Problem 2

Angelia Christiani
405090078
BURNS
SEPSIS
1. Description
Systemic inflammatory response triggered by an infection
in the host and mediated by chemical messengers:
Decreased peripheral vascular resistance
Elevated cardiac output in response to vasodilatation
Later in septic shock, myocardial depression, and reduced
cardiac output (due to injury at the cellular level or mediators
acting on the heart)
Multiple organ dysfunction syndrome (MODS) if sepsis is
ineffectively treated
Adult respiratory distress syndrome (ARDS)
Acute tubular necrosis and kidney failure
Hepatic injury and failure
Disseminated intravascular coagulation

2. Etiology
Gram-negative bacteria most common:
Escherichia coli
Pseudomonas aeruginosa
Rickettsiae
Legionella species

Gram-positive bacteria:
Enterococcus species
Staphylococcus aureus
Streptococcus pneumoniae
Fungi (Candida species)
Viruses

Pediatric Considerations
Children with a minor infection may have
many of the findings of SIRS.
Major causes of pediatric bacterial sepsis
Neisseria meningitis
Streptococcal pneumoniae
Haemophilus influenzae

3. Classification
Sepsis is classified by the systemic
inflammatory response syndrome (SIRS):
Temperature >38C or <36C
Heart rate >90 beats/minute
Respiratory rate >20/minute or PaCO
2
<32 mm Hg
WBC >12,000/mm
3
, <4,000/mm
3
, or >10% band
forms
Sepsis: two or more of the SIRS criteria with
an underlying infection
Severe sepsis:
Sepsis with organ dysfunction as manifested by
one of the following:
Acidosis
Renal dysfunction
Acute change in mental status
Pulmonary dysfunction
Hypotension
Thrombocytopenia or coagulopathy
Liver dysfunction

Septic shock:
Sepsis-induced hypotension despite fluid
resuscitation
Systolic blood pressure (BP) <90 mm Hg or
reduction of >40 mm Hg from baseline

4. Signs and Symptoms

General:
Fever
Tachycardia
Tachypnea
Hypothermia (poor prognosis)
Hypoxemia
Diaphoresis

Cardiovascular:
BP
Normal early in sepsis
Hypotension when septic shock occurs
Poor perfusion with septic shock:
Prolonged capillary refill
Cool and clammy extremities

Gastrointestinal/Genitourinary:
Abdominal pain
Nausea, vomiting
Diarrhea
Dysuria/Frequency
Reduced urine output
Abdominal tenderness:
Diffuse
Localized to right upper quadrant (liver or gallbladder source)
Right lower quadrant (appendicitis with or without abscess)
Suprapubic area or lower quadrants (urinary tract or pelvic source or
diverticulitis)
Flank pain:
With pyelonephritis or retroperitoneal abscess

Pulmonary:
Shortness of breath
Tachypnea:
Present even when the lungs are not the source of
sepsis
Productive cough

CNS:
Change in mental status
Confusion
Delirium
Coma
Neck stiffness (meningitis)

Dermatologic:
Any rash is important.
Localized erythema with lymphangitis (streptococcal or
staphylococcal cellulitis)
Rash involving palms of hands and soles of feet (rickettsial
infection)
Petechiae scattered on the torso and extremities
(meningococcemia)
Ecthyma gangrenosum (pseudomonas septicemia)
Round, indurated, painless lesion with surrounding erythema
and central necrotic black eschar
Decubitus ulcers
Indwelling catheter:
Surrounding skin erythematous with or without purulent drainage

5. Diagnosis
1. Careful history and physical examination
2. Tests
(A) Lab
Serum lactate:
>4 mmol/L defines severe sepsis
CBC with differential:
Leukocytosis is insensitive and nonspecific.
Neutrophil count <500 cells/mm
3
should prompt isolation
and empiric IV antibiotics in chemotherapy patients.
>5% bands on a peripheral smear is an imperfect indicator
of infection


Hematocrit:
Needed to determine whether adequate oxygen
delivery can be achieved
Patients should be maintained with a hematocrit >30%
and hemoglobin >10 g/dl.
Platelets:
May be elevated in the presence of infection or sepsis-
induced volume depletion
Low platelet count is a significant predictor of
bacteremia and death.

Electrolytes, blood urea nitrogen, creatinine,
glucose:
Low bicarbonate suggests inadequate perfusion.
Renal dysfunction or failure indicates a worse
prognosis.
Ca, Mg, Ph
C-reactive protein
Cortisol level
International normalized ratio/prothrombin
time/partial thromboplastin time

Type and screen
Liver function tests
Arterial blood gas:
Mixed acidbase abnormalities: respiratory alkalosis
with metabolic acidosis
Blood cultures:
From two different sites
One may be drawn through an indwelling central line
(i.e., Broviac).
Urine analysis and culture

(B) Imaging
Chest radiograph:
Determine whether pneumonia is the infectious
source.
Fluffy, bilateral infiltrates may indicate that ARDS
is already present.
Free air under the diaphragm indicates the source
of the infection in intraperitoneal and a surgical
intervention

CT scan of the abdomen and pelvis
Suspicion of abdominal source of infection:
Diverticulitis, appendicitis, necrotizing pancreatitis,
microperforation of the stomach or bowel, or formation of an
intra-abdominal abscess
Abdominal ultrasound:
Indicated for suspected cholecystitis
Pelvic ultrasound:
Tubo-ovarian abscess or
MRI:
May be useful to identify soft tissue infections or epidural
abscess


(C) Diagnostic Procedures/Surgery
Lumbar puncture:
Indicated when meningeal signs are present or altered
mental status without a source of infection
Cerebrospinal fluid analysis:
Cell count and differential, tube 1
Total protein and glucose, tube 2
Culture and gram stain, tube 3
Cell count and differential, tube 4
Depending on the clinical situation: cytology, venereal
disease research laboratory, AFB stain/culture, fungal stain

Central venous access:
Central venous pressure (CVP) and ongoing
measurement of central venous oximetry catheter
may be helpful in guiding resuscitation

6. Treatment
Pre Hospital
Aggressive fluid resuscitation for hypotension
Initial Stabilization
ABCs
Supplemental oxygen to maintain PaO
2
>60 mm
Hg
Intubation and mechanical ventilation if shock or
hypoxia are present
Administer 0.9% NS IV

ED Treatment
Early goal-directed therapy:
500 cc boluses of 0.9% saline up to 12 liters empirically
Place central line
Continue 500 cc saline boluses until CVP >8 cm H
2
O
If the mean arterial pressure <65 mm Hg and CVP >8, then
initiate pressors:
Dopamine or norepinephrine to raise blood pressure
Norepinephrine is preferred if tachycardia or dysrhythmias are
present.
Phenyl epinephrine for cases where shock is refractory to other
pressors

If the ScvO
2
<70 and HCT <30, transfuse 2
units PRBCs.
If ScvO
2
>70 and HCT >30, then add
dobutamine.
Administer antibiotics early based on the most
likely organisms or site of infection.

If no source identified after initial assessment:
Normal immune function:
Second- or third-generation cephalosporin and gentamicin
Nafcillin and gentamicin
Add vancomycin if there is a history of methicillin resistant
staphylococcus aureous or the patient resides in a nursing
facility or there is a history of recent hospitalizations.
Immunocompromised host:
Piperacillin and gentamicin
Ceftazidime and either nafcillin or vancomycin and
gentamicin

If source identified, or highly suspected, treat
the most likely organisms:
Pulmonary source:
Second- or third-generation cephalosporin and
gentamicin, and possibly erythromycin
Intra-abdominal source:
Ampicillin and metronidazole and gentamicin
Cefoxitin and gentamicin
Urinary tract source:
Ampicillin or piperacillin and gentamicin

Pediatric Considerations
Antibiotic therapy based on age:
<3 months (2 drugs): ampicillin and gentamicin or
cefotaxime (50180 mg/kg/d div. q4hq6h)
3 months: cefotaxime or ceftriaxone (50100
mg/kg/d div. q12hq24h)
Initiate vasopressors after no response to 60 mL/kg IV
fluid.
Avoid hyponatremia and hypoglycemia.
Dexamethasone for children with bacterial meningitis:
0.15 mg/kg q6h for 4 days

Admission Criteria
Sepsis with toxicity, septicemia, or septic
shock requires admission generally to an
intensive care unit.

6. Differential Diagnosis

Pancreatitis
Trauma
Toxic shock syndrome
Anaphylaxis
Adrenal insufficiency
Drug or toxin reactions
Heavy metal poisoning
Hepatic insufficiency
Neurogenic shock