Response to foreign bodyResponse to foreign body

Inflammatory reactionInflammatory reaction– LocalizedLocalized– GeneralizedGeneralized

Generalized inflammatory reactionGeneralized inflammatory reaction– InfectiveInfective– NoninfectiveNoninfective

Sepsis: Generalized inflammatory, having Sepsis: Generalized inflammatory, having systemic signssystemic signs

Systemic Inflammatory Systemic Inflammatory Response Syndrome (SIRS)Response Syndrome (SIRS)

Patient presents with Patient presents with two or moretwo or more of the of the following criteria. following criteria. – temperaturetemperature > 38°C or < 36°C > 38°C or < 36°C – heart rate heart rate > 90 beats/minute > 90 beats/minute – respirationrespiration > 20/min or PaCO2 < 32mm Hg > 20/min or PaCO2 < 32mm Hg – leukocyte count leukocyte count > 12,000/mm3, < > 12,000/mm3, <

4,000/mm3 or > 10% immature (band) cells 4,000/mm3 or > 10% immature (band) cells

DefinitionDefinitionSepsis:Sepsis: SIRS SIRS plusplus a documented a documented infection site (documented by positive infection site (documented by positive culture for organisms from that site). Blood culture for organisms from that site). Blood cultures do cultures do NOTNOT need to be positive. need to be positive. While SIRS, sepsis, and septic shock are While SIRS, sepsis, and septic shock are associated commonly with bacterial associated commonly with bacterial infection, bacteremia may not be present.infection, bacteremia may not be present.

Septic Shock: Sepsis-induced Septic Shock: Sepsis-induced hypotension despite fluid resuscitation hypotension despite fluid resuscitation

PLUS hypoperfusion abnormalitiesPLUS hypoperfusion abnormalities

The infection site helps in determining the most likely cause of a patient's sepsisThe infection site helps in determining the most likely cause of a patient's sepsis

Suspected Source of SepsisSuspected Source of Sepsis

   LungLung AbdomenAbdomen Skin/Soft TissueSkin/Soft Tissue Urinary TractUrinary Tract CNSCNS

Major Community Major Community Acquired PathogensAcquired Pathogens

Streptococcus Streptococcus pneumoniaepneumoniae Haemophilus Haemophilus influenzaeinfluenzae Legionella sp.Legionella sp. Chlamydia Chlamydia pneumoniaepneumoniae

Escherichia coliEscherichia coli Bacteroides fragilisBacteroides fragilis

Streptococcus Streptococcus pyogenespyogenes Staphylococcus Staphylococcus aureusaureus Clostridium Clostridium sp. sp. Polymicrobial Polymicrobial infectionsinfections Aerobic gram Aerobic gram negative bacilli negative bacilli Pseudomonas Pseudomonas aeruginosaaeruginosa Anaerobes Anaerobes StaphylococcusStaphylococcus sp. sp.

Escherichia coliEscherichia coli KlebsiellaKlebsiella sp. sp. EnterobacterEnterobacter sp. sp. ProteusProteus sp. sp.

Streptococcus Streptococcus pneumoniaepneumoniae Neiserria Neiserria meningitidismeningitidis Listeria Listeria monocytogenesmonocytogenes Escherichia coliEscherichia coli Haemophilus Haemophilus influenzaeinfluenzae

Major Nosocomial Major Nosocomial pathogenspathogens

Aerobic gram Aerobic gram negative bacillinegative bacilli

Aerobic gram Aerobic gram negative bacilli negative bacilli Anaerobes Anaerobes CandidaCandida sp. sp.

Staphylococcus Staphylococcus aureusaureus Aerobic gram Aerobic gram negative bacillinegative bacilli

Aerobic gram Aerobic gram negative bacilli negative bacilli Enterococcus Enterococcus sp.sp.

Pseudomonas Pseudomonas aeruginosaaeruginosa Escherichia coliEscherichia coli Klebsiella Klebsiella sp. sp. Staphylococcus Staphylococcus sp.sp.

Mechanism Mechanism

Organ Dysfunctions associated with Organ Dysfunctions associated with

Severe Sepsis and Septic Shock:Severe Sepsis and Septic Shock: LungsLungs: early fall in arterial PO2, capillary-leakage into alveoli; tachypnea, hyperpnea (ARDS).KidneysKidneys :(acute renal failure): oliguria, anuria, azotemia, proteinuria LiverLiver: elevated levels of serum bilirubin, alkaline phosphatase,cholestatic jaundice HeartHeart: cardiac output is initially normal or elevated, BrainBrain : confusion

Organ Dysfunctions contd:Organ Dysfunctions contd:

Digestive tract: Digestive tract: nausea, vomiting, diarrhea nausea, vomiting, diarrhea and ileus and ileus Skin: Skin: ecthymaecthyma gangrenosumgangrenosum (think (think Pseudomonas aeruginosa Pseudomonas aeruginosa in neutropenic in neutropenic patients), patients),

Petechia or purpura: Petechia or purpura: (think (think Neisseria Neisseria meningitidismeningitidis or or

Rickettsia rickettsia: Rickettsia rickettsia: (if evidence of tick (if evidence of tick bite)), Hemorrhage or bullous lesions bite)), Hemorrhage or bullous lesions

Toxic Shock Syndrome: Staphylococcus Toxic Shock Syndrome: Staphylococcus aureusaureus or or Streptococcus pyogenesStreptococcus pyogenes

Adult respiratory distress syndrome (ARDS) Disseminated Intravascular Coagulation (DIC) Acute Renal failure (ARF) Intestinal bleeding Liver failure Central Nervous system dysfunction Heart failure Death

Complications: Complications:

When to suspectWhen to suspect

Fever or unexplained signs with Fever or unexplained signs with malignancy or instrumentation malignancy or instrumentation

Hypotension Oliguria or anuria Hypotension Oliguria or anuria

Tachypnea or hyperpnea Hypothermia Tachypnea or hyperpnea Hypothermia without obvious cause without obvious cause

Bleeding Bleeding

High fever and bounding pulse, rigor, High fever and bounding pulse, rigor, purpuric rash, tachypnoeapurpuric rash, tachypnoea

THERAPYTHERAPY

Immediate Stabilization of the Patient.Immediate Stabilization of the Patient.

The blood must be rapidly cleared of The blood must be rapidly cleared of microorganismsmicroorganisms

The original focus of infection must be The original focus of infection must be treatedtreated. .