SepsisDr .Syed Inayathullah

Head Of ICU Meeqat General Hospital, Medina ,KSA

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Statistics

Over 750,000 cases of sepsis per year in the US

Severe sepsis : 2% of all US hospital discharges

One of the top 10 causes of death in US and 2nd leading cause of death in noncoronary ICU patientsOver 200,000 deaths per year due to sepsis in US

In hospital mortality from approx. 18%-29%

Mortality in septic shock is much higher … 50 %

ProCESS study of 1,341 patients with septic shock …in hospital mortality at 60 days 19.3% and at 90% 32.1%

General risk factors

• IV lines and catheters ( central lines, foleys catheter)

• Mechanical ventilation

• Chronic ulcers and wounds

• Recent surgery

• Severe disease ( cancer, AIDS, liver disease)

• Immunosuppression

• ICU care• Prolonged hospitalization• Postpartum complications ( endometritis, placental retention,cesarean or vaginal wound infection)

• Invasive procedures

• Advance age ( > 65 years)• Alcoholism and IV drug use

Pathophysiology

• Basic terminology

• SIRS: Systemic inflammatory response syndrome

• Sepsis: SIRS from infection

• Severe sepsis: Sepsis + Organ hypoperfusion

• Septic shock: Sepsis + refractory severe hypotension

Infectious or non infectious insult

SIRS

Haemodynamic:Vasodilation

Myocardial depressionRedistribution/shunting

Microvascular:Endothelial function

MicroemboliGut mucosa ischemia

O2 hypoxia:Oxygen

CellMitochondria

Cellular damage/apoptosis

Cardiovascular system effects of SIRS and Sepsis• Hypotension: Activation of endothelial NO synthase + decreased

vasopressin levels --- increased vascular permeability…. Low PVR and hypotension

+ Microvascular injury: Adhesion protein upregulation + impaired anticoagulation+immune cell, fibrinolytic and complement system activation + decreased RBC flexibility microvascular injury, immune complex cell deposition, capillary clogging, decrease o2 transfer capacity, clotting abnormalities =

Organ damage + Shock + Death

Mechanism: Hypo-oxygenation,tissue hypoperfusion Organ damage, MODS Death.

Diagnosis

Septic Shock

• Septic shock = Severe sepsis + hypotension requiring low dose vasopressor despite adequate resuscitation

• Refractory septic Shock = Severe sepsis + hypotension requiring high-dose vasopressors despite adequate fluid resuscitation

• Vasopressor doses in septic shock and refractory septic shock

• Septic shock : MAP < 60mm Hg DA> 5mcg/kg/min, NE < 0.25 mcg/kg/min, Epi<0.25 mc/kg/min

• Refractory shock: MAP < 60mm Hg DA > 15mcg/kg/min, NE >0.25mcg/kg/min, Epi > 0.25mcg/kg/min

management

Antibiotic therapy initially

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