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Sepsis
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Very common occurrence in patients with infection

Case presentation
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75 year old male
2 days post CABG - fever and SOB (after extubation)
His cxr shows
o Still has central line
o Surgical emphysema on both sides
o Taken at 8 am – showed effusion pretty common after thoracic surgery
 Within 4 hrs had 2 chest drains put in due to rapidly increasing pleural
effusions and v unwell
 Still see surgical emphysema
 NG tube
 and central line
Within 2 hrs his feet v severe necrosis of peripheries
o Hand shows severe necrosis of tips – tipps died off
 Blistering is reaction to severe ischemia
MRSA grown from all blood cultures taken and pleural spaces
o Septic shock 2ry to Staph aureus
o patient died within 36hrs
o Shows aggressiveness of some organisms to result in cathastorphic events

Contents:
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What is sepsis?
Mechanism of sepsis
What causes sepsis
Recognising sepsis
Management of sepsis

What is sepsis? IMP TO REMEMBER BY HEART
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Is a potentially deadly medical condition characterised by a Systemic inflammatory response
syndrome (SIRS) caused by severe infection
o It is SIRS 2ry to infection
o Carries high mortality rate

SIRS
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Can happen in a no of sever conditions eg
...
Can be so unwell secondary to infections without a
temp
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Vascular injury, increased permeability /hypotension
2
...
with toxic
shock syndrome, get Staphyloccal infection produce toxin, can give severe
sepsis)

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o
o
o
o

o

or endotoxin eg
...

Release cytokines eg
...

o Host innate immune system depends on pt’s genetic influences
o Eg
...

o Eg
...


Diagnosis:
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High index of suspicion
o If ppt tells you feeling unwell, and looks unwell; pulse rate high? Tachypnea? could be from sepsis
Is the patient looking sick

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For most septic pts, diagnosis begins as a clinical suspicion needing proof
o First of an inflammatory process
o Secondaly of a microbial disease

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Example:
This pt was extemly obese, high temp, not looking too unwell
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Tachypneia
ABG taken
Pt was diabetic
Non blanching rash ie petichal hemorrhagic rash
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jane way lesions in hand
Staph aurus grown from blood
Eventually found to have hip infected which had to be excised completely
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o Say most likely organisms here are urinary organisms, and these are contracted
from perineum: ie
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If not eating, get secondary bowel
dysfunction coz food not reaching lumen and enterocytes not sustaining themselves
...
if he is stressed won’t be
able to pump up enough steroids for physiological needs: thus cortisol deficiency
In sepsis give low dose steroids
o High dose not gd coz immunosuppresses patient
Management: low dose steroids decrease duration of shock and in hospital mortality

Sepsis maangemtn
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Empirical antimicrobials based on an intelligent guess
General supportive care

Antibiotic general principles
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What is the most likely source? (to target part organisms)

Source of sepsis
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Retrospectively, around 20% of infections originate form each of
o Respiratory
o Intra-abdominal
o Urinary tract sources
imp gd history from patient/relatives
At least 20% unknown source
The earlier the better
o Give antibiotics within the hour

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Immediately take cultures (body fluids/blood) and start antibiotics
Treatment within 4 hrs of admission reduces mortality and length of stay
Delay in hypotensive pt increases mortality by 7
...
If meningitis, neeed penetrate BBB” doxycycline wont penetrate CSF

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Is dosing right? renal/hepatic dysfunction?
o Usually , to descalate when patient gets better
o And when we get back growth
o In dosing the patient, need to know kidney function
o first doses don’t make difference: first and second doses can be high
o by time get renal and hepatic function back, can readjust
o IF PT IN RENAL FAILURE, ONE BIG DOSE WONT HARM THEM

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Is pt allergic?

Antibiotic in sepsis
Initial choice of antibiotics has a major bearing on mortality
Hit hard and then de-escalate as necessary

Take home messages on sepsis

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