Septicemia

Septicemia

Dr. Mashfiqul HasanResident (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