Septicemia

Septicemia

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  SEPTICEMIA BY – AKHILESHKUMAR ROLL NO. - 06 Guided by Dr . MUKESH RANA Sir Dr . BRIJESH Sir Dr . ASIF AKHTAR Sir Dr . JAVED Sir Dr . RAJESH Sir
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  • 1.INFECTION -invasion of normally sterile host tissue by microorganisms • 2.BACTEREMIA - 1. presence of bacteria in blood 2.evidenced by positive blood culture • 3.SEPTICEMIA – presence of microbes or toxins in blood . • Yet sepsis arose in response to many pathogens , and septicaemia was neither a necessary condition nor a helpful term • 4. SIRS ( SYSTEMIC INFLAMMATORY RESPONSE SYNDROME) WHICH ENTAILS TWO OF – a. TEMPERATURE OVER 38⁰C OR UNDER 36⁰C b. pulse rate >90 beats/minute c. RR >20 BREATHS/MINUTE OR PCO₂ < 4.3kPa (32.5 mmHg) d. WBC >12 or 4 × 109 /L • 5.SEPSIS – sepsis is a dysregulated host response to infection that leads to acute organ dysfunction • 6. SEPTIC SHOCK - SEPSIS + HYPOTENSION ( SBP < 90 mmHg or a fall of more than 40 mmHg from baseline that is not responsive to fluid challenge or due to another cause)
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  CRITERIA IN 2016FOR SEPSIS AND SEPTIC SHOCK sepsis Septic shock Suspected (or documented) infection and an acute increase in >2sepsis related organ failure assessment ( SOFA) points Suspected or documented infection + vasopressor therapy needed to maintain MAP at >65 mmHg and serum lactate >2.0 mmol/L despite adequate fluid resuscitation
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  CAUSES OF SEPSIS •Sepsis largely results from host response to microbial lipopolysaccharide , peptidoglycans , lipoproteins or superantigens • It may be community acquired and hospital acquired infection BACTERIAL FUNGAL PARASITIC Staph. Aureus Candida spp. Falciparum malaria Coagulase negative staphylococci Histoplasma capsulatum Babesia microti Streptococcus pneumoniae Other dimorphic fungi Strongyloides stercoralis Neisseria meningitidis Hyperinfection syndrome E.coli , other gram negative bacteria C. difficile Mycobacterium tuberculosis Etc.
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  PATHOGENESIS • The specificreaction of each patient depends on pathogen ( load and virulence ) and host (genetic composition and comorbidity) Pro-inflammatory reactions cause tissue damage Anti-inflammatory reactions Enhanced susceptibility for secondary infection sepsis
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  • Septicemia isa potentially life threatening infection in which large amount of bacteria are present in the blood . It is commonly referred to as blood poisoning ……….. • It may be due to a primary infection (e.g. pneumonia) or it may be the result of clinical interventions for other conditions (e.g. immunosuppressive drugs , chemotherapy , invasive lines) people who are most susceptible are 1. very young , older people 2. weakened immune system(HIV , cancer , cancer therapy) 3. chronic illness – diabetes , lung disease and kidney disease 4. recent surgery and transplant 5. severe burns or other physical trauma 6. INVASIVE LINES : INTRAVENOUS OR ARTERIAL , NASOGASTRIC TUBES
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  CLINICAL FEATURE Early signsof sepsis include • Fever , shivering , or feeling cold • Fast heart rate • FAST BREATHING AND SHORTNESS OF BREATH • SWEATY OR CLAMMY SKIN • CHANGES IN MENTAL STATE , FEELING SLEEPY , CONFUSED , OR LOSING INTEREST
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  IF MEDICAL ATTENTIONIS NOT ACCESSED AT ONCE , SEPTICK SHOCK MAY OCCUR SYMPTOMS ARE a. FEELING DIZZY OR FAINT b. BEING CONFUSED OR LOSING ALERTNESS c. UNUSUAL MENTAL CHANGES , INCLUDING A FEELING OF DOOM OR A FEAR OF DEATH d. SLURRIED SPEECH e. DIARRHEA , NAUSEA, OR VOMITING f. SEVERE MUSCLE PAIN AND EXTREME OVERALL DISCOMFORT g. DIFFICULTY BREATHING h. PASSING VERY LITTLE URINE i. COLD CLAMMY AND PALE OR MOTTLED SKIN j. COLD AND PALE R UNUSUALLYWARM EXTREMITIES k. LOSS OF CONSCIOUSNESS
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  DIAGNOSIS • LABORATORY ANDPHYSIOLOGICAL FINDINGS tachycardia (heart rate > 90 beats/min.) tachypnea ( RR >20 breaths / min.) hypotension (SBP < 100 mmHg) hypoxia leucocytosis ( WBC count > 12,000 / ꙡL) leukopenia ( WBC count <4000 / ꙡL) many features of acute organ dysfunction such as platelet count total bilirubin or serum lactate hypoalbuminemia troponin elevation hypoglycaemia hypofibrinogenemia
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  Diagnostic criteria • Onceinfection is suspected clinicians consider SOFA score for organ dysfunction SOFA score - widely studied in the ICU among patients with infection , sepsis, shock range from 0 to 24 Because SOFA score requires multiple laboratory tests and may be costly to measure repeatedly the quick SOFA score is proposed Quick SOFA score - for outside the ICU patients , ward , and emergency department range from o to 3 > 2 indicate sepsis
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  SOFAvariables SBP SERUM CREATININE Pa0₂ platelets Glasgow comascale bilirubin Mechanical ventilation Vasopressor present /absent Vasopressors >1 SIRSvariables Heart rate RR temperature WBC
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  ELEMENTS OF CAREIN SEPSIS AND SEPTIC SHOCK (international consensus guidelines) • -- RESUSCITATION INFECTIVE CONTROL RESPIRATORY SUPPORT Iv crystalloid (30 ml/ kg) Microbiologic culture before antibiotics Target tidal volume 6ml/kg Haemodynamic assessments Iv antibiotics within 1 hr In severe sepsis prone position is recommended Norepinephrine (DOC) for vasopressor Narrowed once pathogen identified Conservative fluid strategy in sepsis induced ARDS Dobutamine in persistent hypoperfusion Routine use of pulmonary artery catheter not recommended RBC transfusion if Hb concentration <7.0 gm/dl Spontaneous breathing trials
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  EMPIRICAL THERAPY • SEPSISWITHOUT A CLEAR FOCUS 1. SEPTIC SHOCK - vancomycin (15 mg/kg )+ gentamicin( 5 mg/kg /day) either piperacillin / tazobactem or cefepime 2. Post splenectomy sepsis - ceftriaxone + vancomycin 3. Babesiosis - clindamycin + quinine  Sepsis with skin findings 1. Meningococcemia – penicillin (4 mU q4h) or ceftriaxone (2 g q12h) 2. RMSF – doxycycline 100 mg bid 3. Erythroderma :toxic shock syndrome – vancomycin (15 mg/kg) + clindamycin (600 mg q8h)
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  • Sepsis withsoft tissue findings 1.Necrotizing fasciitis – vancomycin (15mg/kg) + clindamycin (600 mg q8h) + gentamicin (5 mg/kg/day) 2.Clostridial mynecrosis – penicillin (2 mU q4h) + clindamycin (600mg q8h)  Neurologic infection 1. Bacterial meningitis – ceftriaxone (2 g q12h) + vancomycin (15 mg/kg q12h) 2. Brain abscess – vancomycin (15 mg/kg q12h) + metronidazole (500 mg q8h) + ceftriaxone (2g q12h) 3. Cerebral malaria – artesunate (2.4 mg/kg iv at 0 , 12, and 24 h : then once daily) or quinine (Iv 20 mg salt/kg then 10 mg/kg q8h) 4. Spinal epidural abscess – vancomycin (15 mg/kg q12h) + piperacillin/tazobactem or cefepime  Acute bacterial endocarditis – (ceftriaxone 2 g q12h) + vancomycin (15 mg/kg q12h)