HELPFUL TO UNDERGRADUATES

1. SEPSIS
DR SOURAB HIREMATH
MD INTERNAL MEDICINE
Emergency Medicine

2. PRETEST QUESTIONS (STATE TRUE OR FALSE)
• Majority of Organ involvement in Sepsis is because of invasion by offending
agent than the immune response
• Hypotension in sepsis is first treated with inotropes
• A MAP of > 65 mm of Hg should be maintained throughout

3. TRUE OR FALSE
• Antibiotic should be administered within 24 hours of admission
• ARDS ventilation always use high tidal volume settings
• Source of infection need to be controlled as early as possible
• Steroids are a must in all cases of sepsis

4. Story of
Chandu

5. 56 year old male chronic smoker
Had road side accident on 10th April 2020
He had lacerated wound over right feet
which was sutured in a local government
hospital
Past h/o Diabetes since 10 years on
metformin Poorly controlled

6. Received daily dressing at local clinic : Hygiene standards
could not be determined
8 days post suturing
of wound
Sutures have given away
Consulted local doctor had prescribe third
generation oral cephalopsporin for three
days
Wound worsened with more purulent
discharge
10th day post wound patient was rushed to
hospital

8. Emergency Room
Pulse rate : 150/min
very feeble regular
rhythm
BP: 70/50 mm of Hg
MAP: 56 mm of hg

9. MAP = DBP + 1/3rd of SBP-
DBP

10. Emergency Room
Pulse rate : 150/min
very feeble regular
rhythm
BP: 70/50 mm of Hg
MAP: 56 mm of hg
RR : 34 /min
Temp 98 degrees F
SPo2 : 86 % RA
Looks Pale
Peripheries warm on touch
CVS : S1 S2 Normal : Tachycardia ++
CNS : Drowsy
No motor Deficits
RS : B/L Scattered Crackles present
PA : Soft non tender , no organomegaly

11. EKG
XRAY
B/L peripheral fluffy
shadows
ARDS

12. LABS
• Hb : 10.2 g/dl
• Tc : 22,000 cells /dl N:87% L: 10 %
• Plt Count 50,000
• CRP 112mg/dl
• Sr Creatine : 2.8 mg/dl
• LFT : Normal
• Procalcitonin 35ng/ml
• Pus culture MRSA
• Blood culture MRSA
ABG : Pao2 : 55
Pco2 : 32
HCO3 : 14
Lactate : 6 mg/dl
INR 1.2

13. DIAGNOSIS

14. SEPSIS with SEPTIC SHOCK
INFECTED WOUND OVER LEG
BACTERIAL AGENT MRSA
ARDS /AKI / Thrombocytopenia/ Metabolic acidosis
UNCONTROLLED DM

15. HISTORY
Galen described sepsis
as
a laudable event
required for wound
healing.
germ theory
“blood poisoning” and was thought to be
due to pathogen invasion and spread in the
blood stream of the host

16. 1992, BONE AND COLLEAGUES
OF SEPSIS.
Proposed that the host, not the germ, was
responsible for the pathogenesis
“ they defined sepsis as a systemic
inflammatory response to infection”

17. SEPSIS DEFINITIONS TASK FORCE IN 2016
sepsis is a dysregulated host immune response to
infection that leads to life threatening acute organ
dysfunction

18. SEPSIS-3”
• To help clinicians in identifying sepsis and septic shock at the
bedside
• Clinical criteria for sepsis include
(1) a suspected infection and
(2) acute organ dysfunction, defined as an increase by two or more points from
baseline (if known) on the sequential (or sepsis-related) organ failure assessment
(SOFA) score

19. SEPTIC SHOCK
sepsis
the need for vasopressor therapy to elevate mean arterial pressure to ≥65 mmHg
a serum lactate concentration >2.0 mmol/L
despite adequate fluid resuscitation.

20. ETIOLOGY
• Community-acquired and Hospital-acquired infections
• Pneumonia is the most common source 50%of cases
• Next most common are intraabdominal and genitourinary infections
• Staphylococcus aureus and Streptococcus pneumoniae are the most common
gram-positive isolates
• Escherichia coli, Klebsiella species, and Pseudomonas aeruginosa are the most
common gram-negative isolates.

21. RISK FACTORS
• Chronic diseases (e.g., HIV infection, chronic obstructive pulmonary disease,
cancers)
• Immunosuppression
• Extremes of age, higher in males than in females, and higher in blacks than in
whites.

22. PATHOGENESIS

24. CLINICAL MANIFESTATIONS
Specific clinical manifestations of sepsis are quite variable, depending on
• the initial site of infection
• the offending pathogen
• the pattern of acute organ dysfunction
• the underlying health of the patient
• the delay before initiation of treatment.

25. CARDIORESPIRATORY FAILURE
• Acute Respiratory Distress Syndrome (ARDS)
defined as hypoxemia and bilateral infiltrates of
noncardiac origin that arise within 7 days of the
suspected infection.
Berlin criteria as
• mild (PaO2/FiO2, 201–300 mmHg),
• moderate (101–200 mmHg), or
• severe (≤100 mmHg). A common competing

26. CARDIOVASCULAR (DISTRIBUTIVE SHOCK)
• Cardiovascular compromise typically presents as hypotension.
The cause can be
•Frank hypovolemia
•Maldistribution of blood flow and intravascular volume
due to diffuse capillary leakage, reduced systemic
vascular resistance
•Depressed myocardial function.

27. KIDNEY INJURY ACUTE KIDNEY INJURY
• AKI is documented in >50% of septic patients, increasing the risk of in-hospital
death by six- to eightfold.
AKI manifests as
• Oliguria
• Azotemia
• rising serum creatinine levels and frequently requires dialysis

28. NEUROLOGIC COMPLICATIONS
• Coma or Delirium MC
• Sepsis-associated delirium is considered a diffuse cerebral dysfunction caused
by the inflammatory response to infection without evidence of a primary
central nervous system infection.
• Critical-illness polyneuropathy and myopathy are also common, especially in
patients with a prolonged course.

29. OTHER ABNORMALITIES
• ileus
• elevated aminotransferase levels,
• altered glycemic control
• thrombocytopenia and disseminated intravascular coagulation,
• adrenal dysfunction, and sick euthyroid syndrome

31. QSOFA

32. LABORATORY
• WBC : >12,000/μL or <4000/μL > 10 % band forms
• Thrombocytopenia
• LFT : Increased bilirubin , transaminitis
• RFT : AKI raised urea and creatine
• CRP raised
• Increase PT/APTT : DIC

33. • Serum procalcitonin : Bacterial sepsis
• Serum lactate levels
• Blood , Urine cultures , From catheter sites
• ABG : Metabolic Acidosis , Hypoxia

34. CHEST XRAY
ARDS

35. TREATMENT

37. A. INITIAL RESUSCITATION
30 mL/kg of IV
crystalloid fluid be
given within the
first 3 hours

38. TARGET BP
Mean arterial pressure (MAP) of 65 mm Hg
IF fluids do not raise MAP then add vasopressors
Noradrenaline

39. ANTIMICROBIAL THERAPY
IV antimicrobials be initiated as soon as
possible after recognition and within one hour
for both sepsis and septic shock

40. ANTIMICROBIAL THERAPY
•Broad Spectrum Empirical antibiotic
•Considering underlying etiological organism

41. APPROPRIATE ANTIMICROBIAL REGIMEN AT EACH
MEDICAL CENTRE AND FOR EACH PATIENT
FACTORS
These include:
a) The anatomic site of infection with respect to the typical pathogen
profile and to the properties of individual antimicrobials to penetrate
that site
b) Prevalent pathogens within the community, hospital, and even
hospital ward
c) The resistance patterns of those prevalent pathogens
d) The presence of specific immune defects such as neutropenia,
splenectomy, poorly controlled HIV infection and acquired or congenital
defects of immunoglobulin, complement or leukocyte function or

42. EXAMPLE OF ANTIBIOTIC CHOICE
Cellulitis
Gram
positive
Staph / Strep
DOC : Penicillin
AMOXYCILLIN
If suspecting MRSA
Vancomycin /
Linezolid

43. SOURCE CONTROL
specific anatomic diagnosis of infection
requiring emergent source control be
identified or excluded as rapidly as
possible in patients with sepsis or septic
shock, and that any required source
control intervention be implemented as
soon as medically and logistically
practical after the diagnosis is made

44. BLOOD PRODUCTS
Red blood cell
transfusion is
recommended only
when the hemoglobin
concentration decreases
to <7.0 g/dL in the
absence of acute
myocardial infarction,
severe hypoxemia, or
acute hemorrhage.
Platelet
transfusion if
platelet count
is less than
10,000 or less
than 20,000
with bleeding
Fresh Frozen
plasma
deranged
PT/aPTT with
bleeding

45. RESPIRATORY SUPPORT
• target tidal volume of 6 mL/kg of predicted body
weight (compared with 12 mL/kg in adult patients) is
recommended in sepsis-induced ARDS
• higher PEEP rather than a lower PEEP

46. AKI
Dialysis
CRRT

47. GLUCOSE CONTROL
Insulin dosing initiated when two
consecutive blood glucose levels are
>180 mg/dL.

48. STRESS ULCER PROPHYLAXIS
Should be given to patients with risk
factors for gastrointestinal bleeding

50. THANK YOU

51. PRETEST QUESTIONS (STATE TRUE OR FALSE)
• Majority of Organ involvement in Sepsis is because of invasion by offending
agent than the immune response
• Hypotension in sepsis is first treated with inotropes
• A MAP of > 65 mm of Hg should be maintained throughout

52. TRUE OR FALSE
• Antibiotic should be administered within 24 hours of admission
• ARDS ventilation always use high tidal volume settings
• Source of infection need to be controlled as early as possible
• Steroids are a must in all cases of sepsis