Sepsis
54 year old man with a past history of smoking
and diabetes presents to the emergency
department with a one week history of
progressive unwellness.
He describes fever and chills over the last three
days with cough and swelling around his left
ankle.
At the triage desk, his blood pressure is 83/44,
heart rate 105, and oxygen saturations 87%
Does this patient have sepsis?
What is the definition of SIRS, sepsis,
severe sepsis, and septic shock?
SIRS – Two or more of the following:
– Temperature >38.5 or <35.0
– Heart rate >90
– Respiratory rate >20 or PaCO2 <32
– WBC >12 or <4 or >10% bands
Sepsis – SIRS in response to documented
infection
Severe Sepsis – Sepsis and at least one of the
following signs of organ hypoperfusion or
dysfunction:
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Mottled skin
Capillary refill > 3 seconds
Urine output < 0.5 mL/kg for at least one hour
Lactate > 2 mmol/L
Change in mental status
Platelet count < 100
DIC
ARDS
Cardiac dysfunction on echocardiogram
Septic Shock – Severe sepsis and MAP < 60
mmHg and need for vasopressors
After bringing the patient into the acute
care area of the ER, he appears more
tachypneic and confused.
What should you do next?
After starting flush oxygen and inserting
two IVs, the patient continues to be
confused, hypotensive, tachycardic and
tachypneic.
Initial ABG: pH 7.21, PCO2 27, PO2 95,
HCO3 14, lactate 5.2
WBC 19.3, Bands 21%
Creatinine 213, Urea 17.3
This patient meets the criteria for sepsis. What
are the possible sources?
What should be done within the next hour?
Why is source control and early antibiotics
critical in sepsis?
After securing the airway, inserting a central line
and arterial line, starting antibiotics and sending
cultures, the patient’s CVP is 4.
Is this a problem and what should be done?
After giving 2 litres of normal saline, the
CVP is 10 but the MAP is 60 mmHg.
Is this acceptable and what should be
done about it?
Levophed is started and titrated to a goal
of 65 mmHg. The central venous
saturations are now 56%.
What would you do next?
What is the pathophysiological relationship
between inflammation and complement
activation, coagulation, and antifibinolysis?
What adjunct treatments can be used in
sepsis to modulate the inflammatory
system?
What is the role of other supportive
therapies such as steroids, vasopressin,
and insulin?
Questions??