بنام خدا

1. بنام خدا

2. کيس بيماردختر 17 ساله است اهل گيلا ن بعلت تب ولرز تکان دهنده دربيمارستان بستری ميگردددرشرح حال بيمار سابقه تالاسمی واسلپکتومی رادر سال قبل ذکر می کند بيمار از 6 روز قبل بطورناگهانی دچار تب ولرز تکان, تنگی نفس شدن , بيمار اسهال نيز دارد سوزش ادرار وتکررادرار ندارد. درمعاينه: T= 39/5 , BP = 110/80 .PR= 140, RR=45

3. درمعاينه بيمار فوالعاده توسيک است کم لنفوژپوری دارد رودوگردن ندارد .درمعاينه ريه کراکل ودرريه ودسمع قلب تاکيکاردی شديددارد , درمعاينه شکم تندرنس در هيپوکنوراست دارد آزمايش اوليه: راديوگرافی ريه : انفليتراسيون وسيع دوطرفه ريه دارد. WBC = 2500 pog =80% Band =%10 SGT = 250 Hb = 8 SLM =140 HCT =24 PT = 15 RBS =150 NU = 135 R = 4/5

4. Sepsis SIRS Two or more of the following conditions 1- Fever > 38 or hypothermia<36 2- Tachypnea >24 3- Tachycardia>90 4- Leukocytosis >12000, or<40000, band>10%

5. Sepsis syndrome • Sepsis with one or more sign of organ dysfunction 1- Cardiovascular: BP90 or mean arterial pressure≤70 2- Renal urine out put <0/5ml/Kg per hours 3- Respiratory: 4- Haematologic :platelet <80000 or 50%decrease in platelet count

6. Sepsis syndrome 5- Unexplained Metabolic acidosis PH≤7.30 or base deficit ≥5meq /L Or plasma lactate Level >1/5 times upper Limit of normal 6- Adequate fluid resuscitation :pulmonary artery wedge pressure ≥12 mmHg or CVP≥ 8mmHg

7. Septic shock 1- Sepsis with hypotension BP<90 Or 40 mmhg less than patients normal blood pressure for at least 1hr despite adequate fluid resuscitation Or 2- Need for vasopressors to maintain systolic blood pressure ≥90 mmHg Mean arterial pressure ≥70 mmHg

8. Refractory septic shock • Septic shock that lasts for >1hr and does not respond to fluid or pressor administration

9. Multiple – organ dysfunction • Dysfunction of more than one organ , requiring intervention to maintain homeostasis

10. Etiology • Gram – Negative bacteria 40% • Gram – positive bacteria 31% • Fungi 6% • Poly microbial 16%

11. Condition that may predispose to Infections Gram- negative bacilli • Diabetic mellitus • Lymphoproliferative diseases • Cirrhosis • Burns • Invasive procedures or devices • Neutropenia • Indwelling urinary catheter • Diverticulitis , perforated viscous

12. Conditions that may predispose to infections Gram – positive bacteria • Intravascular catheters • Indwelling mechanical devices • Burns • Neutropenia • Intra venous drug use • Infection with super antigen – producing streptococcus pyogenes

13. Condition that may predisposeto Infections Fungi • Neutropenia • Broad – spectrum antimicrobial therapy

14. Diagnosis • There is no specific diagnostic test 1- blood culture and other culture 2- Leukocytosis 3- Thrombocytopenia 4- Leukopenia 5- Hyperbilirubinemia 6- proteinuria 7- D- dimer 8- decreased fibrinogen

15. Treatment 1- Hemodynamic support 2- Antibiotic therapy 3- Vasopressors 4- Steroids 5- Human Activated protein C 6- Glucose control 7- Renal Replacement 8- Bicarbonate therapy 9- Deep vein thrombosis prophylaxis 10 - Stress ulcer prophylaxis

16. Treatment 1- Hemodynamic support (goals ) • Central venous pressure 8- 12 mmHg • Mean arterial pressure ≥65 mmHg • Urine output ≥0/5 ml .kg .hr • Central venous mixed venous oxygen saturation≥70%

17. Treatment 2- Antibiotic therapy Immunocompetent adult • Ceftriaxone • Tazocin • Imipenem • Meropenem • Cefepime

18. Antibiotic therapy Allergic to ß lactam agents Ciprofloxacin (IV) plus Clindamycin

19. Antibiotic therapy • Neutropenia • Imipenem • Meropenem + Aminoglycoside • Cefepime • Tazocin • Vancomycin?

20. Antibiotic Therapy Spelenectomy • Ceftriaxone ± Vancomycine Allergic to ß lactam • Vancomycine ± Plus Ciprofloxacin

21. Antibiotic Therapy IV Drug User Nafcillin Or } + Gentamycin Oxacillin MRSA or Allergic to ß- Lactam Vancomycin + Gentamycin