Sepsis

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Sepsis
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• 54 year old man with a past history of smoking
  and diabetes presents to the emergency department
  with a one week history of progressive
  unwellness.
• He describes fever and chills over the last three
  days with cough and swelling around his left
  ankle.
• At the triage desk, his blood pressure is 83/44,
  heart rate 105, and oxygen saturations 87

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• Does this patient have sepsis?
• What is the definition of SIRS, sepsis, severe
  sepsis, and septic shock?

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• SIRS Two or more of the following
• Temperature gt38.5 or lt35.0
• Heart rate gt90
• Respiratory rate gt20 or PaCO2 lt32
• WBC gt12 or lt4 or gt10 bands
• Sepsis SIRS in response to documented infection

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• Severe Sepsis Sepsis and at least one of the
  following signs of organ hypoperfusion or
  dysfunction
• Mottled skin
• Capillary refill gt 3 seconds
• Urine output lt 0.5 mL/kg for at least one hour
• Lactate gt 2 mmol/L
• Change in mental status
• Platelet count lt 100
• DIC
• ARDS
• Cardiac dysfunction on echocardiogram
• Septic Shock Severe sepsis and MAP lt 60 mmHg
  and need for vasopressors

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• After bringing the patient into the acute care
  area of the ER, he appears more tachypneic and
  confused.
• What should you do next?

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• After starting flush oxygen and inserting two
  IVs, the patient continues to be confused,
  hypotensive, tachycardic and tachypneic.
• Initial ABG pH 7.21, PCO2 27, PO2 95, HCO3 14,
  lactate 5.2
• WBC 19.3, Bands 21
• Creatinine 213, Urea 17.3

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• This patient meets the criteria for sepsis. What
  are the possible sources?
• What should be done within the next hour?
• Why is source control and early antibiotics
  critical in sepsis?
• After securing the airway, inserting a central
  line and arterial line, starting antibiotics and
  sending cultures, the patients CVP is 4.
• Is this a problem and what should be done?

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• After giving 2 litres of normal saline, the CVP
  is 10 but the MAP is 60 mmHg.
• Is this acceptable and what should be done about
  it?
• Levophed is started and titrated to a goal of 65
  mmHg. The central venous saturations are now
  56.
• What would you do next?

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• What is the pathophysiological relationship
  between inflammation and complement activation,
  coagulation, and antifibinolysis?
• What adjunct treatments can be used in sepsis to
  modulate the inflammatory system?
• What is the role of other supportive therapies
  such as steroids, vasopressin, and insulin?

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Questions??