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Sepsis
Continuum of clinical pathophysiology and severity Process rather than an event Mild dysfunction to frank organ failure Changes in the function of every organ system mediated by the host immune system.
Sepsis
Systemic Inflammatory Response SyndromeACCP/SCCM Consensus Temperature >38C or <36 Heart rate >90 bpm Respiratory Rate>20 or PaCO2<32mmHg WBC>12,000/l or <4,000/l
Sepsis
Sepsis: 2 or more Tachycardia >90bpm Rectal temp>38C or <36C Tachypnea(>20bpm) With 1 or more Alteration in mental status Hypoxemia (PaO2<72mmHG at FiO20.21) Elevated plasma lactate Oligouria
Sepsis
Severe Sepsis
Tachycardia >90bpm Rectal temp>38C or <36C Tachypnea(>20bpm) or PaCO2<32mmHg Hypotension despite fluid resuscitation Presence of perfusion abnormalities: lactic acidosis, oligouria, alteration in mental status
Sepsis
Mediators of Sepsis
Lipospolysaccharide (gram-negative bacteria) Lipoteichoic acid (gram-positive bacteria Peptidoglycan Cytokines
IL-1 mediates systemic effects of infection IL-6 effects liver function TNF-- potentiates the activation of neutrophils and macrophages IL-8 regulates neutrophil function, mediates lung injury in sepsis
Sepsis SIRS plus a culture-documented infection Severe Sepsis Sepsis plus organ dysfunction, hypotension, or hypoperfusion (including but not limited to lactic acidosis, oliguria, or acute mental status changes) Septic Shock Hypotension (despite fluid resuscitation) plus hypoperfusion
Cirrhosis
Alcoholism
Diabetes
Steroids Neutropenia
Mucormycosis and Pseudomonas ssp. (malignant external otitis), Escherichia coli Tuberculosis, fungi, herpes virus Enteric GNR, Pseudomonas, Aspergillus, Candida, and Mucor spp., Staphylococcus aureus Listeria, Salmonella, and Mycobacteria spp., herpes virus group (herpes simplex virus, cytomegalovirus, varicella zoster virus)
T-cell abnortmalities
Clinical Manifestations
Fever, chills, hypotension Hypothermia, especially in the elderly Hyperventilation - respiratory alkalosis Change in mental status
History
Community versus hospital-acquired Prior or current medications Recent manipulations or surgery Underlying diseases Travel history
Skin
Furuncles, cellulitis, bullous lesions Intravenous sites, phlebitis Erythema multiforme Ecchymotic or purpuric lesions DIC, petechiae Ecthyma gangrenosum Purpura fulminans
Cardiovascular Signs
Warm shock - CO, SVR Cold shock - CO, SVR Anaerobic metabolism - lactic acidemia
Pulmonary Signs
Tachypnea Hyperventilation, respiratory alkalosis ARDS, respiratory failure Ventilation-perfusion mismatch Widened alveolar-arterial oxygen gradient Reduced lung compliance
Hematologic Findings
Neutrophilic leukocytosis Leukemoid reaction Neutropenia Thrombocytopenia Toxic granulations DIC
Laboratory Studies
Blood cultures Infected secretions/body fluids Stool for WBC, C. difficile Aspirate advancing edge of cellulitis Skin biopsy/scraping Buffy coat
Hospital-acquired
Nonneutropenic: 3rd generation cephalosporin + metronidazole, -lactam / -lactamase inhibitor, menopenem all + AG Neutropenic: Timentin + AG, meropenem + AG; ceftazidime + metronidazole + AG
Septic Shock
Outcomes for Patients on Hospital Wards versus ICUs
Ward patients: Delays in ICU transfer (67 mins.) IV fluid boluses (27 vs 15 mins.) Inotropic agents (310 vs 22.5 mins) Mortality: Wards (70%) vs ICUs (39%) Apache II scores (18.5 vs 24) Candidemia