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Tim IGD RSSA 2011

Sepsis is a systemic response to infection.


Be diagnosed two or more of the following
 Respiratory rate >20 breaths/min or
PaCO2 <4.3 kPa.
 Heart rate >90 beats/min.
 Temperature >38ºC or <36ºC.
 WBC>12,000 cells/mm3, <4000
cells/mm3, or >10 percent immature
forms.
 Plus suspected or confirmed infection
 Severesepsis is present when organ
dysfunction, hypoperfusion (e.g. lactic
acidosis, oliguria, or an acute alteration
in mental status) or hypotension (systolic
BP <90mmHg) .
 Septic shock is broadly defined as the
development of hypotension and organ
failure as a result of severe infection.
 Septic shock is a clinical diagnosis,
confirmed by positive blood cultures
in only a proportion of cases.
 Specific clinical features:
 • Auscultation may reveal evidence of
pneumonia or endocarditis.
 • Abdomen - tenderness, peritonitis.
 • Skin - rash, petechiae in meningoccaemia.
 • Skin: cellulitis, evidence of IVDA.
 • CNS: Photophobia and neck stiffness in
meningitis.
 • Urinary tract symptoms? Loin pain?
 • Lines - Intravascular
 • Trauma
• Airway: usually secure initially unless
reduced conscious level.
• Breathing: tachypnoea is common and an
early sign.
Circulation:
 Tachycardia and hypotension .
 In early shock there is peripheral
vasodilatation and increased cardiac output.
 In advanced septic shock cardiac output
falls due to hypovolaemia,(+/- myocardial
depression) and the skin becomes cold,
cyanotic and mottled with increased
capillary refill time.
 If unresponsive to volume resuscitation the
patient is at high risk of death.
 Disability
- GCS, pupils, focal
neurological signs.
• Community-acquired sepsis: Coliforms,
Streptococcus pneumoniae,
 Neisseria meningitidis, Staphylococcus
aureus. Group A Streptococcus.
• In hospital patients or recently
discharged patients MRSA is increasingly
encountered as are multi-resistant gram
negatives.
• Clostridium difficile may develop up to 8
weeks after antibiotic.
 In patients with abdominal sepsis, mixed
infection with coliforms, anaerobes.
 In patients with neutropenia, Pseudomonas
aeruginosa must be covered.
 Splenectomised patients are at particular
risk from capsulated organisms
(Streptococcus pneumoniae, Haemophilus
influenzae, Neisseria meningitidis) and
severe malaria.
 Seek advice from ID or Microbiology if
unusual freatures – travel history, animal
contact, IVDU.
 Blood cultures.
 Chest X-ray
 Urine: dipstick for WCC and nitrites
 Pus, wound swabs
 Sputum
 CSF
 Blood (EDTA or clotted) PCR if meningitis
suspected
 Stool if diarrhoea
 FBC,CRP
 High concentration oxygen  SpO2 >96%.
 Secure adequate IV access and commence
volume replacement  Saline 0.9% or colloid
 Take blood cultures x2
 start appropriate IV antibiotics.
 Draw venous blood for FBC, U&Es, glucose,
clotting.
 Check arterial blood gases and blood lactate.
 Insert a urinary catheter.
 Observe carefully for fluid overload and be
aware of the possibility of acute renal failure.
 Remove or drain any obvious source of infection
such as an abscess or infected IV line.
 Septic shock unresponsive to oxygen
therapy and initial volume loading has
a high mortality. Invasive monitoring
and vasopressor therapy are likely to
be necessary.
 CALL ICU EARLY.
Thank You