Sepsis Flashcards
What is necrotizing fasciitis?
Flesh eating bacteria!
Not common in vet med however in dogs the agent is Streptococcus canis
Definition of sepsis
Infection + organ dysfunction
Dysregulated host response to infection
Presence of an infectious etiology and the presence of clinical signs (indicating systemic involvement)
Approach to sepsis
Individualized!
Each patient is different; there is no cook-book solution
What is included in a SOFA score (3 things)
Hypotension
Altered mental status
Tachypnea
Note: can also do bloodwork to look at arterial blood gas, BUN, lactate, bilirubin, platelet count
Definition of septic shock
Hypotension requiring vasopressors to regulate/maintain adequate blood pressure
Vasopressor example: norepinephrine
Old definition of sepsis and why it is not used anymore
Sepsis = infection + SIRS (Systemic Inflammatory Response Syndrome)
SIRS is too broad
SIRS Criteria (4 things)
Tachycardia
Tachypnea
Hypo or hyperthermic
Leukocytosis or leukopenia
What is MODS?
Multiple Organ Dysfunction Syndrome
Physiologic derangements of the endothelial cardiopulmonary, renal, nervous, endocrine, and/or GI systems
Once this starts occuring in a patient, most likely have reached the point of no return (MODS + SIRS + DIC)
Common causes of sepsis in dogs
Diabetes
Hypoadrenalcorticism
GI Tract
Respiratory Tract
Common causes of sepsis in cats
FIP
FeLV
CKD
Cholangitis
Diagnosis of sepsis (5 things)
Fever/hypothermia (cats) Tachycardia/Bradycardia (cats) Altered mental status Edema or positive fluid balance Hyperglycemia (cats initially)/Hypoglycemia
Cat lethal triad
Hypothermic
Hypotensive
Bradycardic
Early Septic Shock
Dog
Tachycardia Tachypnea Hyperemia Decreased CRT Pyrexia
Warm phase
Early Septic Shock
Cat
Lethargic Bradycardic Hypothermic Pale mucous membranes Weak pulses Hypotensive
Early Decompensated Sepsis
Clinical Signs
Sympathetic system not compensating Pale mm Poor pulse quality Hypotension Hypoperfusion Mental depression Hyperlactaemia Endothelial dysfunction
Late Decompensated Septic Shock
Clinical Signs
Hypothermia
Stuporous/comatose
Pale mm, no CRT
Poor pulse quality
MODS
Examples
AKI
Respiratory failure
Loss of vasomotor tone
Cardiac impairment
What is hemostasis?
Balance between pro-coagulation and anticoagulation
Maintain blood free of clots but allow clots to form when needed
Endothelium is responsible for this
Organ dysfunction:
Cardiovascular
Increased permeability of vasculature
Impaired cardiac contractility
Loss of vascular tone
Where does fluid leak?
Abdomen, tibiotarsal joint, SQ space
Cats: chest, pulmonary effusion
Organ Dysfunction:
Respiratory
Endothelial and epithelial injury
Accumulation of protein rich fluid in the alveoli
Decreased microvascular perfusion
Acute lung injury (ALI)
Acute Respiratory Distress Syndrome (ARDS)
Organ Dysfunction:
Renal
Acute tubular necrosis secondary to renal ischemia
Tissue injury may be due to ischemia-reperfusion injury
Kidneys need high blood flow (receive 20% of CO)
Look for decreased urine production
Organ Dysfunction:
Neurological
Poorly understood
Reduction of cerebral blood flow
Capillary leakage and damage of the blood brain barrier
Organ Dysfunction:
GI
Ileus, poor tolerance to enteral feeding, vomiting, diarrhea, GI ulceration, melena, hematochezia
May need liquid diet with prokinetic
Organ Dysfunction:
Hepatic
Hypoalbuminemia Coagulopathies Hypoglycemia Icterus Mental depression Encephalopathies
Organ Dysfunction:
Endothelium
Increased vascular permeability
Decreased vascular tone due to endothelial dysfunction
Rx: now trying Vitamin C
Diagnosis of Sepsis
CBC
Leukocytosis (bands-left shift, toxic neutrophils, degenerative neutrophils)
Anemia (especially in cats)
Thrombocytopenia (consumption, sequestration)
Activation of hemostasis (hypercoagulable then hypocoagulable)
Diagnosis of Sepsis
Chemistry
Hyperbilirubinemia
Hyperglycemia followed by hypoglycemia
Hypoalbuminemia
Other evidence of organ failure (MODS)
Note: liver is a sympathetic organ, sensitive to hypoxia
How to treat Sepsis
3 classes of drugs
Treat ASAP
Antibiotics
Vasopressors
Ionotropes
How to treat Sepsis
Antibiotics
First submit samples for culture and sensitivity
Empiric broad spectrum/4-quadrant to start then wean off when tests return (want to avoid resistance)
How to treat Sepsis
Vasopressors
Epinephrine (bradycardic and decreased systolic function) Norepinephrine Dopamine Vasopressin Phenylphrine
How to treat Sepsis
Ionotropes
Dobutamine (helps with cardiac contractility)
How to treat Sepsis
Other Rx Considerations
Glucocorticoids; physiologic dose may be okay, assists with vascular response to vasopressors
Critical illness-related corticosteroid insufficiency (adrenal insufficiency)
Vitamin C to help endothelium (work still being done)
