Sepsis
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Transcript of Sepsis
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Sepsis And Sepsis Related Syndrome:
Dr Saurav HamalMBBS.
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Objectives• To know definitions of SIRS, sepsis, septic
shock, MODS.• To learn basic pathophysiology of sepsis.• Basic management of Sepsis.
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‘SIRS’(Systemic inflammatory response syndrome);• A clinical response arising from a nonspecific insult manifested by 2 or more of the
following: a. Temp >38ºC or <36ºC b. HR >90 beats/minc. RR >20 breaths/min or PaCO2 <4.5kPa d. WBC >12,000 or <4000 cells/mm3, or >10% immature (band) forms
Definitions:
‘Sepsis’• SIRS in the presence of proven or suspected infection.
• Infection:– Presence of organisms in a closed space or location where not
normally found.
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‘Severe Sepsis’• Sepsis associated with hypotension, hypoperfusion and/or organ-dysfunction.
‘Septic Shock’:- Sepsis with hypotension despite adequate fluid resuscitation.- May be ‘vasodilatory’ and/or ‘distributive’ shock.- Include all patients on vasopressors or inotropic support.
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Sepsis: A Complex Disease
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Infection/ SIRS Sepsis Severe Sepsis Trauma
Infection/ SIRS Sepsis Severe Sepsis Trauma
Sepsis: Defining a Disease Continuum
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Disorder Due to Uncontrolled Inflammation?• Increased inflamatory mediators like IL-1, TNF,
IL-6.• Based on animal studies.• In a study in children with meningococcemia, TNF levels directly
correlated with mortality.• Clinical trials involving TNF anagonist, antiendotoxin antibodies, IL-1
receptor antagonists, cortocosteroids failed to show any benefits.
Pathophysiology of Sepsis
Failure of Immune System to EliminateMicroorganism?
• Shift from inflammatory (ThI) to antiinflammatory response (Th2).• Anergy.• Apotosis of B cells, T cells, Dendritic cells.• Loss of macrophage expression of MHC Class I and co-stimulatory
molecules. • Immunosuppressive effect of apoptotic cells.
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Pathogenesis:-
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• MODS occurs late and is the most common cause of death in patients with Sepsis.
• Lactic acidosis led investigators to think that this is due to tissue ischaemia.
• Minimal cell death in postmortem samples taken from the failed organs of patients with Sepsis.
• Recovery from Sepsis is associated with near complete recovery of organ function, even in organs whose cells have poor regenerative capacity.
• Increased tissue oxygen tensions in various organs (muscle, gut, bladder) in animals and patients with Sepsis.
Multiple Organ Dysfunction Syndrome (MODS)
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Treatment of SepsisIdentify Sepsis as early as possible
Broad Spectrum antibiotics ASAP and Identify source(s) of infection
Identify severity: Vitals, mental status, Lactate, other labs.
Volume and physiologic resuscitation ASAP with GOALS.
Tweak your system so these things happen FAST. Train all providers.
Vital sign/Laboratory alerting systems.
?Biomarkers
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Basic support:-• Airway; Assess the airway, respiration, and perfusion.
• Blood pressure; avoid hypotension, volume resuscitation.
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1. Eradication of Infection:-Choice of Antibiotics; If pseudomonas is an unlikely pathogen, combine- Vancomycin with one of the following:• Cephalosporin, 3rd or 4th generation • Beta-lactam/beta-lactamase inhibitor • Fluroquinolones eg., Levofloxacin.
If pseudomonas is suspected, combine Vancomycin with two of the following :
• Antipseudomonal cephalosporin (e.g cefoperazone).• Antipseudomonal carbapenem (eg imipenem, ).• Antipseudomonal beta-lactam/beta-lactamase inhibitor
(e.g. pipercillin-tazobactam, ).• Aminoglycoside • Fluoroquinolone with good anti-pseudomonal activity .• Monobactam .
Other measure :-
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2.Coticosteroids• Anti-inflammatory actions such as inhibiting the production of
proinflammatory cytokines, enhancing the release of anti-inflammatory mediators.
3.Tight Glycemic Control using insulin.
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Does Everyone Know what to do?Established Core Rx:• Source Control• Antibiotics• Resuscitation• Supportive Care
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Conclusions…• The incidence of Sepsis is increasing.• Possible contributing factors :
– Use of antibiotics leading to microbial resistance.– More invasive procedures.– Increasing use of immunosuppressants.
• There have been new insights into the pathogenesis of Sepsis which could be potential therapeutic targets in the future.
• Treatment of Sepsis includes early institution of antibiotics, volume resuscitation, tight glycemic control, steroids, protein C when indicated.
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