SEPSIS

SEPSISBYDR MUHAMMAD AKRAM KHANMATERNITY AND CHILDREN HOSPITALMAUSADIA, JEDDAHDECEMBER 2015

Sepsis OverviewSevere sepsis and septic shock have mortality rates of 30-50%Account for up to 45% of ICU admissionsHigher mortality and incidence than STEMI and strokeComplex pathophysiology which routinely causes shock without significantly abnormal vital signs

INFECTIONmicrobial phenomenon characterised by an inflammatory response to the presence of micro organisms or the invasion of normally sterile host tissue by these organisms

DefinitionsThe ACCP/SCCM consensus conference committee. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992.SIRSWidespread inflammatory responseTwo or more of the followingTemp>38 C90 bpmTachypnea RR>20 or hyperventilation PaCO2 12,00010% immature neutrophils. Sepsis: SIRS + definitive source of infection

SEVERE SEPSISSepsis associated with organ dysfunction, hypoperfusion or hypotensionMay include lactic acidosis,oliguria,altered mentation

SEVERE SEPSISSepsis associated with organ dysfunction, hypoperfusion or hypotensionMay include lactic acidosis,oliguria,altered mentation Systemic response to infection manifested by 2 of:Temp > 38oC or < 36oCHR > 90 bpmRR > 20 bpm or PaCO2 < 32 mmHgWBC > 12 x 109/L, < 4 x 109/L or >10% band form

ORGAN DYSFUNCTIONArterial hypotension SBP 5 mmol/L OR S.lactate > 1.5 x upper value

MODSPresence of altered organ function lasting for > 24 hrs in an acutely ill patient, such that homeostasis cant be maintained without intervention.

MODS

Surviving Sepsis Campaign BundlesTO BE COMPLETED WITHIN 3 HOURS:Measure lactate levelObtain blood cultures prior to administration of antibioticsAdminister broad spectrum antibioticsAdminister 30 mL/kg crystalloid for hypotension or lactate 4 mmol/LTO BE COMPLETED WITHIN 6 HOURS:Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP 65 mmHgIn the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/L :Measure CVPMeasure ScvO2Remeasure lactate if initial lactate was elevated

Liver (& Lung) diseaseAccelerated glycolysisCongenital disordersThiamine deficiencyAnaerobic metabolismToxic and drug effectsExtracellular movement in alkalosisSepsisGlucosePyruvateLactateAcetyl CoAAdrenaline, salbutamolCori cycle

Liver disease decreases the conversion of lactate to glucoseCongenital disorders and toxic/drug effects may affect aerobic metabolism (decrease in krebs cycle and Electron transport chain)Thiamine deficiency reduces the conversion of pyruvate to acetyl CoA by inhibiting PDHAnaerobic metabolism increases lactate production

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Lactate TestingLactate > 4mmol/L is associated with much higher mortality ratesLactate has been proven to be a better indicator of shock, risk, prognosis and mortality than any other vital sign in sepsis

28 day mortality (%)

http://www.laktate.com/wp-content/uploads/2013/09/lactate-plus-meter1.pngp=0.001p65 mm HgUrine output >0.5 mL/kg/hourCentral venous (superior vena cava) or mixed venous oxygen saturation >70% or >65%, respectively

IF CENTRAL VENOUS OXYGEN SATURATION NOT ACHIEVEDFLUIDPRBC ( Hct >30)Vasopressors

DIAGNOSIS

ANTIBIOTICS

HEMODYNAMIC SUPPORT

CVP

MAP

ScvO2