Sepsis resident survival guide: Difference between revisions
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==Definition== | |||
:*'''Sepsis = Infection + SIRS''' | :*'''Sepsis = Infection + SIRS''' | ||
Revision as of 21:39, 26 November 2013
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, M.D. [2]
Definition
- Sepsis = Infection + SIRS
- The presence of systemic inflammatory syndrome (SIRS) is due to many factors. The presence of infection increases the chances of sepsis and increase the SIRS criteria .
- The endothelial dysfunction is the main trigger transforming the localized infection into systemic organ dysfunction
- There is no definitive biomarkers have been associated with the endothelial dysfunction of sepsis.
SIRS is diagnosed by 2 or more of the following:
- Tachycardia > 90 bpm
- Tachypnea > 20 breaths per minute or on blood gas, a PaCO2 < 32 mm Hg
- Temperature < 36 (96.8 °F) or > 38 °C (100.4 °F)
- White blood cell count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 109 or > 12 x 109 cells/L), or > 10% band forms (immature white blood cells / bandemia).
Sepsis is diagnosed by at least 1of the following signs of organ failure: [HOME]
- Hypoxemia (arterial oxygen tension [PaO2] < 72 mm Hg at fraction of inspired oxygen [FiO2] 0.21; overt pulmonary disease not the direct cause of hypoxemia)
- Oiguria (urine output < 30 mL or 0.5 mL/kg for at least 1 h)
- Mental status alteration
- Elevated plasma lactate level > 4mg
Severe Sepsis
- Sepsis + organ dysfunction
- Organ damage can present as decreased urine output, acute kidney injury, and elevated liver function tests.
Septic Shock
- Severe sepsis + persistent hypotension after adequate fluid challenge.
Multiple Organ Dysfunction Syndrome (MODS) is the presence of altered organ function in a acutely ill patient whom homeostasis cannot be maintained without intervention.
- The criteria for ALI:[1]
- Oxygenation abnormality with a PaO2/FiO2 ratio < 300
- Bilateral opacities on chest radiograph compatible with pulmonary edema
- Pulmonary artery occlusion pressure < 18 mm Hg or no clinical evidence of left atrial hypertension if PaO2 is not available
ARDS is a more severe form of ALI and is defined similarly but a characteristic PaO2/FiO2 ratio is < 200.
Causes
Life Threatening Causes
Prognosis
- Diabetes and renal disease may explain the higher rates of infection related septic shock.
- Immunosuppression
- Advanced age> 65 year old: a strong correlation exists between the incidence of septic shock in patients older than 50 years.
- Community acquired pneumonia: 48% develop severe sepsis.[7]
- Organ dysfunction is more related to bad prognosis than meeting SIRS criteria. A study found that just meeting SIRS criteria without evidence of organ dysfunction did not predict increased mortality. This concludes the importance of identification of organs dysfunction over the presence of SIRS criteria.[8]
Common Causes
Management
Aggressive therapy with hemodynamic monitoring
Do's
- Appropriate antibiotic administration has a significant influence on mortality.
- Initiating broad-spectrum coverage until the specific organism is cultured and antibiotic sensitivities are determined is important.
Don'ts
References
- ↑ Bernard, GR.; Artigas, A.; Brigham, KL.; Carlet, J.; Falke, K.; Hudson, L.; Lamy, M.; Legall, JR.; Morris, A. (1994). "The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination". Am J Respir Crit Care Med. 149 (3 Pt 1): 818–24. doi:10.1164/ajrccm.149.3.7509706. PMID 7509706. Unknown parameter
|month=ignored (help) - ↑ Jones, GR.; Lowes, JA. (1996). "The systemic inflammatory response syndrome as a predictor of bacteraemia and outcome from sepsis". QJM. 89 (7): 515–22. PMID 8759492. Unknown parameter
|month=ignored (help) - ↑ Brun-Buisson, C.; Doyon, F.; Carlet, J.; Dellamonica, P.; Gouin, F.; Lepoutre, A.; Mercier, JC.; Offenstadt, G.; Régnier, B. (1995). "Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis". JAMA. 274 (12): 968–74. PMID 7674528. Unknown parameter
|month=ignored (help) - ↑ Sands, KE.; Bates, DW.; Lanken, PN.; Graman, PS.; Hibberd, PL.; Kahn, KL.; Parsonnet, J.; Panzer, R.; Orav, EJ. (1997). "Epidemiology of sepsis syndrome in 8 academic medical centers". JAMA. 278 (3): 234–40. PMID 9218672. Unknown parameter
|month=ignored (help) - ↑ Kumar, A.; Roberts, D.; Wood, KE.; Light, B.; Parrillo, JE.; Sharma, S.; Suppes, R.; Feinstein, D.; Zanotti, S. (2006). "Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock". Crit Care Med. 34 (6): 1589–96. doi:10.1097/01.CCM.0000217961.75225.E9. PMID 16625125. Unknown parameter
|month=ignored (help) - ↑ Bernard, GR.; Vincent, JL.; Laterre, PF.; LaRosa, SP.; Dhainaut, JF.; Lopez-Rodriguez, A.; Steingrub, JS.; Garber, GE.; Helterbrand, JD. (2001). "Efficacy and safety of recombinant human activated protein C for severe sepsis". N Engl J Med. 344 (10): 699–709. doi:10.1056/NEJM200103083441001. PMID 11236773. Unknown parameter
|month=ignored (help) - ↑ Dremsizov, T.; Clermont, G.; Kellum, JA.; Kalassian, KG.; Fine, MJ.; Angus, DC. (2006). "Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course?". Chest. 129 (4): 968–78. doi:10.1378/chest.129.4.968. PMID 16608946. Unknown parameter
|month=ignored (help) - ↑ Shapiro, N.; Howell, MD.; Bates, DW.; Angus, DC.; Ngo, L.; Talmor, D. (2006). "The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection". Ann Emerg Med. 48 (5): 583–90, 590.e1. doi:10.1016/j.annemergmed.2006.07.007. PMID 17052559. Unknown parameter
|month=ignored (help)