SEPSIS AND SIRS

Definition
SIRS The systemic inflammatory response syndrome is systemic level of acute inflammation that may or may not be due to infection. Sepsis is defined as SIRS in response to infection.

Severe sepsis is sepsis associated with:

organ dysfunction hypotension Organ hypoperfusion

Septic shock Describes sepsis with hypotension despite adequate fluid resuscitation.

Criteria for SIRS

It is characterized by the presence of two or more of the following features:
Temperature >38.3 or <36.0 C Tachypnea (RR>20 or MV>10L) Tachycardia (HR>90, in the absence of intrinsic heart disease) White Blood Cell > 10,000/mm3 or <4,000/mm3 or >10% band forms on differential

Clinical features of sepsis and SIRS

Cardiorespiratory effects
Increased cardiac output Decreased vascular resistance Increased oxygen consumption Fever or hypothermia Tachycardia Tachypnoea

Metabolic or haematological effects

Respiratory alkalosis Deranged liver function Deranged renal function Altered whit cell count and platelets Disseminated intravascular coagulation

Management of Sepsis
Resuscitate: ABCs Restore tissue perfusion Glucose Control Nutrition

RESUSCITATION
Resuscitation ABC; Airway: AMS, unable to protect airway Breathing: Respiratory failure Circulation: Restoration of blood pressure to levels which perfuse core organs.
Sphygmomanometer unreliable Arterial catheter CVP Mixed Venous O2 sat

ESTORE TISSUE PERFUSI

Causes of poor tissue perfusion
Leaky vessels Decreased vascular tone Myocardial depression

Interventions
Volume infusion
Intravenous fluids PRBCs

Vasopressors Inotropes

Intravenous fluid
Either colloids or crystalloids can be used. No evidence to recommend one over the other Use fluid challenges of 300-500 ml of colloid or 500-1000 ml of crystalloid over 30 mins Fluid input-output balance of no value in assessing fluid requirements during first 24 h because of capillary leak Continued until blood pressure, tissue perfusion, and oxygen delivery acceptable or presence of pulmonary edema

vasopressors
If adequate fluid therapy does not restore adequate BP and organ perfusion start vasopressor May also be required transiently before hypovolaemia has been completely corrected in patients who are severely hypotensive, in order to maintain life. Norepinephrineordopamineare agents of choice Vasopressin
Consider in patients with refractory shock despite adequate fluid resuscitation and high dose conventional vasopressors Not recommended as first line therapy Dose: 0.01-0.04 units/min. Higher doses may be associated with myocardial ischaemia, decreased cardiac output and cardiac arrest

inotropes
Dobutamine first choice inotrope for patients with low cardiac output despite adequate fluid resuscitation Should be combined with a vasopressor in hypotensive patients

Glucose Control
Recommends are to keep serum glucose levels < 150

Nutrition
Nutritional support improves wound healing and decreases susceptibility to infection. Nutritional support results in higher lymphocyte counts and higher serum albumin (surrogate markers of immune competency)

Skin sepsis

This rash, called petechia and purpura, may be a sign of bacteria in the bloodstream (bacteremia).