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Septicemia
Dr. Mashfiqul Hasan
Resident (Phase A)
Endocrinology & metabolism
Terminology to describe septic
patient
2
Infection
• Invasion of normally sterile host tissue by
microorganisms
3
Bacteremia
• Presence of bacteria in blood
• Evidenced by positive blood culture
4
Septicemia
• Presence of microbes or toxins in blood
5
SIRS
• Two or more of the following conditions:
– Fever or hypothermia
– Tachypnea
– Tachycardia
– Leukocytosis or leukopenia or >10% bands
• Infectious / Noninfectious
6
Sepsis
• SIRS with proven or suspected microbial
etiology
7
Severe sepsis
• Sepsis with signs of one or more organ dysfunction
– Cardiovascular: hypotension that responds to
administration of IV fluids
– Renal
– Respiratory
– Hematologic
– Unexplained metabolic acidosis
8
Septic shock
• Sepsis with
– Hypotension, for at least 1 h, despite adequate fluid
resuscitation
– Need for vesopressor
9
Refractory septic shock
• Last for >1 hour
• Does not respond to fluid or pressor administration
10
MODS
• Dysfunction of >1 organ
• Requiring intervention to maintain homeostasis
11
12
Inflammatory response to sepsis
13
14
15
APPROACH TO SEPTIC
PATIENT
16
17
18
19
Treatment: Severe Sepsis &
Septic Shock
Antimicrobial agents
• Without delay
• Appropriate
• IV
• Maximal recommended dose
• Local microbial susceptibility 21
Immunocompetent patient
• Any of the following
– Piperacillin-tazobactam
– Imipenem-cilastin or meropenem
– Cefepime
• If allergic to ß lactam agents
– Ciprofloxacin or levofloxacin plus clindamycin
• Vancomycin should be added to each of
the above regimen 22
Neutropenic patient
• Imipenem-cilastin or meropenem or cefepime
• Piperacillin-tazobactam plus tobramycin
• Vancomycin should be added if indicated
• Empirical antifungal therapy if hypotensive or
has been receiving broad spectrum antibiotic
23
Other special situations
• Splenectomy
– Cefotaxime or Ceftriaxone
– Vancomycin plus either moxifloxacin or
levofloxacin or aztreonam
• IV drug user
– Vancomycin
24
Other special situations: cont
• AIDS
– Cefepime or peperacillin-tazobactam
plus tobramycin
– Ciprofloxacin or levofloxacin
plus vancomycin
plus tobramycin
25
Source Control
• Evaluation for a focused infection
• Abscess drainage or tissue debridement
Management of hypotension
• Fluid challenge over 30 min
• 500–1000 ml crystalloid
• 300–500 ml colloid
• Repeat based on response and tolerance
27
Management of hypotension
• Vasopressor therapy
– Titrating dose of norepinephrine or dopamine
– Dobutamine if myocardial dysfunction
28
Steroid
• CIRCI: inadequate corticosteroid activity for the
severity of the illness
• Hypotension that does not respond to fluid
replacement therapy
• Hydrocortisone, 50 mg IV q6h
• If clinical improvement, continue for 5-7 days,
slowly taper
• Hastens recovery from septic shock
• No increase in long term survival
29
Activated protein C
• Approved by USFDA
• Indicated for
– Very sick patient (APACHE II)
– Low risk of hemorrhage
• Complex anti-inflammatory, anti-apoptotic,
anticoagulant effect
• Trials going on 30
Glucose control
– Insulin to lower blood glucose to 100-120
mg/dl is potentially harmful
– Needed only to maintain blood glucose below
150 mg/dl
31
Other measures
• Nutritional supplementation
• Prophylactic heparinization
• Erythrocyte transfusion
– When Hb <7 g/dl
– Target level 9 g/dl
32
Other measures: cont…
• Bicarbonate
• Fresh frozen plasma and platelets
• Ventilator support
• Hemodialysis or hemofiltration
33
Ongoing trials
• IV Ig
• Endotoxin antagonist (eritoran)
• GM CSF
34
35
36
37

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Septicemia

Notes de l'éditeur

  1. Should be started as soon as blood &amp; relevant samples are sent for investigations