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Sepsis Syndrome

Sepsis Syndrome. Cynthia L. Gibert, M.D. Washington VA Medical Center Georgetown University Medical Center. 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.

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Sepsis Syndrome

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  1. Sepsis Syndrome Cynthia L. Gibert, M.D. Washington VA Medical Center Georgetown University Medical Center

  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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