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Sepsis

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  • 1. Sepsis Syndrome Cynthia L. Gibert, M.D. Washington VA Medical Center Georgetown University Medical Center
  • 2. Sepsis and Septic Shock
    • 13th leading cause of death in U.S.
    • 500,000 episodes each year
    • 35% mortality
    • 30-50% culture-positive blood
  • 3. Mortality Percentage 0 10 20 30 40 50 60 UVA Hospital Johns Hopkins UVA newborn ICU UVA Enterococcus UIHC CNS UIHC Candida UIHC SICU
  • 4. Stages of Sepsis Consensus Conference Definition
    • Systemic Inflammatory Response Syndrome (SIRS) Two or more of the following:
      • Temperature of >38 o C or <36 0 C
      • Heart rate of >90
      • Respiratory rate of >20
      • WBC count >12 x 10 9 /L or <4 x 10 9 /L or 10% immature forms (bands)
    • Sepsis SIRS plus a culture-documented infection
    • Severe Sepsis Sepsis plus organ dysfunction, hypotension, or hypoperfusion (including but not limited to lactic acidosis, oliguria, or acute mental status changes)
    • Septic Shock Hypotension (despite fluid resuscitation) plus hypoperfusion
  • 5. Multiple Organ Dysfunction Syndrome
    • Dysfunction of 2 or more systems
    • Four or more systems - mortality near to 100 percent
  • 6.  
  • 7.  
  • 8. Factors Associated with Highest Mortality
    • Respiratory > abdominal > urinary
    • Nosocomial infection
    • Hypotension, anuria
    • Isolation of enterococci or fungi
    • Gram-negative bacteremia, polymicrobial
    • Body temperature lower than 38°C
    • Age greater than 40
    • Underlying illness: cirrhosis or malignancy
  • 9. Predisposing Underlying Diseases
    • Heart disease-rheumatic or congenital
    • Splenectomy
    • Intraabdominal sepsis
    • Septic abortion or pelvic infection
    • Intravenous drug abuse
    • Immunocompromised
  • 10. Organisms Responsible for Septic Shock in Relation to Host Factors
  • 11.  
  • 12. Bacteremia in the Preantibiotic Era
    • Streptococcus pneumoniae
    • Group A streptococcus
    • Staphylococcus aureus
    • Haemophilus influenzae
    • Neisseria mennigitidis
    • Salmonella spp.
  • 13. Emergence of Gram-Negative Organisms
    • Antibiotic pressure on normal flora
    • Use of invasive devices
    • Immune suppression
  • 14. Differential Diagnosis of Fever and Shock
    • Purulent bacterial pericardial effusion
    • Peritonitis
    • Pneumonia with severe hypoxia
    • Mediastinitis
    • Anaphylaxsis
    • Staphylococcal toxic shock syndrome
    • Streptococcal toxic shock syndrome
  • 15. Clinical Manifestations
    • Fever, chills, hypotension
    • Hypothermia, especially in the elderly
    • Hyperventilation - respiratory alkalosis
    • Diaphoresis, apprehension, change in mental status
  • 16. History
    • Community versus hospital-acquired
    • Prior or current medications
    • Recent manipulations or surgery
    • Underlying diseases
    • Travel history
  • 17. Approach to Septic Patient
    • Seek primary site of infection
    • Direct therapy to primary site
    • Repeated examination
  • 18. Skin
    • Furuncles, cellulitis, bullous lesions
    • Intravenous sites, phlebitis
    • Erythema multiforme
    • Ecchymotic or purpuric lesions
    • DIC, petechiae
    • Ecthyma gangrenosum
    • Purpura fulminans
  • 19. Cardiovascular Signs
    • “ Warm shock” -  CO,  SVR
    • “ Cold shock” -  CO,  SVR
    • Anaerobic metabolism - lactic acidemia
    • Myocardial depressant factor - ??
  • 20. Pulmonary Signs
    • Tachypnea
    • Hyperventilation, respiratory alkalosis
    • ARDS, respiratory failure
    • Ventilation-perfusion mismatch
    • Widened alveolar-arterial oxygen gradient
    • Reduced lung compliance
  • 21. Hematologic Findings
    • Neutrophilic leukocytosis
    • Leukemoid reaction
    • Neutropenia
    • Thrombocytopenia
    • Toxic granulations
    • DIC
  • 22. Renal and Gastrointestinal Signs
    • Acute tubular necrosis, oliguria, anuria
    • Upper GI bleeding
    • Cholestatic jaundice
    • Increased transaminase levels
    • Hypoglycemia
  • 23. Acute Physiology and Chronic Health Evaluation
    • APACHE II
    • Temp Arterial pH
    • MAP Serum Na; Serum Cr
    • Heart rate Hematocrit
    • Resp. rate WBC
    • Oxygenation Glasgow Coma Score
    • Acute physiology score + Age + Chronic health points
  • 24. Laboratory Studies
    • Blood cultures
    • Infected secretions/body fluids
    • Stool for WBC, C. difficile
    • Aspirate advancing edge of cellulitis
    • Skin biopsy/scraping
    • Buffy coat
  • 25. Therapy of Septic Shock
    • Correct pathologic condition
    • Optimize intravascular volume
    • Administer empiric antimicrobial therapy
    • Administer vasoactive drugs
  • 26. Failure of Fluid Replacement and Vasopressors
    • acidosis - pH<7.3
    • hypocalcemia
    • adrenal insufficiency
    • hypoglycemia
  • 27. Empiric Antimicrobial Regimens for Sepsis Syndrome
    • Community-acquired non-neutropenic
      • Urinary tract: 3rd generation cepholosporin, piperacillin, quinolone + AG
      • Non-urinary tract: 3rd generation cepholosporin + metronidazole,  -lactam/  -lactamase inhibitor + AG
  • 28.
    • Hospital-acquired
      • Nonneutropenic: 3rd generation cephalosporin + metronidazole,  -lactam /  -lactamase inhibitor, menopenem all + AG
      • Neutropenic: Timentin + AG, meropenem + AG; ceftazidime + metronidazole + AG
  • 29. Septic Shock Outcomes for Patients on Hospital Wards versus ICU’s
    • Ward patients: Delays in ICU transfer (67 mins.)
    • IV fluid boluses (27 vs 15 mins.)
    • Inotropic agents (310 vs 22.5 mins)
    • Mortality: Wards (70%) vs ICUs (39%)
    • Apache II scores (18.5 vs 24)
    • Candidemia
    JS Lunberg, Crit. Care Med. 26:1020; 1998
  • 30. Immunotherapies for Septic Shock
    • Corticosteroids
    • Antiendotoxin monoclonal antibodies E-5, HA-1A
    • Anti-TNF antibodies
    • IL-1 receptor antagonists
  • 31. Other Treatment Modalities
    • Granulocyte transfusions
    • Recombinant colony-stimulating factors
    • Diuretics
    • Pentoxifylline, ibuprofen, naloxone
    • Oral nonabsorbable antimicrobial agents