuscitation and perfusion abnormalities.

Front 8

MODS/MOSF/MSOF

Back 8

-Multiple Organ Dysfunction Syndrome/Multiple Organ System Failure/Multisystem Organ Failure

Front 9

SIRS criteri

Back 9

-at least 2:
1. temp >38 degrees C or <36
2. HR >90bpm
3. Respiratory rate >20 bpm or PaCO2 <32 mmHg
4. WBC >12,000 or <4,000 OR >10% bands
-may seen tachypnea, clammy skin, pul edema, tissue edema, cyanotic fingers, clotting disorders

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Back 10

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Front 11

sepsis

Back 11

-the most common cause of SIRS
-~750,000 cases/yr
-15% mortality!!!
-Criteria:
1. at least 2 SIRS criteria met
2. known or suspected infx
-initially you may see non-specific clinical signs: tachypnea, AMS

Front 12

severe sepsis

Back 12

-sepsis + 1 of the following
hypotension: SBP <90, if pt is normally hypertensive, a dec in SBP >40 from baseline is sig
hypoperfusion: abml peripheral circulation, organ dysfunction

Front 13

shock

Back 13

-a condition in which oxygen supply does not meet demand
-4 types:
1. hypovolemic - low bl vol --> hemorrhagic or not
2. Cardiogenic - hearts not pumping; ischemic, valvular, arrithymic
3. Distributive - septic*, adrenal crisis, neurogenic, anaphylactic
4. Obstructive - pum embolism, tension PTX, cardiac tamponade, constrictive pericarditis

Front 14

hemodynamic profiles of shock

Back 14

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Front 15

Septic shock

Back 15

-a type of distributive shock
-a progression of severe sepsis with: hypotension despite adequate fluid resuscitation, the presence of perfusion abnormalities
-40% of pts with sepsis will progress to septic shock
-pts with septic shock have a 40-70% mortality

Front 16

whos at risk?

Back 16

1. elderly
2. co-mobidities: DM, COPD< vavlular disease, HIV/neutropenia, malignancy, malnourished
3. surgery or instrumentation
4. prior abc therapy
5. recent or current hospitalization
6. genetics

Front 17

common sites of infection

Back 17

1. lungs
2. urinary tract
3. intra-abd
4. IV catheter -staph
5. skin
6. heart valves (endocarditis)
7. sinuses/meninges

Front 18

HPI

Back 18

-fever?
-constitutional sx
-localized ssx

Front 19

PMH

Back 19

-previous surgery or dental procedures
-hospitalizations
-recent travel
-medications including abx, immunosuppresants, NSAIDs, bblockers (HR may not be inc even though they are septic)
-gyn
-ETOH, IVDU

Front 20

PE

Back 20

-ABCs
-general appearance
-VS: rectal temp, pulse (quality), resp rate, BP
-skin: warm and flushed then becomes cool and clammy
-HEENT
-pulmonary
-CV
-abd: scars, ascites, tenderness
-Pelvic/GU/rectal
-MS: pain due to septic joint?
-neuro
SERIAL EXAMS

Front 21

Labs

Back 21

1. CBC with diff
2. SMA20
3. coag profile
4. blood cultures: 2 sets from 2 different sites, 10 ml per cx, take from noninfected sites
5. ABG
6. Lactate! -> follow these serially!
7. CRP
8. procalcitonin -> marker for severe sepsis

Front 22

diagnostic studies

Back 22

1. UA
2. gram stain
3. LP
4. wound cxs
5. Radiographs: CXR,
6. Head/chest. abd CT
7. US

Front 23

mgmt

Back 23

#1 You must intervene early!
#2 Constant re-evaluation is necessary
-Patients will require a monitored setting
#3 Therapy should be goal directed
-What are you trying to accomplish?
-Keep O2 saturation >90%
-SBP >90
-Urine output 30-60ml/hr (0.5ml/kg/hr)***
-Clear the infection

Front 24

mgmt- the first 6 hours - initial resuscitation

Back 24

1. Initial resuscitation:
1. begin immediately in pts who are hypotensive or have lactate >4mmol
2. start with 500-1000ml crystalloid or 300-500ml colloid over 30 min
3. Resuscitation goals:
-CVP 8-12 mmHg
-MAP (mean arterial BP) >/= mmHg
-U/O >/= 0.5 ml/kg/hr
-ScvO2 >/= 70% (central venous oxygenation)
4. constantly evaluate and monitor pts response

Front 25

first 6 hours- diagnosis

Back 25

1. obtain appropriate bl cultures BEFORe starting abx
-2+ cltures
-get one from each vascular site placed within 48hrs
-cx other sites
2. do NOT delay starting abc if you cnanot obtain bl cultures
3. get appropriate imaging studies

Front 26

first 6 hours- abx therapy

Back 26

1. ALWAYS within 1st hr of recognizing severe sepsis or septic shock
2. start with broach spectrum coverage with good penetration into the likely source
-re-eval abx daily
3. stop antimicrobial therapy if the cause is noninfectious

Front 27

first 6 hours- source identification and control

Back 27

A specific site of infection should be established as rapidly as possible within the first six hours of presentation.
Formally evaluate a patient to see if their infection can be treated with a source control measure (ie: tissue debridement, abscess drainage).
Implement the source control measure as soon as possible after initial resuscitation (unless it’s pancreatic necrosis).
Remove intravascular devices if potentially infected.

Front 28

mgmt- respiratory

Back 28

-continuous pulse ox
-keep SpO2 >90%
-use supplemental O2
-intubate
-mechanical ventilation in sepsis-induced ALI/ARDS
1. tidal vol: 6 ml/kg
2. place pt in semirecumbant position

Front 29

Vasopressors

Back 29

-used ot keep MAP >/= 65 mHg
-NE and dopamine are the first line choice (must be administered through central venous catheter)
-add vasopressin if needed
-insert an arterial line

Front 30

Inotropes

Back 30

-used to inc CO by increasing contractility
-dobutamine should be the first choice

Front 31

Steroids

Back 31

-controversial!
-only consider if sepsis is causing a shock state or if the pts pmhx warrants corticosteroid therapy
-hydrocortisone dose should be <300mg/day

Front 32

glucose mgmt

Back 32

-Goal: gluc </= 150 mg/dl
-when using IV insulin, monitor every 1-2 hrs
-tight glucose control (80-110) has been associated with increased rates of hypoglycemia, thus the guidelines now recommend against IV insulin therapy titrated to the "nml" range

Front 33

other mgmt

Back 33

1. DVT prophylaxis
2. stress ulcer prophylaxis
3. nutrition
4. prevention of nosocomial infxs
5. blood transfusions: consider if heme is <7
6. discuss advanced care plannign with pts families

Front 34

Recombinant Human Activated protein C (Xigris)

Back 34

-Antithrombotic, profibrinolytic, and anti-inflammatory properties
-shown to reduce mortality
-ONLY considered for pts who are extremely sick with multi-organ dysfunction (APACHE II score >/=25)
-most common AE: BLEEDING

Front 35

Etiology

Back 35

1. gram positive sepsis: Staph ,strep, enterococcus
-at risk: IVDU, burn pts, indwelling IVs, mechanical devices
2. gram neg sepsis: e.coli, klebsiella, proteus, pseudomonas
-DM, Etoh, cirrhosis, burns, CA, chemo, steroids, TPN, elderly, COPD, GI/GU infections, neutropenic
3. fungal sepsis: Candida
-Immunosuppressed, neutropenic, steroid use, TPN, prolonged use of broad spectrum abx
-splenectomy pts are at inc risk for S.pneumo, H. flu, and N.meningitidis