Sepsis and Septic Shock

According to the latest Surviving Sepsis Campaign 2016 Guideline, sepsis is defined as life-threatening organ dysfunction caused by dysregulated host response to infection, while septic shock is its subset with circulatory and cellular/metabolic dysfunction associated with higher mortality risk.

Below is a mind map to show you the scary effect bacteria causing a series of event leading to sepsis --> septic shock and eventually death if left untreated or treated late.


The main effect of sepsis is vasodilation (arterial and venous), increased vascular permeability, global tissue hypoxia causing lactic acidosis and cellular injury, which leads to multi organ dysfunction.

Recognizing sepsis



Complications
1. Acute respiratory distress syndrome (ARDS)
2. Acute kidney injury
3. Disseminated intravascular coagulation (DIC)
4. Chronic renal failure
5. Mesenteric ischemia
6. Myocardial ischemia and dysfunction
7. Liver failure

Investigations
1. Initial lab studies

  • Full blood count with differential: high/low WBC (immunocompromised may have low WBC), Hb maintain above 7g/dl, platelet is an acute phase reactant, hence will be raised in inflammatory state. However, it will fall if sepsis is persistent and DIC may develop.
  • Coagulation studies: PT and aPTT (to watch out for DIC), it will be elevated in DIC
  • Blood urea and serum electrolytes + creatinine levels: To assess for dehydration
  • Blood glucose level: Hyperglycemia increases mortality
  • Serum lactate: Best marker of tissue perfusion, associated with mortality
  • Liver function test: check for complication
2. Microbiology studies
  • Blood cultures: at least 2 obtained before commencement of antibiotics, with one percutaneously drawn and the other obtained through vascular access (unless the device was inserteed <48 hours beforehand)
  • Urinalysis and urine culture: TRO occult UTI
  • Gram stain and culture: source from CSF, sputum, wounds, respiratory secretions or any body fluid, at least 1ml
3. Plain radiography
  • Chest Radiograph (TRO pneumonia/ARDS)
4. Ultrasonography
To look for source of infection like acute cholecystitis/asceding cholangitis
Echo can be used for cardiac evaluation.

5. CT & MRI
TRO intraabdominal abscess/retroperitoneal cause of infection
TRO raised ICP before lumbar puncture

6. Lumbar puncture

If meningitis/encephalitis is suspected

Treatment
1. Fluid resuscitation (30ml/kg for first 3 hours - crystalloids, albumin if needed) and frequent assessment of haemodynamic status
- Target MAP of 65mmHg
2. Start antibiotic early - for 7-10 days
3. Give vasopressor if needed
Norepinephrine, if needed + epinephrine/vasopressin
Hydrocortisone- only if patient is not responsive to fluid + vasopressors
4. Glucose control with insulin if needed
5. Adequate nutrition (enteral/IV glucose)
6. Mechanical ventilation if needed


Comments

Post a Comment

Popular posts from this blog

Ortho Fracture Series 1: Proximal Humerus Fracture

Image
The new Ortho Fracture Series will cover the most important type of fractures. It is a compilation of info from various websites and textbook. In our very first series, we will look into proximal humerus fracture. It comprise of 4-6% of all fractures and the third most common fracture in elderly with females having higher incidence (2:1 ratio). Increasing age is also a risk factor for women. Understanding anatomy The 5 most important parts of proximal humerus: Greater tuberosity Lesser tuberosity Humeral head Anatomical neck (the epiphyseal plate) - located distal to the head of the humerus, at an oblique angle to the shaft of the humerus (fracture here,although rare, may lead to avascular necrosis) Surgical neck -  most frequently fractured  site of the proximal humerus (so surgeon operate here more often, hence the name, surgical neck), putting the  axillary nerve  and  posterior circumflex humeral branch  of the axillary artery at risk. Muscle around proxi
Read more

Baby gerak ok? (Approach to Reduced Fetal Movement)

Image
Very often reduced fetal movement causes anxiety to mothers. They are often worried something might have gone wrong to their child. Let's us dive into this topic to understand more about it and hopefully may help future mothers to alleviate their anxiousness. So, how do we define fetal movement? Fetal movement, defined as any discrete kick, flutter, swish or roll, is very subjective. It is usually based on maternal perception and varies according to individual. Most mothers will be able to feel the movement by 20 weeks of gestation (primiparous:18-20 weeks or later than 20 weeks, multiparous: ~16 weeks onward). These movements would increase until 32nd week and will then be plateau. During afternoon and evening periods, the fetal movement is at its peak. After moving much, there will of course be a sleeping period, which could last for 20-40 minutes, rarely exceeding 90 minutes, and occur throughout day and night. Presence of fetal movement symbolises the maturity of central ne
Read more

Cold Sweat Series 1: Oxygen Desaturation

Image
Nurse A: Dr, Dr! Patient desat.... New Dr : >< ohhh..desat..desat...what to do? God, please help me save this patient Below is the overview of the approach in this case Treatment: 1. Identify underlying cause 2. Supplementary oxygen maintain Pa02 at 60-80mmHg / SPO2 of 92-100%  to avoid oxygen toxicity as PaO2 of >80% is not proven to improve oxygen delivery and hence unnecessary Oxygen toxicity is concentration and time-dependent Lowest FiO2 should be used as FiO2 >60% leads to inflammatory changes, alveoli infiltration and then pulmonary fibrosis Nasal cannulae: 1-6L/min of oxygen (because 6L/min is adequate to fill the nasopharynx) - Fi02<40% Fi02>40% is delivered via oxygen mask with a reservoir Remember the oxygen dissociation curve? In the context of anesthesiologists, there are a few important points in the curve. They are ICU point, mixed venous point, arterial point, and P50. Definition of each term is as follows: ICU point
Read more