BENADIR UNIVERSITY

Faculty of Medicine and SurgeryBatch 8

Lecture: SEPSISPrepared by

Mohamed Abdullahi Osman

WHAT IS SEPSIS?

Sepsis :medical condition characterized by a whole-body inflammatory state (called a systemic inflammatory response syndrome or SIRS) caused by severe infection .

It's sometimes called blood poisoningSevere Sepsis :One sepsis related organ

dysfunction

Septicemia:medical term referring to the presence of

pathogenic organisms in the bloodstream, leading to sepsis

Septic ShockSevere sepsis with Persistant hypotentionWhen hypotention can not be corrected by

infution of fluid Septic focus (abscess / cavity / tissue mass)

Common places where an infection might start include:

The bloodstream The bones (common in children)The bowel (usually seen with peritonitis)The kidneys (upper urinary tract infection or

pyelonephritis)The lining of the brain (meningitis)The liver or gallbladderThe lungs (bacterial pneumonia)The skin (cellulitis)

In hospitalized patients, common sites of infection

include

intravenous lines, surgical wounds, surgical drains, urinary catheters and sites of skin breakdown known as bedsores

(decubitus ulcers).

Pathogenesis of Sepsis

Pathogenesis of Sepsis

• tissue oxygenation may decrease as number of functional capilaries is reduced by luminal obstruction due to swallowing of endothelial cells , decrease deformability of RBC, leukocyte – platelet – fibrin Thrombi

What are Clinical manifestations of sepsis?

History/symptoms• Fever, chills, lethargy, or malaise• Productive cough• Headache• Sore throat• Diarrhea, abdominal pain• Dysuria, cloudy urine• Sick contacts• Recent surgery/instrumentation• Recent chemotherapy

Signs• Disorientation• Tachypnea: Respiratory Rate >20• Tachycardia:HR >90• Hypoxia• Hyper/hypo-thermia >38 or <36• Decreased urine output• Hypotension

Hypotention and DIC predispose to Acrocyanosis and schemic necrosis of prepheral tissues most commonly in Digits.

Cellulitis or hemorrhagic lesions may develop when Hematogenous bacteria or fungi seed in the skin

When sepsis is accompanied by cutaneous petchiea or purpura , infection with neisseria meningitis , h.influenza should be suspected

Who is at risk of sepsis?

Those with a weakened immune system. This could be due to a diseases like AIDS, Diabetes etc. or due to medical treatment that suppresses the immunity like anti-cancer chemotherapy

Very young children and infants and the elderly

Who is at risk of sepsis?

Those admitted in the hospital with a serious illness

After a major surgery or a major accidentAfter surgeries such as illegal abortion or

instrumentationAlcohol abusersThose with extensive burns

Why Septic patients are Anemic ?

Causes of anemia in septic patient :Hemodilution – due to crystaloid infution Increase blood lose

bleeding : Tauma , because of intumentsReduction of half life of Red cells due to

destruction mediated by systamic inflamation Direct inhibition of Erytheropoiesis by

inflammatory Mediatories like interluekins 1,6, TNF

Are they need Blood transfusion ?

Its recommend that red blood cell transfusion occur only when hemoglobin concentration decreases to <7.0 g/dL to target a hemoglobin concentration of 7.0 –9.0 g/dL in adults

What is the consequence of Blood transfusion in patient

with sepsis?• 1. Transfusion increase pulmonary Resistance • 2. viral Infectious complication Like Hepatitis

and HIV• 3.Bacterial complication(most common in Platelet

transfusion)• 4. Non Infectious Complication • a)Hemolytic reaction• b) Tranfussion related Acute lung injury• c) Hypotensive transfused reaction

RiskStored blood transfussion

Has less oxygen Carrying capacity Risk of deformity RBC can produce Splenic

Schemia

Did you Know this patiens have hyperglycemia!

What is Name of this hyperglycemic

How did you feel this patients become hyperglycemic

Stress Hyperglycemia

A decreased release of insulin, increased release of hormones with effects countering insulin, and increased insulin resistance combine to produce stress hyperglycemia in many critically ill patients.

Hyperglycemia diminishes the ability of neutrophils and macrophages to combat infections. Also insulin possesses antiapoptotic effects.

• .

Stress Hyperglycemia

• A large, single-center, randomized trial of more than 1500 critically ill patients demonstrated that, maintaining serum glucose levels between 80 and 110 mg/dL (mean morning glucose of 103 mg/dL) through the use of a continuous insulin infusion decreased mortality (4.6% vs 8%; P < 0.04), development of renal failure (P = 0.04), and episodes of septicemia (P = 0.003), compared with conventional treatment (mean morning glucose of 153 mg/dL.

• Physicians liberalize their insulin treatment to keep blood glucose levels less than 150 mg/dL due to concerns of hypoglycemia

The Mortality Rate of this patients high,

What is the Cause you suspect to increase rate of mortality ?

How we can lower the incidence and make better Prognosis?

The Mortality Rate of this patients high Because of :

Admit ion of patient to the hospital in late Time

Treatment is given too late

How we can lower the incidence

Increase Awareness of health care

Improve the Early , accurate diagnosis of Sepsis

Which is basic investigations you need

CBCBlood CultureKidney function tests lactatePT/PTT, CXR

Steps of sepsis Management in Order Set

1).Assess airway

2)Insert/maintain 2 peripheral IV lines (18 gauge or larger) or place TLC for central IV access.

3. Initial Resuscitation

Goals during the first 6 hrs of resuscitation• Urine output ≥ 0.5 mL/kg/hr d)• In patients with elevated lactate levels targeting resuscitation

to normalize lactate (grade 2C).• a) Central venous pressure 8–12 mm Hg

4.Diagnosis

Cultures as clinically appropriate before antimicrobial therapy.

Imaging studies performed promptly to confirm a potential source of infection

5.Antimicrobial Therapy

Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis

6.Source Control : Drainage of focal source of infection is essential , catheter should be Removed

The possibility of paranasal sinusitis is considered if patient undergone NASAL INTUBATION

7.Infection Prevention:

Selective oral decontamination and selective digestive decontamination should be introduced and investigated as a method to reduce the incidence of ventilator-associated pneumonia.

Oral chlorhexidine gluconate (antiseptic) be used as a form of oropharyngeal decontamination to reduce the risk of ventilator-associated pneumonia in ICU patients with severe sepsis

Fluid Therapy of Severe Sepsis

. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock

Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids

Why we need Albumin?How you determine if there is little

hemodynemic improvement ?

7.Vasopressors:Vasopressor therapy initially to target a mean

arterial pressure (MAP) of 65 mm HgNorepinephrine as the first choice vasopressorDopamine as an alternative vasopressor agent

to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia)?

Inotropic Therapy1. A trial of dobutamine infusion up to 20

micrograms/kg/min be administered or added to vasopressor (if in use) in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of

Consider hydrocortisone 50mg Q6H for 7 to 10 days in patients with hyperdynamic vasopressor-dependent shock despite adequate fluid resuscitation, which may help improve hemodynamic response to catecholamines. If shock resolves more rapidly, the dose may be discontinued sooner.

8.Mechanical Ventilation of Sepsis-Induced ARDS:

That mechanically ventilated sepsis patients be maintained with the head of the bed elevated to 30-45 degrees to limit aspiration risk and to prevent the development of ventilator-associated pneumonia

9. Glucose Control:

Make intensive momitoring to pervent HYPOGLYCEMIC

Physicians liberalize their insulin treatment to keep blood glucose levels less than 150 mg/dL due to concerns of hypoglycemia.

10.Deep Vein Thrombosis Prophylaxis

Patients with severe sepsis receive daily pharmacoprophylaxis against venous thromboembolism (VTE) .

This should be accomplished with daily subcutaneous low-molecular weight heparin in the absence of significant bleeding risk

Patients with severe sepsis be treated with a combination of pharmacologic therapy and intermittent pneumatic compression devices whenever possible (grade

Stress Ulcer Prophylaxis:

Stress ulcer prophylaxis using H2 blocker proton pump inhibitor be given to patients

with severe sepsis/septic shock who have bleeding risk factors .

H2 blocker is the 2nd line

Nutrition Therapy;Maintain blood glucose 100 to 150 through the

use of appropriate caloric support and insulininfusion following initial stabilization.

Do not administer sodium bicarbonate for metabolic (anion-gap) acidosis, such as lactic acidosis if the pH is > 7.15. For a lower pH, consider a trial of 50 to 100 mEq NaHCO3 by slow infusion, with evaluation for improvement in hemodynamic

Importance of Documentation

• Documentation in a manner that is accurate and accessible to all disciplines is imperative:– Necessary for the ongoing treatment of the patient– Necessary to monitor quality of care metrics• Blood cultures before antibiotics• Early, appropriate, adequate antibiotics• Initial fluid resuscitation• Use of vasopressors for hypotension despite

initial fluids

Conclusions

The incidence of Sepsis is increasing.Possible contributing factors : –Use of antibiotics leading to microbial

resistance–More invasive procedures– Increasing use of immunosuppressants

what can you do to protect yourself from sepsis?

1. Make sure you're up-to-date on all appropriate immunizations: Influenza and pneumonia are common precursors to sepsis, and they're highly preventable.

2. Wash your hands regularly: And if you are in the hospital, make sure all health providers wash their hands.

3. Don't take antibiotics for common ailments like colds: Improper antibiotic use creates drug-resistant bacteria that make sepsis dangerous

4.proper care of urinary catheters and IV

Reference

Sepsis book, Authors:

http://www.nlm.nih.gov/medlineplus/ency/article/000668.htm

Harrison’s Internal Medicine Book