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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
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
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.
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