by Ihab Tarawa

2. Aims
 Early recognition
 Early goal directed therapy
 Source control
Modified by Ihan Tarawa 01/02/13 2

3. Less than one half of the patients who have signs and symptoms of sepsis have
positive blood culture results.
Fishing in
the dark
Ihab B Abdalrahman 11/16/2011 3

4. Modified by Ihan Tarawa 01/02/13 4

5.  50 year old male smoker
 Right hemicolectomy for colon cancer
 Day 5 post-op
 Temperature 37.2°C
 WCC 15.2
 Respiratory rate 30/min
 HR 110/min
Modified by Ihan Tarawa 01/02/13 5

6.  What is going on?
Modified by Ihan Tarawa 01/02/13 6

7.  Confused
 Oliguric
 BP 80/40
Modified by Ihan Tarawa 01/02/13 7

8. Modified by Ihan Tarawa 01/02/13 8

9.  Although the 1991 Consensus Conference laid
the framework to define sepsis, it had
important limitations.
 The “2 out of 4” criteria for SIRS and the
thresholds were somewhat arbitrary and not
specific to sepsis alone.
 The criteria did not include biochemical
markers, such as CRP, procalcitonin, IL-6, all
of which are elevated in sepsis.
Modified by Ihan Tarawa 01/02/13 9

10.  The criteria for sepsis were revised to include
infection and the presence of any of the
diagnostic criteria.
 These criteria were based on an expansion of
the clinical and laboratory parameters.
Modified by Ihan Tarawa 01/02/13 10

11. Modified by Ihan Tarawa 01/02/13 11

12.  There was no single parameter or set of
clinical or laboratory parameters that are
adequately sensitive or specific to diagnose
sepsis.
Modified by Ihan Tarawa 01/02/13 12

13. Challenge
 Early recognition remains a challenge.
 Tissue hypoperfusion can occur in the
absence of hypotension and could be present
for hours before organ dysfunction manifests.
Modified by Ihan Tarawa 01/02/13 13

14. Spectrum of sepsis
continuum
Modified by Ihan Tarawa 01/02/13 14

15. SIRS
Ihab B Abdalrahman 11/16/2011 15

16. Sever sepsis, SIRS plus organ
dysfunction
Ihab B Abdalrahman 11/16/2011 16

17. Ihab B Abdalrahman 11/16/2011 17

18.  Sepsis is described as an autodestructive
process.
Ihab B Abdalrahman 11/16/2011 18

19. It permits extension of the normal
pathophysiologic response to infection
to involve otherwise normal tissues
and results in MODS.
Ihab B Abdalrahman 11/16/2011 19

20. Severe sepsis & septic shock
 Severe sepsis  Septic shock
 Sepsis  Sepsis
 plus organ dysfunction,  hypotension despite
hypotension or adequate fluid
hypoperfusion resuscitation
 plus evidence of
abnormal perfusion
Modified by Ihan Tarawa 01/02/13 20

21.  What do you want to do for this patient?
 What are your goals?
Modified by Ihan Tarawa 01/02/13 21

22. Management principles
 Early aggressive resuscitation
 Early treatment
 Rapid identification of source of sepsis
 Early source control
 Early, appropriate antibiotics
Modified by Ihan Tarawa 01/02/13 22

23. Initial history
& examination
Further history
& examination
1 hour
Investigations
Resuscitate
Microbiological
specimens
Antibiotics
Modified by Ihan Tarawa 01/02/13 23

24. Need to work rapidly to
achieve goals:
 to administer antibiotics within 1 hour.
 In this time the patient has to be
resuscitated,
 diagnosis made and microbiological
specimens taken
Modified by Ihan Tarawa 01/02/13 24

25. Modified by Ihan Tarawa 01/02/13 25

26. Resuscitate
 Fluid resuscitate
 Fluid challenges
 300-500 ml colloid
 500-1000 ml crystalloid
 Titrate against response (BP & tissue perfusion)
and adverse effects
 Ignore fluid balance in first 24h
Modified by Ihan Tarawa 01/02/13 26

27. Resuscitate
 Vasopressors
 Indications:
 Hypotension not responsive to fluid
 Life threatening hypotension
 Agents:
 Norepinephrine
 Dopamine
 Dobutamine
 Tissue hypoperfusion despite adequate fluid
resuscitation and blood pressure
Modified by Ihan Tarawa 01/02/13 27

28.  CVP 10
 BP 110/50, MAP 65
 Urine output 50 ml/h
 Central venous saturation 65%
Modified by Ihan Tarawa 01/02/13 28

29. Resuscitation Goals
 Initial target:
 MAP ≥65 mmHg
 CVP 8-12 mmHg (12-15 if ventilated)
 Rise of 3-5 mmHg after fluid challenge
 Urine output ≥0.5 ml/kg
 If central venous saturation <70%
 transfusion of packed cells to achieve a haematocrit
≥0.3
 dobutamine
Modified by Ihan Tarawa 01/02/13 29

30. Likely sources of sepsis
 Chest
 Intra-abdominal
 Urinary tract infection
Modified by Ihan Tarawa 01/02/13 30

31. Source of sepsis
 Breathless, bilateral crackles
 Abdomen soft
 Urine dipstick:
 WBC 0
 Protein +
Modified by Ihan Tarawa 01/02/13 31

32. Modified by Ihan Tarawa 01/02/13 32

33. Investigations
 Other radiology depending on history and
examination
Modified by Ihan Tarawa 01/02/13 33

34. Investigations
 Microbiology
 Blood cultures
 2 sets
 Strict asepsis
 20 ml blood sample
 Urine specimen
 Other cultures depending on clinical features
Modified by Ihan Tarawa 01/02/13 34

35. Treatment
 Assess every patient for a source of infection
that is amenable to source control measure
Modified by Ihan Tarawa 01/02/13 35

36. Treatment
 Source control
 Percutaneous or open drainage
 Excision
 Debridement
 Removal of potentially infected devices
Modified by Ihan Tarawa 01/02/13 36

37. Treatment
 Antibiotics
 Early
 Initially cover all likely organisms
 Local flora and sensitivity patterns
 After appropriate microbiological specimens have
been taken
Modified by Ihan Tarawa 01/02/13 37

38. Likely organisms
 Source
 Environment
 Community
 Healthcare facility
 Intensive Care
 Local factors
 Patient factors
 Co-existing illness
 Previous antibiotics
 Immunosuppression
Modified by Ihan Tarawa 01/02/13 38

39. Antibiotics
 Healthcare associated peritonitis
 More resistant flora
 Similar organisms to those seen in other
nosocomial infections
Modified by Ihan Tarawa 01/02/13 39

40. Antibiotics
 Re-assess
 Clinical response
 Microbiological results
 Aim to use narrower spectrum
Modified by Ihan Tarawa 01/02/13 40

41. Antibiotics
 Penetration
 Aminoglycosides and glycopeptides have
relatively poor tissue penetration
 Most agents have poor CNS penetration unless
meninges inflammed
 Adverse effects
Modified by Ihan Tarawa 01/02/13 41

42. Antibiotics
 Dual therapy
 Pseudomonas aeruginosa
Modified by Ihan Tarawa 01/02/13 42

43. Activated protein C
Withdrawn
Modified by Ihan Tarawa 01/02/13 43

44. Other Support Modalities
 Steroids
 Glucose control
 Early RRT in those AKI

45. Other Support Modalities
 Early feeding
 enteral feeding lowers risk of infection and
improves survival compared with delayed feeding
in the critically ill.
 Other studies demonstrate the superiority of
enteral over parenteral feeding in critically ill
patients, with respect to costs and complications,
including risk of infection

46. Summary
 Early recognition
 Early resuscitation
 Early identification of source
 Early appropriate antibiotics
 Early source control
Modified by Ihan Tarawa 01/02/13 46