Sepsis

SEPSIS

By Dr. LORN SAKANA

Emergency department Stung Treng Referral Hospital

Objective:

1. Definition
2. Classification or degree of sepsis
3. Etiology
4. Diagnosis
5. Management
6. Monitoring

Definition:

Systemic Inflammatory Response Syndrom (SIRS):

SIRS criteria: two or more of:

•Temperature more than 38 C or  less than 36 C

•Heart Rate more than 90/min

•Respiratory rate more than 20/min

•WBC > 12,000/mm3 - 4,000/mm3

Not including any other type of inflammation like burn, trauma, SLE, Thyroid storm…

Classification of degree of sepsis:

1. Sepsis
2. Severe sepsis
3. Septic shock

1. Sepsis: Presence of SIRS criteria due a culture or biology proven infection or an infection identify by clinical examination.

2. Severe sepsis: 

                          Sepsis + one of the following signs of:

• Area of mottled skin
• Capillary refill > 3seconds
• Urine output less than 0 -.5-1ml per hour
• Mental status change brutally
• Platelet < 100,000/ml
• Disseminated intravascular coagulation
• Acute respiratory distress syndrom (ARDS)

3. Septic shock:

Sepsis + Hypotension

•Hypotension:

Main Artery Pressor(MAP) less than 60mmHg

Main Artery Pressor(MAP) less than 80mmHg (HTN patient)

Etiology:

Risk factors:

• Compromised immune system: HIV, Cancer, Diabetic...
• Very old and young patient
• Uncompleted antibiotherapy
• Associated with many health problem...

Develop from other infection:

• Respiratory focus
• Abdominal source
• Urinary focus
• Septic arthritis
• Bacteria meningitis
• Skin and soft tissue infection

The most frequent etiological argent:

• Staphylococcus aureus (Rarely non aureus staphylococci)
• Streptococci (Pneumococcus and other)
• E-Coli and other Enterobacteriacease (Klebsiella sp, Enterobacter sp.)
• Salmonella Typhi/Paratyphi A and non-typhoid Samonella
• Burkhoderia pseudomallei (Melioidosis)

Diagnosis:

Clinical argument:

• Predisposing condition: Underlying disease that cause immune deficiency (Diabetic, HIV, steroid use, liver cirrhosis, chronic renal disease, cancer, chemotherapy...)
• Clinical syndroms/sign: Present of SIRS criteria's plus other soft infection:
• Respiratory focus: tachypnea (RR>25/min), signs of consolidation (decrease Breathing sound/vocal vibration, crackle, localized dullness...) 
• Urinary tract infection (UTI): dysuria, urinary frequency and urgency, abdominal pain, altered mental status...
• Septic arthritis: A warm, swollen and painful join(s) with restricted movements...
• Bacteria meningitis: Classic triad (Fever, headache, neck stiffness), Bruzenski's sign, Kernig's sign...
• Skin and soft tissue infection: Skin lesion, cutaneous hemorrhage, blister with dark fluid...

Investigation:

• CBC, Creatinine, Urea, electrolytes, transaminase, blood sugar.
• Blood culture
• Urine analysis, urine microscopic, urine culture
• CSF examination or CSF culture
• Pus culture
• Malaria smear
• Serum amylase (if suspect pancreatitis)
• HIV Test
• Chest X-Ray
• Abdominal ultrasound

Management:

1. Stabilize the patient:

• Stabilize the patient according to ABC (Air ways, Breathing, Circulation)
• IV Fluid resuscitation: NSS or Ringer Lactat
• 20 - 60ml/kg for the first 6 hours (Max 4 - 6L over 24h
• Dopamine 5micrograme/kg/min (max 20 micrograme/kg/min) if IV fluid challenge is unsuccessful at least 3 - 4L in the first 1 - 2h
• If have signs of Disseminate Intravascular Coagulation (DIC) or hypoxia should be  transfusion even Hemoglobin > 7g/dl
• The goal of fluid resuscitation:
• Improve vital signs
• Urine output > 0.5 - 1ml/h

   2.  Treatment causal:

• Sepsis from respiratory focus:
• 1st line: Amoxicilline - clavulanic acide: 1000/250mg    q4-6h (IV)
• 2nd line: Ceftriaxone: 2g   qD (IV)
• If severe sepsis with ARDS: add Gentamicine: 1-2.5mg/kg/dose q8h - q12h (IM/IV)

• Sepsis from abdominal source:
• 1st line: Ceftriaxone: 2g   qD   (IV)
• 2nd line: Amoxicilline - clavulanic acide: 1000/250mg   q4-6h (IV)
• If severe sepsis or septic shock: add Gentamicine: 1-2.5mg/kg/dose q8-12h (IM/IV)

• Sepsis from urinary focus:
• 1st line: Ceftriaxone: 2g  qD  (IV)
• If severe sepsis or septic shock: add Gentamicine: 1-2.5mg/kg/dose q8-12h (If renal function work well)

• Septic arthritis:
• 1st line: 
• Cloxacilline: 2g q4H (IV) + Ampicilline: 2g q4h or Penicilline 4MIG q4h (IV) + Gentamicine loading dose 3mg/kg IV then 1mg/kg q8h

• Sepsis by bacteria meningitis:
• 1st line: Ceftriaxone: 2g q12h (IV)
  if very young or very old and immune deficiency patient: add Ampicilline: 2g q4h (IV)
• Dexamethazone: 8-10mg q8h IV for 5 days

• Skin and soft tissue infection:
• Cloxacilline: 2g q6h (IV)
• In case Penicilline allergy: Limcomicine 600mg q8h (IV)
• If suspect melioidosis:
  Ceftriaxone: 2g q8h (IV)
  Cotrimaxazole 8/40mg/kg q12h (PO) Plus Folic acide 5mg qD (PO)

Monitoring:

•Clinical monitoring:

–Urine output

–Vital signs, Consciousness level

–Blood sugar: if BS > 150mg/dl (finger stick)

•Laboratory monitoring:

–BS (Goal < 150mg/dl)

–Ht > 21%

–CBC, creatinine…

  

Thanks