sepsis

Ronald Chrisbianto Gani405090223

Faculty of MedicineTarumanagara University

EMERGENCY MEDICINE BLOCK

SEPSIS SYNDROME

SEPSIS SYNDROMES

DEFINITIONS

• Activated Inflammatory cascade cause the body’d defenses and regulatory system become overwhelmed leading to disruption of hemeostasis

• Systemic Inflammatory Response Syndrome (SIRS) 2 or more : tachycardia, tachypnea, hyperthermia or hypothermia, high or low WBC count, bandemia.

Rosen’s Emergency Medicine 7th Ed

DEFINITIONS

• Sepsis : SIRS + infection• Severe Sepsis : Sepsis + Organ Dysfunction• Septic Shock : Severe Sepsis + hypotension

which is not responsive to fluid challange• Approach : PIRO (predisposition, infection

source, response of host, organ dysfuntion)• Bacteremia is not obligatory in diagnosis of

sepsis


EPIDEMIOLOGY

• In United States :– 10th most common

cause of death– 571.000 cases of severe

sepsis– Mortality rate 20-50%– Incidence


PATHOPHYSIOLOGY

• Infection host response neutrophil and macrophage mobilization to injury site release cytokines inflammatory cascade synthesis is not well regulated sepsis

• Ongoing toxin persistent inflammatory response mediator activation cellular hypoxia, tissue injury, shock, Multi-Organ Failure, death


PATHOPHYSIOLOGY

• Mediators of Sepsis– Proinflammatory : IL-1, IL8, TNF– Anti-inflammatory IL-10, IL-6 TGF B, IL-1ra– Growth promoting

• Arachidonat acid pathway peripheral dilation, vasocontriction, leukocyte and platelet aggregation

• PG fever


PATHOPHYSIOLOGY

• Vasopressin release in stress condition, cause vasoconstriction, osmoregulation, maintenance of normovolemia

• NO Regulating vascular tone, platelet adhesion, insulin secretion, neurotransmission, tissue injurt, inflammation and cytotoxicity


ORGAN SYSTEM DYSFUNCTION AND DEATH


ORGAN SYSTEM DYSFUNCTION

• Neurologic– Altered mental status and lethargy septic

encephalopathy• Cardiovascular– Myocardial depression : killed organism / bacteria– Distributive shock : toxic mediators– Early sepsis : Cardiac output ↑, vascular

resistance ↓– Reversible cardiac function usually in 10 days



• Pulmonary– Right-to-left shunting, arterial hypoxemia,

intractable hypoxemia– Sepsis : High catabolic state + airway resistance

ARDS• Gastrointestinal– Ileus hypoperfusion. ↓ splanchnic blood flow.– Aminotransferase ↑ + bilirubin ↑ hepatic

failure (rare)



• Endocrine– Adrenal insufficiency– IL-1 & IL-6 activate hypothalamic-pituitary axis– TNF-A & corticostatin, depressed bloow flow,

depress pituitary function and secretion• Hematologic– DIC, fibrin deposition, microvascular thrombi– Associated with Protein C


CLINICAL SIGNS & SYMPTOMS

• Identify systemic infection and the source• Altered conciousness intubation• Systemic Infection : tachycardia, tachypnea,

hypo/hyperthermia, hypotension (severe)• Flushed/warm skin while in vasodilation state• Hypoperfused mottled and cyanotic• Shock exclude other shock etiologies• Use MEDS score for risk stratification


MEDS SCORE


SOURCE OF INFECTIONS

• Respiratory (most common) : cough, fever, chills, throat and ear pain, pneumonia, etc

• GI (2nd most common) : abdominal pain, Murphy sign, McBurney Sign, etc

• Neurologic : meningitis• Genitourinary :Flank pain,dysuria,polyuria, etc• Musculoskeletal• IV drug abuse, artificial heart valve, endocarditis


DIAGNOSTIC FEATURES• Hematology– Leukocytosis– Febrile neutropenic admission, isolation,

empirical IV antimicrobial– Bandemiarelease of immature cell from marrow– Ht >30%, Hb >10g/dL– Acute phase platelet ↑– Low platelet shock– Thrombocytopenia, pTT & aPTT ↑, fibrinogen ↓,

DIC & severe sepsis syndrome


DIAGNOSTIC FEATURES

• Chemistry– bicarbonate ↓ acidosis & inadequate perfusion– serum creatinine ↑ ARF– Lactate ↑ inadequate perfusion, shock– Arterial blood gas detect acid base disturbance– Metabolic acidosis inadequate perfusion– Bilirubin ↑ source from gallbladder– Amilase & Lipase ↑ pancreatitis


DIAGNOSTIC FEATURES

• Microbiology– Culture from blood, sputum, urine, CSF, tissue– Obtained before/soon after AB administration– Start with empirical therapy

• Radiology– Chest pneumonia, ARDS– Bowel perforation free air aunder diaphragm– Pneumomediastinum esophageal perforation,

mediastinitis


DIAGNOSTIC FEATURES

– Ct-Scan diverticulitis, appendicitis, necrotizing pancreatitis, microperforation, intra-abdominal abscess

– Head CT septic emboli– Abdominal USG Cholycystitis– Pelvic USG endometritis– Transesophageal USG --> endocaditis– MRI soft tissue


DIFFERENTIAL DIAGNOSIS


MANAGEMENT• Principles– AB therapy– Maintenance of adequate tissue perfusion


MANAGEMENT

• Respiratory Support– Airway protection, intubation, mechanical

ventilatory support if needed• Cardiovascular support– Initial therapy 2L of isotonic crystalloid– Normal Saline/ LR. – Maintain MAP >65mmHg, but 75mmHg in patient

ith history of severe hypertensive patient


MANAGEMENT

– Drugs : Vasopresin, Norepinephrine, Dopamine, Phenylephrine, Epinephrine.

– Inotropic agents : Dobutamine, Bicarbonate, AB• Novel Therapies– Activated Protein C– Steroid Therapy


MANAGEMENT


sepsis

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