Notesale: Turn your study into money

Document Preview

Extracts from the notes are below, to see the PDF you'll receive please use the links above

---

DR IHEJI CHUKWUNONSO

 Introduction
 Sepsis

2
 Sepsis 3
 Where are we getting it wrong?
 Conclusion
 Literature review
 References

Iheji CC - Sepsis Cascade

 “True

learning always creates a paradox
of promoting disagreement in order to
create a consensus” – Anonymous

 The

field of medicine is an ever evolving
one; not just in practice but even in
acceptable terms and definitions

Iheji CC - Sepsis Cascade

 Among

the terms which have generated so
much controversy is SEPSIS, of which several
modifications have evolved in the past few
decades

 This

presentation is not aimed at adding to
the already existing controversies but
enlighten us on the current trend in SEPSIS

Iheji CC - Sepsis Cascade

 Sepsis

is from a Greek word, “sepsin”
meaning “to make putrid”

 It

is a systemic inflammatory response to
infection – bacteria,viruses, fungi, protozoa,
or rickettsiae

 Sepsis

is one of the causes of the systemic
inflammatory response syndrome (SIRS),
which also has noninfectious causes as well
Iheji CC - Sepsis Cascade

Sepsis is one of the most common deadly conditions
worldwide
 Estimated 20 – 30 million patients afflicted every
year globally
 Every hour, about 1,000 people; each day around
24,000 people; and annually more than 8 million
people die from sepsis worldwide!
 In developing countries, sepsis is considered the
most common cause of mortality among children
accounting for 60-80% of all deaths
...



Iheji CC - Sepsis Cascade

 COLONIZATION

– presence of microorganism
in the body without host response
 INFECTION – presence of microorganism in
the body with some host response usually
local or systemic

Infection

Iheji CC - Sepsis Cascade

 SIRS:

A clinical
response arising
from a nonspecific
insult manifested by
2 of the following:
Temperature
>38
...



Pancreatitis

Burns

Infection

Iheji CC - Sepsis Cascade

Trauma
Others

 SEPSIS:


Known or
suspected
infection

Infection

+


SIRS criteria

Iheji CC - Sepsis Cascade

SIRS

 SEVERE

SEPSIS =
Sepsis with signs of
acute organ
dysfunction

Sepsis
SIRS

Infection

Areas of mottled skin

DIC

Capillary refill >5 secs

AKI

UOP < 0
...


 MODS:

Presence of altered organ function
such that homeostasis cannot be maintained
without medical intervention

Iheji CC - Sepsis Cascade

Iheji CC - Sepsis Cascade

Physiologic
Infection
Inflammation

Biochemical
Severe
Sepsis

Specific Organ
Severity

Iheji CC - Sepsis Cascade

Pre-existing

disease
 Cardiac, Pulmonary, Renal
 HIV
Age (extremes of age)
Gender (males)
Genetics
 TNF polymorphisms (TNF promoter
high secretor genotype)
Iheji CC - Sepsis Cascade

 PHYSIOLOGIC

Heart rate
 Respiration
 Fever
 Blood pressure
 Cardiac output
 WBC
 Hyperglycemia
 Hypoglycaemia


Iheji CC - Sepsis Cascade

 MARKERS

OF
INFLAMMATION
TNF
 IL-1
 IL-6
 Procalcitonin


Lungs
 Kidneys
 CVS
 CNS
 Coagulation



GI
 Liver
 Endocrine
 Skeletal Muscle

















Acute Respiratory Distress Syndrome
Acute Tubular Necrosis
Shock
Metabolic encephalopathy
DIC
Gastroparesis and ileus
Cholestasis
Adrenal insufficiency
Rhabdomyolysis

Iheji CC - Sepsis Cascade

SIRS

Sepsis

Severe Sepsis Septic Shock

-SIRS
-SIRS CRITERIA (≥2 of the ff)

...
5oC or <36oC

...
Tachycardia or Bradycardia (<1yr)

...


 In

lay terms, sepsis is a life-threatening
condition that arises when the body’s response
to an infection injures its own tissues and
organs

 Organ

dysfunction can be identified as an acute
change in total SOFA score ≥2 points
consequent to the infection
...
1 OR Nor ≤ 0
...
1 OR Nor >0
...
2 – 1
...
0 – 5
...
0 – 11
...
0 [>204]

4

If bilirubin is less than 1
...
2 – 1
...
0 – 3
...
5 – 4
...
0 [ >440] (or <200ml/d)

4

Iheji CC - Sepsis Cascade

 SOFA

score ≥2 significant
 An initial score <9 predicted a mortality of
<33%
 An initial score >11 predicts a mortality of
≥95%


SOFA score is a bit complicated




6 organ systems
9 physiologic variables
Total 24 points
Iheji CC - Sepsis Cascade

quick-SOFA )
 Introduced

in Feb 2016 as a simplified
version of the SOFA Score

 It

is an initial way of identifying patients at
high risk for poor outcome with an infection

 qSOFA

simplifies the SOFA score drastically by
only including it’s 3 clinical criteria
Assessment

qSOFA

Low BP (SBP ≤ 100mmHg)

1

High Resp Rate (≥22 br/min)

1

Altered mental state (GCS < 15)

1

Iheji CC - Sepsis Cascade

 The

score ranges from 0 to 3 points

 Score

≥2 was associated with a greater risk of
death or prolonged ICU stay

 qSOFA

gives an alarm that means “don’t
loose time, if you haven’t done anything yet,
please act now”
...


The broad definition of sepsis as the presence
of organ dysfunction due to dysregulated
response to infection was welcome as the
previous notion of sepsis as a pure
inflammatory host response is no longer
physiologically plausible

2
...
The definition of organ
dysfunction, was based on the predictive
validity for death or prolonged intensive care
unit (ICU) stay
Iheji CC - Sepsis Cascade

3
...


The nomenclature simplification: no more
“severe” sepsis but rather only “sepsis”
...


It brought attention to some neglected
variables such as reduced level of
consciousness and low BP as markers of
disease severity and mortality
Iheji CC - Sepsis Cascade

6
...


The main concern generated by the new
definitions is the reduced sensitivity to detect
cases that might have an unfavorable course,
mainly in low and middle income countries
...


The use of variables in SOFA score, even if
limited to clinical and epidemiological studies,
is not simple
...


A third issue is the devaluation of isolated
hyperlactatemia in acute phase of infection as
a metabolic organ derangement
...


Another issue is the new qSOFA score
...
?usefulness in ED
(sensitivity needed); ICU specificity needed
Iheji CC - Sepsis Cascade

 “After

you’ve done a thing the same way for 2
years, look it over carefully
...
And after 10years, throw
it away and start all over” – Alfred Edward
Perlman (New York Times, 3 July 1958)

 Sepsis

3 may not have told the whole story
about sepsis, but this is a time to embrace it
while putting our arsenal ready for better
definition in the near future

Iheji CC - Sepsis Cascade



TITLE: An Emergency Department Validation of the
SEP-3 Sepsis and Septic Shock Definitions and
Comparison With 1992 Consensus Definitions

AUTHORS:Henning DJ, Puskarich MA, Self WH, Howell
MD, Donnino MW, Yealy DM, Jones AE, Shapiro N
 ON: Annals of Emergency Medicine, March 2, 2017




AIM: To evaluate the performance of the SEP-3
definitions for prediction of inhospital mortality in an
emergency department (ED) population and compare
the performance of the SEP-3 definitions to that of
the previous definitions
...
In
accordance with the SEP-3 definitions, the [qSOFA]
score ≥2 and septic shock (vasopressor dependence
plus lactate level >2
...
4

14
...
8

Sensitivity(%)

52

83

Specificity (%)

86

50

Mortality Rate(%)

MORTALITY FOR SEPTIC SHOCK
qSOFA

SIRS

Mortality (%)

23

22

Sensitivity (%)

12

23

Specificity (%)

98
...
6

Iheji CC - Sepsis Cascade

CONCLUSION:
 Both the new SEP-3 and original sepsis
definitions stratify ED patients at risk for
mortality, albeit with differing performances


In terms of mortality prediction, the SEP-3
definitions had improved specificity, but at
the cost of sensitivity

 Use

of either approach requires a clearly
intended target: more sensitivity versus
specificity
Iheji CC - Sepsis Cascade

2


TITLE: Application of the Third International
Consensus Definitions for Sepsis (Sepsis-3)
Classification: a retrospective population-based
cohort study



AUTHORS: Donnelly JP, Safford MM, Shapiro NI,
Baddley JW, Wang HE



JOURNAL: Lancet of Infectious Diseases
...


Iheji CC - Sepsis Cascade

 Of

2593 first infection events, 1526 met SIRS
criteria, 1080 met SOFA criteria, and 378 met
qSOFA criteria
SIRS

SOFA

qSOFA

Incidence per 1000 person-years

8
...
8 events

2
...

 The findings support the use of the SOFA and
qSOFA classifications to identify patients with
infection who are at elevated risk of poor
outcomes
...


2
...


4
...


Kliegman Robert M, Stanton Bonita F, St
...
Nelson Textbook of
Pediatrics; 18th ed
...
Paediatrics And Child
Health in a Tropical Region
...
Getting a consensus: advantages
and disadvantages of Sepsis 3 in the context of middleincome settings
...
2016;28(4):361-365
Mervyn Singer, Clifford S, Christopher Warren Seymour, Manu
Shankar-Hari, Djillali Annane, et al
...

JAMA February 23, 2016 Volume315, No
...

Shukri Kh
...
Bull Emerg Trauma
...

Iheji CC - Sepsis Cascade

Iheji CC - Sepsis Cascade



---