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Sepsis Syndrome

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. UIHC SICU. UIHC Candida. UIHC CNS. UVA Enterococcus. UVA newborn ICU.

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Sepsis Syndrome

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  1. Sepsis Syndrome Bahram Hajikarim MD/MPH ZUMS Feb 2010

  2. Sepsis and Septic Shock • 13th leading cause of death in U.S. • 500,000 episodes each year • 35% mortality • 30-50% culture-positive blood

  3. Mortality Percentage UIHC SICU UIHC Candida UIHC CNS UVA Enterococcus UVA newborn ICU Johns Hopkins UVA Hospital 0 10 20 30 40 50 60

  4. 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

  5. Multiple Organ Dysfunction Syndrome • Dysfunction of 2 or more systems • Four or more systems - mortality near to 100 percent

  6. 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

  7. Predisposing Underlying Diseases • Heart disease-rheumatic or congenital • Splenectomy • Intraabdominal sepsis • Septic abortion or pelvic infection • Intravenous drug abuse • Immunocompromised

  8. Organisms Responsible for Septic Shock in Relation to Host Factors

  9. Bacteremiain the Preantibiotic Era • Streptococcuspneumoniae • Group A streptococcus • Staphylococcusaureus • Haemophilusinfluenzae • Neisseriamennigitidis • Salmonella spp.

  10. Emergence of Gram-Negative Organisms • Antibiotic pressure on normal flora • Use of invasive devices • Immune suppression

  11. 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

  12. Clinical Manifestations • Fever, chills, hypotension • Hypothermia, especially in the elderly • Hyperventilation - respiratory alkalosis • Diaphoresis, apprehension, change in mental status

  13. History • Community versus hospital-acquired • Prior or current medications • Recent manipulations or surgery • Underlying diseases • Travel history

  14. Approach to Septic Patient • Seek primary site of infection • Direct therapy to primary site • Repeated examination

  15. Skin • Furuncles, cellulitis, bullous lesions • Intravenous sites, phlebitis • Erythema multiforme • Ecchymotic or purpuric lesions • DIC, petechiae • Ecthyma gangrenosum • Purpura fulminans

  16. Cardiovascular Signs • “Warm shock” -  CO,  SVR • “Cold shock” -  CO,  SVR • Anaerobic metabolism - lactic acidemia • Myocardial depressant factor - ??

  17. Pulmonary Signs • Tachypnea • Hyperventilation, respiratory alkalosis • ARDS, respiratory failure • Ventilation-perfusion mismatch • Widened alveolar-arterial oxygen gradient • Reduced lung compliance

  18. Hematologic Findings • Neutrophilic leukocytosis • Leukemoid reaction • Neutropenia • Thrombocytopenia • Toxic granulations • DIC

  19. Renal and Gastrointestinal Signs • Acute tubular necrosis, oliguria, anuria • Upper GI bleeding • Cholestatic jaundice • Increased transaminase levels • Hypoglycemia

  20. 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

  21. Laboratory Studies • Blood cultures • Infected secretions/body fluids • Stool for WBC, C. difficile • Aspirate advancing edge of cellulitis • Skin biopsy/scraping • Buffy coat

  22. Therapy of Septic Shock • Correct pathologic condition • Optimize intravascular volume • Administer empiric antimicrobial therapy • Administer vasoactive drugs

  23. Failure of Fluid Replacement and Vasopressors • acidosis - pH<7.3 • hypocalcemia • adrenal insufficiency • hypoglycemia

  24. 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

  25. Hospital-acquired • Nonneutropenic: 3rd generation cephalosporin + metronidazole, -lactam / -lactamase inhibitor, menopenem all + AG • Neutropenic: Timentin + AG, meropenem + AG; ceftazidime + metronidazole + AG

  26. 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

  27. Immunotherapies for Septic Shock • Corticosteroids • Antiendotoxin monoclonal antibodies E-5, HA-1A • Anti-TNF antibodies • IL-1 receptor antagonists

  28. Other Treatment Modalities • Granulocyte transfusions • Recombinant colony-stimulating factors • Diuretics • Pentoxifylline, ibuprofen, naloxone • Oral nonabsorbable antimicrobial agents

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