sepsis

1. G M C
SEPSIS AND SEPTIC
SHOCK

2. CONTENTS
• Definitions
• Causes
• Risk factors
• Pathophysiology
• Sign and symptoms
• Investigations
• Treatment

4. DEFINITONS
• Bacteremia :presence of bacteria in blood,as evidenced
by positive blood culture
• Septicemia: presence of microbes or their toxins in blood

5. SIRS
• Systemic inflammatory response syndrome: defined by
the presence of two or more of the following
1. tachypnea : RR>20 breaths/min or PaCO2<32mmHg
2. WBC count<4000 cells/µL or >12000 cells/µL
3. Tachycardia: pulse>90 beats/min
4. Hypo or hyperthermia : temp>38°c or <36°c

6. • In 2016, SIRS was replaced with a shortened sequential
organ failure assessment score(SOFA score) known as
the quick SOFA score(qSOFA)
The score ranges from 0 to 3 points.
The presence of 2 or more qSOFA points near the onset of
infection is associated with a greater risk of death or
prolonged intensive care unit stay.
Assesment qSOFA score
Low blood pressure(SBP≤100mmHg) 1
High RR(≥22breaths/min) 1
Altered mental status(GCS≤14) 1

7. SEPSIS
• SIRS that has proven or suspected microbial etiology

8. SEVERE SEPSIS
• Sepsis with one or more signs of organ dysfunction
1. CVS: arterial SBP≤90 mmHg or mean arterial BP ≤70
mmHg that responds to administration of iv fluid
2. Renal: urine output <0.5 ml/kg per hour for 1 h despite
adequate fluid resuscitation
3. Respiratory: PaO2/FiO2 ≤250 or, if the lung is only
dysfunctional organ ,≤200
4. Hematologic: platelet count <80000/µL or 50%
decrease in platelet count from highest recorded over
previous 3 days
5. Unexplained metabolic acidosis ;ph ≤7.30 or base
deficit ≥5 mEq/L and plasma lactate level >1.5 times
upper limit of normal for reporting lab

9. SEPTIC SHOCK
• Sepsis with hypotension(arterial SBP<90 mmHg or 40
mmHg less than patients normal BP) for at least 1 h
depite adequate fluid resuscitation
• OR
• Need for vasopressor to maintain SBP≥90 mmHg or
MAP ≥70mmHg
• Stages :
a) Hyperdynamic(warm) shock
b) Hypodynamic (cold) shock

11. CAUSES
• Infections leading to sepsis are usually bacterial, but may
be fungal or viral.
• gram-positive bacteria, most commonly staphylococci,are
thought to cause more than 50% of cases of
sepsis.(enterococci, streptococcus pneumoniae)
• Gram negative bacteria such as enterobacteriaceae,
pseudomonads, haemophilus spp
• Fungal sepsis accounts for approximately 5% of severe
sepsis and septic shock cases; the most common cause of
fungal sepsis is infection by Candida species of yeast,

12. RISK FACTOR
• Diabetes mellitus
• Immunodeficiency
• Trauma
• Burns
• Alcohol and substances abuse
• Chronic disease(heart, lungs, kidneys, liver)
• Haematological disorders
• Recent surgeries or procedure
• Invasive lines:iv or arterial , urinary catheters ,NG tubes

13. PATHOPHYSIOLOGY

14. SIGN AND SYMPTOMS

15. • It is important to identify any potential source of infection.
Localizing signs and symptoms referable to organ
systems may provide useful clues to the etiology of
sepsis and are as follows:
• Head and neck infections – Severe headache, neck
stiffness, altered mental status, earache, sore throat,
sinus pain/tenderness, cervical/submandibular
lymphadenopathy

16. • Chest and pulmonary infections – Cough (especially if
productive), pleuritic chest pain, dyspnea, dullness on
percussion, bronchial breath sounds, localized rales, any
evidence of consolidation
• Cardiac infections – Any new murmur, especially in
patients with a history of injection or IV drug use

17. • Abdominal and gastrointestinal (GI) infections –
Diarrhea, abdominal pain, abdominal distention,
guarding or rebound tenderness, rectal tenderness or
swelling
• Pelvic and genitourinary (GU) infections – Pelvic or
flank pain, adnexal tenderness or masses, vaginal or
urethral discharge, dysuria, frequency, urgency

18. • Bone and soft-tissue infections – Localized limb pain
or tenderness, focal erythema, edema, swollen joint,
crepitus in necrotizing infections, joint effusions
• Skin infections – Petechiae, purpura, erythema,
ulceration, bullous formation, fluctuance

19. SOFA SCORE
• The SOFA scoring system is useful in predicting the
clinical outcomes of critically ill patients
• RESPIRATORY system:
PaO2/FiO2 (mmHg) SOFA score
≥ 400 0
< 400 +1
< 300 +2
< 200 and mechanically ventilated +3
< 100 and mechanically ventilated +4

20. • NERVOUS SYSTEM:
Glasgow coma scale SOFA score
15 0
13–14 +1
10–12 +2
6–9 +3
< 6 +4

21. • CARDIOVASCULAR
Mean arterial pressure OR
administration of vasopressors required
SOFA score
MAP ≥ 70 mmHg 0
MAP < 70 mmHg +1
dopamine≤ 5 µg/kg/min
or dobutamine(any dose)
+2
dopamine > 5 µg/kg/min
OR epinephrine≤ 0.1 µg/kg/min
OR norepinephrine≤ 0.1 µg/kg/min
+3
dopamine > 15 µg/kg/min OR
epinephrine > 0.1 µg/kg/min OR
norepinephrine > 0.1 µg/kg/min
+4

22. • LIVER
Bilirubin (mg/dl) [μmol/L] SOFA score
< 1.2 [< 20] 0
1.2–1.9 [20-32] +1
2.0–5.9 [33-101] +2
6.0–11.9 [102-204] +3
> 12.0 [> 204] +4

23. • COAGULATION
Platelets×103/µl SOFA score
≥ 150 0
< 150 +1
< 100 +2
< 50 +3
< 20 +4

24. • KIDNEYS
Creatinine (mg/dl) [μmol/L] (or urine
output)
SOFA score
< 1.2 [< 110] 0
1.2–1.9 [110-170] +1
2.0–3.4 [171-299] +2
3.5–4.9 [300-440] (or < 500 ml/d) +3
> 5.0 [> 440] (or < 200 ml/d) +4

25. Maximum
SOFA Score
Mortality
0 to 6 < 10%
7 to 9 15 - 20%
10 to 12 40 - 50%
13 to 14 50 - 60%
15 > 80%
15 to 24 > 90%

26. INVESTIGATIONS
• Haematological : hb, hematocrit , white cell counts,
prothrombin time
• Biochemical : serum urea, s.creatinine, Na+, k+,
RBS,lactate
• Coagulation studies:PT,aPTT, fibrinogen level

27. • Cultures:(pus, blood, urine)
• To identify the causative organism(s), at least two sets
of blood cultures using bottles
with media for aerobic and anaerobic organisms should
be obtained, with at least one drawn through the
skin and one drawn through each vascular access
device (such as an IV catheter) in place more than 48
hours.

28. • Imaging modalities:
• Chest radiography to rule out pneumonia and diagnose
other cause of pulmonary infiltrates
• Abdominal USG
• Abdominal CT or MRI for assessing a suspected
nonbiliary intra abdominal source of infection or
delineating intrarenal and extrarenal pathology

29. • Invasive diagnostic procedures:
• Thoracocentesis(in patient with substantial pleural
effusion)
• Paracentesis(in patients with gross ascites)

30. TREATMENT OF SEVERE SEPSIS/SEPTIC
SHOCK
1. Volume resuscitation
2. Cardiovascular supports
3. Antimicrobial therapy
4. Source control
5. Early goal directed therapy
6. Surgery

31. VOLUME RESUSCITATION
• Iv access with 2 wide bore cannulas are secured
• Patient should initially receive 30mL/kg iv crystalloid fluid
within first hour of presentation
• Then re-assess, and repeat as appropriate
• Urethral catheter is passed to empty the bladder then to
monitor the hourly urine output(30-50ml/hr)
• Central venous catheter is inserted(10-15cmH20)

32. RESPIRATORY SUPPORT
• Supplemental oxygen should be administered to all
patients with suspected sepsis.
• Early intubation and mechanical ventilation should be
strongly considered for patients with any of the following:
• Oxygen requirement
• Dyspnea or tachypnea
• Persistent hypotension
• Evidence of poor peripheral perfusion

33. CORRECTION OF ANEMIA AND
COAGULOPATHY
• if hemoglobin levels fall below 7 g/dL, red blood cell
(RBC) transfusion is recommended to a target
hemoglobin range of 7-9 g/dL
• Platelet transfusion may also be considered when
bleeding risk is increased and platelet counts are below
20 × 109/L (20,000/µL).

34. CARDIOVASCULAR SUPPORT
• If the patient does not respond to resuscitation with
several liters (usually ≥4 L) of isotonic crystalloid solution
or if evidence of volume overload is present, the
depressed cardiovascular system can be stimulated by
means of vasopressor therapy.
• First-line agents: Norepinephrine,dopamine
• Norepinephrine has predominant alpha-receptor agonist
effects and results in potent peripheral arterial
vasoconstriction without significantly increasing heart
rate or cardiac output.

35. • The dosage range for norepinephrine is 5-20 µg/min,
and it is not based on the weight of the patient.
• Norepinephrine is preferred to dopamine for managing
septic shock because dopamine is known to cause
unfavorable flow distribution (more arrhythmias). In this
setting, norepinephrine has been shown to be both
significantly safer and somewhat more effective.

36. • Dopamine: is used only in certain highly specific
situations, such as when there is a low risk of
tachyarrhythmias and in the presence of coexistent
bradycardia.
• Treatment usually begins at 5-10 µg/kg/min IV, and the
infusion is adjusted according to the blood pressure and
other hemodynamic parameters.

37. • Second-line agents:synthetic human angiotensin II,
epinephrine, phenylephrine, and vasopressin.

38. ANTI MICROBIAL THERAPY
• Agents suitable for empiric monotherapy regimens may
include the following:
• Imipenem
• Meropenem
• Tigecycline
• Piperacillin-tazobactam
• Ampicillin-sulbactam
• Moxifloxacin

39. IMMUNOCOMPETENT ADULT
• If no obvious source:
(1) piperacillin-tazobactam (3.375 g q4–6h)
(2) imipenem-cilastatin (0.5 g q6h), ertapenem (1 g q24h),
or meropenem (1 g q8h)
(3) cefepime (2 g q12h
(4) If the patient is allergic to β-lactam agents, use
ciprofloxacin (400 mg q12h) or levofloxacin (500–750 mg
q12h) plus clindamycin (600 mg q8h).
(5) Vancomycin (15 mg/kg q12h) should be added to each
of the above regimens if there is high prevalence of
MRSA

40. • If urosepsis:
• aerobic gram-negative bacilli employs aztreonam,
levofloxacin, a third- or fourth-generation cephalosporin,
or an aminoglycoside.
• urosepsis due to enterococci (E faecalis) involves the
use of ampicillin or vancomycin (penicillin-allergic).

41. • In case of iv drug user
Vancomycin (15 mg/kg q12h) is essential
• In case of AIDS: Cefepime alone (2 g q8h) or
piperacillintazobactam (3.375 g q4h) plus tobramycin (5–
7 mg/kg q24h) should be used.
• If the patient is allergic to β-lactam drugs, ciprofloxacin
(400 mg q12h) or levofloxacin (750 mg q12h) plus
vancomycin (15 mg/kg q12h) plus tobramycin should be
used.

42. • Treatment duration is typically 7–10 days with the type of
antibiotic used directed by the results of cultures.
• If the culture result is negative, antibiotics should be de-
escalated according to person's clinical response or
stopped altogether if infection is not present

43. REMOVAL OF THE SOURCE OF
INFECTION
• Sites of occult infection should be sought carefully,
particularly in the lungs, abdomen, and urinary tract.
• Indwelling IV or arterial catheters should be removed
• Foley and drainage catheters should be replaced

44. EARLY GOAL DIRECTED THERAPY
• is an approach to the management of severe sepsis
during the initial 6 hours after diagnosis
• involves monitoring of hemodynamic parameters and
specific interventions to achieve key resuscitation targets
which include maintaining a central venous pressure
between 8–12 mmHg, a mean arterial pressure of
between 65–90 mmHg, a central venous oxygen
saturation (ScvO2) greater than 70% and a urine output
of greater than 0.5 ml/kg/hour

46. SURGERY
• Patients with focal infections should be sent for definitive
surgical treatment after initial resuscitation and
administration of antibiotics
• Certain conditions will not respond to standard treatment
for septic shock until the source of infection is surgically
removed

47. • for example:
• intra-abdominal sepsis (perforation, abscesses),
empyema, mediastinitis, cholangitis, pancreatic
abscesses, pyelonephritis or renal abscess from ureteric
obstruction, infective endocarditis, septic arthritis,
infected prosthetic devices, deep cutaneous or perirectal
abscess, and necrotizing fasciitis.

49. REFERENCES
• Harrisons principle of internal medicine,kasper,19th
edition
• The washington manual of medical therapeutics,wolters
kluwer,35th edition
• Medscape

50. •Thank you