Sepsis SyndromesSepsis Syndromes

Sepsis and Septic ShockSepsis and Septic Shock

• 13th leading cause of death in U.S.13th leading cause of death in U.S.• 500,000 episodes each year500,000 episodes each year• 35% mortality35% mortality• 30-50% culture-positive blood30-50% culture-positive blood

Consensus Conference DefinitionConsensus Conference Definition

• Systemic Inflammatory Response Syndrome (SIRS)Systemic Inflammatory Response Syndrome (SIRS)Two or more of the following:Two or more of the following:– Temperature of >38Temperature of >38ooC or <36C or <3600CC– Heart rate of >90Heart rate of >90– Respiratory rate of >20Respiratory rate of >20– WBC count >12 x 10WBC count >12 x 1099/L or <4 x 10/L or <4 x 1099/L or 10% immature forms (bands)/L or 10% immature forms (bands)

• SepsisSepsisSIRS plus a culture-documented infectionSIRS plus a culture-documented infection

• Severe SepsisSevere SepsisSepsis plus organ dysfunction, hypotension, or hypoperfusionSepsis plus organ dysfunction, hypotension, or hypoperfusion(including but not limited to lactic acidosis, oliguria, or acute mental (including but not limited to lactic acidosis, oliguria, or acute mental status changes)status changes)

• Septic ShockSeptic ShockHypotension (despite fluid resuscitation) plus hypoperfusion Hypotension (despite fluid resuscitation) plus hypoperfusion

Multiple Organ Dysfunction Multiple Organ Dysfunction SyndromeSyndrome

• Dysfunction of 2 or more systemsDysfunction of 2 or more systems• Four or more systems - mortality Four or more systems - mortality

near to 100 percentnear to 100 percent

Factors Associated with Factors Associated with Highest MortalityHighest Mortality

• Respiratory > abdominal > urinaryRespiratory > abdominal > urinary• Nosocomial infectionNosocomial infection• Hypotension, anuriaHypotension, anuria• Isolation of enterococci or fungiIsolation of enterococci or fungi• Gram-negative bacteremia, polymicrobialGram-negative bacteremia, polymicrobial• Body temperature lower than 38°CBody temperature lower than 38°C• Age greater than 40Age greater than 40• Underlying illness: cirrhosis or malignancyUnderlying illness: cirrhosis or malignancy

Clinical ManifestationsClinical Manifestations

• Fever, chills, hypotensionFever, chills, hypotension• Hypothermia, especially in the elderlyHypothermia, especially in the elderly• Hyperventilation - respiratory alkalosisHyperventilation - respiratory alkalosis• Diaphoresis, apprehension, change in Diaphoresis, apprehension, change in

mental statusmental status

Cardiovascular SignsCardiovascular Signs

• ““Warm shock” - Warm shock” - CO, CO, SVR SVR• ““Cold shock” - Cold shock” - CO, CO, SVR SVR• Anaerobic metabolism - lactic Anaerobic metabolism - lactic

acidemiaacidemia• Myocardial depressant factor - ??Myocardial depressant factor - ??

Pulmonary SignsPulmonary Signs

• TachypneaTachypnea• Hyperventilation, respiratory alkalosisHyperventilation, respiratory alkalosis• ARDS, respiratory failureARDS, respiratory failure• Ventilation-perfusion mismatchVentilation-perfusion mismatch• Widened alveolar-arterial oxygen gradientWidened alveolar-arterial oxygen gradient• Reduced lung complianceReduced lung compliance

Hematologic FindingsHematologic Findings

• Neutrophilic leukocytosisNeutrophilic leukocytosis• Leukemoid reactionLeukemoid reaction• NeutropeniaNeutropenia• ThrombocytopeniaThrombocytopenia• Toxic granulationsToxic granulations• DICDIC

Renal andRenal and Gastrointestinal Signs Gastrointestinal Signs

• Acute tubular necrosis, oliguria, anuriaAcute tubular necrosis, oliguria, anuria• Upper GI bleedingUpper GI bleeding• Cholestatic jaundiceCholestatic jaundice• Increased transaminase levelsIncreased transaminase levels• HypoglycemiaHypoglycemia

Therapy of Septic ShockTherapy of Septic Shock• Correct pathologic conditionCorrect pathologic condition• Optimize intravascular volumeOptimize intravascular volume• Administer empiric antimicrobial therapyAdminister empiric antimicrobial therapy• Administer vasoactive drugsAdminister vasoactive drugs• Support failing systems.Support failing systems.

Latest advances Latest advances

• Tight glucose control.Tight glucose control.• Early goal directed resuscitation.Early goal directed resuscitation.• Corticosteroids.Corticosteroids.• Activated protein C (?)Activated protein C (?)