Sepsis Infection, local symptoms.

Pneumonia, cough; UTI, dyuria When the effects of inflammation from the infections become systemic, consider sepsis. (Note that sepsis is not septicemia -meaning that blood cultures can be negative and still have sepsis. Inflammatory mediators affect entire body). Risk Factors: 1. 2. 3. 4. Bacteremia. If bacteria in blood, systemic consequences of infection. Advanced age. >65 Diabetes and cancer and immunosuppression Genetic factors- defects of antibody production, or lack of phagocytes or T cells.

SIRS criteria, must have 2/4 criteria met Inflammatory mediators, vasodilation 1. Increases cardiac output-HR, >90 2. Increased RR>20, or Pco2<32 As you might expect in infection: Temp >38, WBC >12 Or in patients who are very sick, with HIV, or about to die: Temp <36, WBC < 4 Beyond SIRS criteria, must look at end organ damage. How bad is the inflammatory response? 1. Kidney, BUN/cr 2. Brain, MSE. 3. Liver, LFTs+coags 4. cardiovascular system: HR, BP

So now we rank sepsis into severity: SIRs = two or more criteria, even without source of infection Sepsis = two or more criteria, with identified source. Remember dont need bacteria in bloodstream, just intended source. Severe Sepsis= two or more criteria, with a source, but with at least one or more organ damaged. Septic shock= IVF failed or pressor fails to bring BP up Patients die of septic shock, but before they die, they go into MODS, in which they have 2 or more organs fail. Treatment is called early goal directed therapy, one study suggests that meeting these goals can decrease mortality: 1. 2. 3. 4. CVP 8-12, enough venous return to maintain CO MAP>65, determining how well arteries are perfusing end organs Urine output cc/kg/hr, good indicator of fluid status of patient Venous02>70%, meaning the body is extracting less than 30% of oxygen and meeting metabolic demands.

How to maintain goals: 1. 2. 3. 4. 5. IVF, getting them quickly .5-1 liter Remove all sources of infection: PIC lines, urinary catheters O2, as much as they require, may need ventilation If fluids fail, use pressors Empiric antibiotics while waiting for cultures. *****Recently, using external cooling methods seems to suggest efficacy, using ice packs or ice-cold bed sheets to achieve a core body temperature. Study shows with these methods you have decreased 14 day mortality and that your more likely to have vasopressor dose lowered and shock reversed.

1. Early goal-directed therapy in the treatment of severe sepsis and septic shock. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group. N Engl J Med. 2001;345(19):1368 2. Fever control using external cooling in septic shock: a randomized controlled trial. Schortgen F, Clabault K, Katsahian S, Devaquet J, Mercat A, Deye N, Dellamonica J, Bouadma L, Cook F, Beji O, Brun-Buisson C, Lemaire F, Brochard L. Am J Respir Crit Care Med. 2012;185(10):1088.

3. Internal Medicine: Essentials for Students