2. Case2
• A 67-year-old man is evaluated in the surgical intensive
care unit. He underwent laparotomy and diverting
colostomy for a ruptured diverticulum 72 hours ago, and
now has a temperature of 40.0 °C (104.0 °F) and a heart
rate of 135/min. In the past 3 hours his mean arterial blood
pressure has dropped to 58 mm Hg despite three 1-L
boluses of normal saline; urine output was only 15 mL in
the past hour. The patient’s oxygen saturation is 85% on
100% oxygen by nonrebreather mask. Platelet count is
42,000/µL (42 × 109/L)
1. What is the diagnosis?
2. What is the next step in management?
4. Infection
• Infection is the invasion of an organism's
body tissues by disease-causing agents, their
multiplication, and the reaction of host tissues to the
infectious agents and the toxins they produce
• The process begins with infection in one part of the
body that triggers a localised inflammatory response
• Appropriate source control and a competent
immune system will, in most cases, contain the
infection at this stage.
5. Propagation Of Infection To Sepsis
If certain factors are present the host response to
infection become systemic:
• a genetic predisposition to sepsis
• a large microbiological load
• high virulence of the organism
• delay in source control (either surgical or
antimicrobial)
• resistance of the organism to treatment
• patient factors (immune status, nutrition, frailty).
6. Systemic Inflammatory Response
(SIRS)
• The diagnosis of SIRS requires that the patient have at
least two or more of the following clinical
manifestations:
• A body temperature of > 38 °C or < 36 °C
• Heart rate of > 90 beats/minute
• Tachypnea, as manifested by respiratory rate of > 20
breaths/minute or hyperventilation, as indicated by
PaCO2 of < 4.3 kPa
• An alteration of the white blood cell count of > 12 000
cells/mm3, < 4000 cells/mm3, or the presence of > 10%
immature neutrophils (bandforms)
7. Sepsis
• SEPSIS: SIRS occurring in presence of
infection
• Severe sepsis: sepsis with evidence of organ
hypoperfusion, eg hypoxemia,oliguria, lactic
acidosis or altered cerebral function
• Classically patients with sepsis are warm and
vasodilated but may be cold and shut down
8. Septic Shock
• Severe sepsis with hypotension(systolic BP<90
mmHg or MAP <60 mmHg) despite adequate
fluid resuscitation or the requirement for
vasopressors/inotropes to maintain BP
• Sepsis and both of (after fluid resuscitation):
1. Persistent hypotension requiring vasopressors to
maintain a MAP > 65 mmHg
2. Serum lactate > 2 mmol/L (18 mg/dL)
9. Pathphysiology Of Organ Damage In
Sepsis
• Macrovascular: sever hypovolemia, vasodilation or
septic cardiomyopathy decreasing oxygen delivery to
tissues
• Microvasuclar: hypoxia and endothelial injury leading
to leaking of protein and fluids
• Cellular :
1. direct injury by microorganisms;
2. injury from toxins produced by immune cells
3. mitochondrial injury causing cytopathic hypoxia – cells are unable
to metabolise oxygen
4. apoptosis – if the cell injury is sufficient, capsase enzymes are
activated within the nucleus and programmed cell death occurs
5. hypoxia from micro- and macrovascular pathology
11. the Sequential Organ Failure
Assessment (SOFA) score
Patients with suspected infection who have 2 or
more of:
• Hypotension – systolic blood pressure < 100 mmHg
• Altered mental status – Glasgow Coma Scale score
≤ 14
• Tachypnoea – respiratory rate ≥ 22 breaths/min
12. General Measures In Rx Of Sepsis And
Septic Shock
1. Deliver high-flow oxygen
2. Take blood cultures
3. Administer intravenous antibiotics
4. Measure serum lactate and send full blood count
5. Start intravenous fluid replacement
6. Commence accurate measurement of urine
Output
7. Circulatory support
13. Early Administration Of Antibiotics In
Suspected Sepsis
• Broad-spectrum antibiotics should be
administered as soon as possible after sepsis
is suspected
• Every hour of delayed treatment is associated
with a 5–10% increase in mortality
14. Sepsis Mimics
SIRS can result from insults other than sepsis:
• Pancreatitis
• Drug reactions
• Widespread vasculitis – catastrophic antiphospholipid
syndrome, Goodpasture’s syndrome
• Autoimmune diseases – inflammatory bowel disease,
rheumatoid arthritis, systemic lupus erythematosus
• Malignancy – carcinoid syndrome
• Haematological conditions – haemophagocytic syndrome,
diffuse lymphoma, thrombotic thrombocytopenic purpura
15. Case2
• A 67-year-old man is evaluated in the surgical intensive
care unit. He underwent laparotomy and diverting
colostomy for a ruptured diverticulum 72 hours ago, and
now has a temperature of 40.0 °C (104.0 °F) and a heart
rate of 135/min. In the past 3 hours his mean arterial blood
pressure has dropped to 58 mm Hg despite three 1-L
boluses of normal saline; urine output was only 15 mL in
the past hour. The patient’s oxygen saturation is 85% on
100% oxygen by nonrebreather mask. Platelet count is
42,000/µL (42 × 109/L)
1. What is the diagnosis?
2. What is the next step in management?
