05-06 Sepsis (Ch 27)

Question 1

What is sepsis?

Answer 1

infection + SIRS

Question 2

Definition & Causes of SIRS

Answer 2

Definition of SIRS (Systemic Inflammatory Response Syndrome)

• 2+ disturbances of temp, HR, RR/PaO2, or WBC

Causes

• # 1 = INFECTION
• Endogenous organ damage (pancreatitis)
• Immune system freak-out (lupus)
• Trauma
• Misc (thyroid storm, e.g.)

Question 3

What is septic shock?

Answer 3

sepsis + SBP < 60mmHg

Question 4

REVIEW the epidemiology of sepsis

Answer 4

Not that uncommon, hits fast and hard, can kill even young and healthy people

• Treatments have not improved much reccently

Question 5

DESCRIBE the predominant causes of sepsis

• Classes of organisms
• Infectious syndromes/diseases

Answer 5

Organisms

• Most sepsis is caused by bacteria
• Some by yeast & fungi
• Not really by viruses

Diseases

• # 1 is pneumonia (36%)
• # 2 is 1° bloodstream infx, e.g. endocarditis (20%)
• # 3 is intra-abd (19%)
• # 4 is UTI (13%)
• # 5 is skin/soft tissue (7%)
• rest “other”

Question 6

Pathophysiology of sepsis

• Four immunologic responses that become maladaptive

Answer 6

Four immunologic responses that become maladaptive

1. BVs dilate
   
   • INTENT: improve tissue perfusion
   • RESULT: low BP
2. BVs leaky
   
   • INTENT: improve WBC diapedesis
   • RESULT: low BP
3. Cytokine chorus
   
   • INTENT: recruit help
   • RESULT: runaway imm resp
4. Sympathetic storm
   
   • INTENT: route blood to critical areas
   • RESULT: ischemia in “non-crit” areas

Maladaptive Coagulation

• Causes DIC (disseminated intravascular coagulation)

Superimposed Tissue Injury –> Further inflamm freak-out

Organ Damage

• Examples: renal failure, digital necrosis, AMS, abnl LFTs etc.

**Cause of Death **= multi-organ system failure

Question 7

REVIEW the clinical manifestations of sepsis

Answer 7

• hypotension
• tachy
• temp

Question 8

REVIEW the diagnosis of sepsis

Answer 8

.

Question 9

DESCRIBE the role of body fluid cultures in the systematic work-up of sepsis

Answer 9

If you can’t find the source of infection, culture everything:

• urine to r/o UTI
• sputum to r/o pneumonia
• CSF to r/o meningitis
• blood to r/o bacteremia

Question 10

DESCRIBE the role of imaging in the evaluation of patients with sepsis

DESCRIBE the role of common imaging modalities in the systematic work-up of sepsis

Answer 10

Check for source of unknown infection using CT (e.g. liver abscess, pleural empyema, etc.) and MRI (e.g. to r/o necrotizing fasciitis)

Question 11

REVIEW the treatment of sepsis

DESCRIBE the antibiotic and other treatments of sepsis

Answer 11

Treat quickly!

Start w/ antibiotics: tx for the known infection (which is likely the cause of sepsis)

• If source of infx is not obvious hunt for it quickly (empyema w/ that pneumonia? CT it! MRI leg maybe there’s necrotizing fasicitis, etc.)

Maintain hemodynamic stability

• IV fluids (crystalloids; little evidence to support giving blood or colloids)
• pressors (NE or vasopressin)

Good ICU Care

• maintain tight glucose control
• ventilate, PRN
• hemodialysis, PRN
• prevent harm: DVTs, contractures, line infxs, psychosis, etc.

Consider adjuvant steroids and activated protein C

Question 12

REVIEW the role of drainage of pus in the management of sepsis

Answer 12

If you find collections of pus, e.g. empyema, you need to drain in addition to abx Rx