sepsis syndrome bahram hajikarim md/mph zums feb 2010
TRANSCRIPT
Sepsis Syndrome
Bahram Hajikarim MD/MPH
ZUMS
Feb 2010
Sepsis and Septic Shock
• 13th leading cause of death in U.S.
• 500,000 episodes each year
• 35% mortality
• 30-50% culture-positive blood
Mortality Percentage
0 10 20 30 40 50 60
UVA Hospital
Johns Hopkins
UVA newborn ICU
UVA Enterococcus
UIHC CNS
UIHC Candida
UIHC SICU
Stages of SepsisConsensus Conference Definition
• Systemic Inflammatory Response Syndrome (SIRS)Two or more of the following:– Temperature of >38oC or <360C
– Heart rate of >90
– Respiratory rate of >20
– WBC count >12 x 109/L or <4 x 109/L or 10% immature forms (bands)
• SepsisSIRS plus a culture-documented infection
• Severe SepsisSepsis plus organ dysfunction, hypotension, or hypoperfusion(including but not limited to lactic acidosis, oliguria, or acute mental status changes)
• Septic ShockHypotension (despite fluid resuscitation) plus hypoperfusion
Multiple Organ Dysfunction Syndrome
• Dysfunction of 2 or more systems
• Four or more systems - mortality near to 100 percent
Factors Associated with Highest Mortality
• Respiratory > abdominal > urinary• Nosocomial infection• Hypotension, anuria• Isolation of enterococci or fungi• Gram-negative bacteremia, polymicrobial• Body temperature lower than 38°C• Age greater than 40• Underlying illness: cirrhosis or malignancy
Predisposing Underlying Diseases
• Heart disease-rheumatic or congenital
• Splenectomy
• Intraabdominal sepsis
• Septic abortion or pelvic infection
• Intravenous drug abuse
• Immunocompromised
Organisms Responsible for Septic Shock in Relation to Host Factors
Asplenia Encapsulated organismsPneumococcus spp.,Haemophilus influenzae,Neisseria meningtidis,Capnocytophagiacanimorsus Babesiosis
Cirrhosis Vibrio, Yersinia, andSalmonella spp., otherGram-negative rods (GNRs),encapsulated organisms
Alcoholism Klebsiella spp.,pnemococcus
Diabetes Mucormycosis and Pseudomonas ssp.(malignant external otitis), Escherichiacoli
Steroids Tuberculosis, fungi, herpes virus
Neutropenia Enteric GNR, Pseudomonas,Aspergillus, Candida, and Mucor spp.,Staphylococcus aureus
T-cell abnortmalities
Listeria, Salmonella, and Mycobacteriaspp., herpes virus group (herpes simplexvirus, cytomegalovirus, varicella zostervirus)
Bacteremia in the Preantibiotic Era
• Streptococcus pneumoniae
• Group A streptococcus
• Staphylococcus aureus
• Haemophilus influenzae
• Neisseria mennigitidis
• Salmonella spp.
Emergence of Gram-Negative Organisms
• Antibiotic pressure on normal flora
• Use of invasive devices
• Immune suppression
Differential Diagnosis of Fever and Shock
• Purulent bacterial pericardial effusion
• Peritonitis
• Pneumonia with severe hypoxia
• Mediastinitis
• Anaphylaxsis
• Staphylococcal toxic shock syndrome
• Streptococcal toxic shock syndrome
Clinical Manifestations
• Fever, chills, hypotension
• Hypothermia, especially in the elderly
• Hyperventilation - respiratory alkalosis
• Diaphoresis, apprehension, change in mental status
History
• Community versus hospital-acquired
• Prior or current medications
• Recent manipulations or surgery
• Underlying diseases
• Travel history
Approach to Septic Patient
• Seek primary site of infection
• Direct therapy to primary site
• Repeated examination
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
• Myocardial depressant factor - ??
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
Renal and Gastrointestinal Signs
• Acute tubular necrosis, oliguria, anuria
• Upper GI bleeding
• Cholestatic jaundice
• Increased transaminase levels
• Hypoglycemia
Acute Physiology and Chronic Health Evaluation
APACHE II
Temp Arterial pH
MAP Serum Na; Serum Cr
Heart rate Hematocrit
Resp. rate WBC
Oxygenation Glasgow Coma Score
Acute physiology score + Age + Chronic health points
Laboratory Studies
• Blood cultures
• Infected secretions/body fluids
• Stool for WBC, C. difficile
• Aspirate advancing edge of cellulitis
• Skin biopsy/scraping
• Buffy coat
Therapy of Septic Shock
• Correct pathologic condition
• Optimize intravascular volume
• Administer empiric antimicrobial therapy
• Administer vasoactive drugs
Failure of Fluid Replacement and Vasopressors
• acidosis - pH<7.3
• hypocalcemia
• adrenal insufficiency
• hypoglycemia
Empiric Antimicrobial Regimens for Sepsis Syndrome
• Community-acquired non-neutropenic– Urinary tract: 3rd generation cepholosporin,
piperacillin, quinolone + AG– Non-urinary tract: 3rd generation
cepholosporin + metronidazole, -lactam/ -lactamase inhibitor + AG
• Hospital-acquired– Nonneutropenic: 3rd generation cephalosporin +
metronidazole, -lactam / -lactamase inhibitor, menopenem all + AG
– Neutropenic: Timentin + AG, meropenem + AG; ceftazidime + metronidazole + AG
Septic ShockOutcomes for Patients on
Hospital Wards versus ICU’s
• 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
JS Lunberg, Crit. Care Med. 26:1020; 1998
Immunotherapies for Septic Shock
• Corticosteroids
• Antiendotoxin monoclonal antibodies E-5, HA-1A
• Anti-TNF antibodies
• IL-1 receptor antagonists
Other Treatment Modalities
• Granulocyte transfusions
• Recombinant colony-stimulating factors
• Diuretics
• Pentoxifylline, ibuprofen, naloxone
• Oral nonabsorbable antimicrobial agents