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Sepsis

Sepsis. 54 year old man with a past history of smoking and diabetes presents to the emergency department with a one week history of progressive unwellness. He describes fever and chills over the last three days with cough and swelling around his left ankle.

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Sepsis

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  1. Sepsis

  2. 54 year old man with a past history of smoking and diabetes presents to the emergency department with a one week history of progressive unwellness. • He describes fever and chills over the last three days with cough and swelling around his left ankle. • At the triage desk, his blood pressure is 83/44, heart rate 105, and oxygen saturations 87%

  3. Does this patient have sepsis? • What is the definition of SIRS, sepsis, severe sepsis, and septic shock?

  4. SIRS – Two or more of the following: • Temperature >38.5 or <35.0 • Heart rate >90 • Respiratory rate >20 or PaCO2 <32 • WBC >12 or <4 or >10% bands • Sepsis – SIRS in response to documented infection

  5. Severe Sepsis – Sepsis and at least one of the following signs of organ hypoperfusion or dysfunction: • Mottled skin • Capillary refill > 3 seconds • Urine output < 0.5 mL/kg for at least one hour • Lactate > 2 mmol/L • Change in mental status • Platelet count < 100 • DIC • ARDS • Cardiac dysfunction on echocardiogram • Septic Shock – Severe sepsis and MAP < 60 mmHg and need for vasopressors

  6. After bringing the patient into the acute care area of the ER, he appears more tachypneic and confused. • What should you do next?

  7. After starting flush oxygen and inserting two IVs, the patient continues to be confused, hypotensive, tachycardic and tachypneic. • Initial ABG: pH 7.21, PCO2 27, PO2 95, HCO3 14, lactate 5.2 • WBC 19.3, Bands 21% • Creatinine 213, Urea 17.3

  8. This patient meets the criteria for sepsis. What are the possible sources? • What should be done within the next hour? • Why is source control and early antibiotics critical in sepsis? • After securing the airway, inserting a central line and arterial line, starting antibiotics and sending cultures, the patient’s CVP is 4. • Is this a problem and what should be done?

  9. After giving 2 litres of normal saline, the CVP is 10 but the MAP is 60 mmHg. • Is this acceptable and what should be done about it? • Levophed is started and titrated to a goal of 65 mmHg. The central venous saturations are now 56%. • What would you do next?

  10. What is the pathophysiological relationship between inflammation and complement activation, coagulation, and antifibinolysis? • What adjunct treatments can be used in sepsis to modulate the inflammatory system? • What is the role of other supportive therapies such as steroids, vasopressin, and insulin?

  11. Questions??

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