Sepsis
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Sepsis. Presentation to Clinical Officers at Lewanika Hospital in Mongu Western Zambia [via Skype] February 2014 Dr Glynn Jones on behalf of OKAZHI. Goals of this presentation.

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Sepsis

Sepsis

Presentation to Clinical Officers at Lewanika Hospital in Mongu Western Zambia [via Skype] February 2014

Dr Glynn Jones on behalf of OKAZHI


Goals of this presentation

Goals of this presentation

  • At the end of this presentation participants will have an understanding of the patho - physiology of sepsis, leading to early recognition and treatment

  • The importance of the first 2 hours will be emphasized


Definitions

Definitions


Infection

Infection

  • Is the invasion of normally sterile tissue by organisms


Bacteremia

Bacteremia

  • Is the presence of viable bacteria in the blood


Sepsis1

Sepsis

  • Is defined as the presence [probable or documented] of infection together with systemic manifestations of infection


Diagnostic criteria for sepsis

Diagnostic criteria for sepsis

  • Include infection [documented or suspected] and some of the following:

    • Temperature > 38.3 or < 36o Celsius

    • Heart rate > 90 beats/min or more than 2 standard deviations above normal value for age

    • Tachypnea, respiratory rate > 20 breaths/min

    • Altered mental status

    • Significant edema

    • Hyperglycemia


Inflammatory variables

Inflammatory variables

  • Leukocytosis [WBC count > 12,000 ] or leukopenia [WBC count <4000]

  • Plasma C reactive protein, Procalcitonin


Hemodynamic variables

Hemodynamic variables

  • Arterial hypotension [systolic BP < 90 mmHg]


Organ dysfunction variables

Organ dysfunction variables

  • Arterial hypoxemia

  • Acute oliguria [urine output <0.5 ml/kg/hr for at least 2 hours despite adequate fluid resuscitation]

  • Coagulation abnormalities

  • Thrombocytopenia

  • Hyperbilirubinemia


Tissue perfusion variables

Tissue perfusion variables

  • Hyperlactatemia

  • Decreased capillary refill or mottling


Symptoms of malaria

Symptoms of Malaria


Meningitis

Meningitis


Management during the first 2 hours

Management during the first 2 hours

  • Recognize – Clinical diagnosis of severe sepsis or septic shock

    • Suspected infection

    • Hypotension (systolic blood pressure<

    • 90mmHg] and one or more of the

    • following:

      pulse> 100bpm

      respiratory rate >24

      abnormal temperature [<36o or >38o C]


Fix the physiology

Fix the physiology

  • Oxygen:

    • titrate toSpO2 90

  • Fluids:

    • After initial bolus of 1000ml continue rapid fluids LR or NS at 20ml/kg/hr up to 60ml/kg within the first 2 hours.


Treat infection

Treat infection

  • Urgent empirical antimicrobials

  • Antibiotics

  • Antimalarials

  • Influenza – specific antiviral if suspect influenza


Identify source of infection

Identify source of infection

  • Use sign or symptoms to consider source

  • Malaria test

  • TB or AFB smear of sputum, if cough

  • CXR, Gram – stain sputum

  • Send blood for cultures


Monitor record

Monitor Record

  • Every 30 minutes until stable then every hour

  • SBP pulse

  • Respiratory rate

  • SpO2

  • Mental status

  • JVP, auscultate for crackles


Check results of emergency laboratory

Check results of emergency laboratory

  • If hemoglobin < 7 mg/dl [Hct <20]

    • consider transfusion

  • If glucose < 3 mmol/l

    • then give D50 [25 – 50 ml] iv


If respiratory function declining increasing rr falling spo 2

If respiratory function declining [increasing RR, falling SpO2]

  • Check oxygen supply

  • If JVP elevated and/or increasing crackles

    • consider fluid overload


Take home message

Take Home Message

  • Sepsis is common

  • Be vigilant

  • Recognize and intervene early

  • Early intervention yields results and gives the best chance of avoiding progressing down the sepsis pathway ending in multi organ failure and death.


Thank you for your attention

Thank you for your attention


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