Problem 2 KGD Angelia.pptx

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    Problem 2

    Angelia Christiani

    405090078

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    BURNS

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    SEPSIS

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    1. Description

    Systemic inflammatory response triggered by an infectionin the host and mediated by chemical messengers: Decreased peripheral vascular resistance Elevated cardiac output in response to vasodilatation

    Later in septic shock, myocardial depression, and reducedcardiac output (due to injury at the cellular level or mediatorsacting on the heart)

    Multiple organ dysfunction syndrome (MODS) if sepsis isineffectively treated

    Adult respiratory distress syndrome (ARDS) Acute tubular necrosis and kidney failure Hepatic injury and failure Disseminated intravascular coagulation

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    2. Etiology

    Gram-negative bacteria most common:

    Escherichia coli

    Pseudomonas aeruginosa

    Rickettsiae

    Legionella species

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    Gram-positive bacteria:

    Enterococcus species

    Staphylococcus aureus

    Streptococcus pneumoniae

    Fungi (Candida species)

    Viruses

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    Pediatric Considerations

    Children with a minor infection may havemany of the findings of SIRS.

    Major causes of pediatric bacterial sepsis

    Neisseria meningitis

    Streptococcal pneumoniae

    Haemophilus influenzae

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    3. Classification

    Sepsis is classified by the systemicinflammatory response syndrome (SIRS): Temperature >38C or 90 beats/minute Respiratory rate >20/minute or PaCO212,000/mm3, 10% bandforms

    Sepsis: two or more of the SIRS criteria withan underlying infection

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    Severe sepsis: Sepsis with organ dysfunction as manifested by

    one of the following:

    Acidosis Renal dysfunction

    Acute change in mental status

    Pulmonary dysfunction

    Hypotension Thrombocytopenia or coagulopathy

    Liver dysfunction

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    Septic shock:

    Sepsis-induced hypotension despite fluidresuscitation

    Systolic blood pressure (BP) 40 mm Hg from baseline

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    4. Signs and Symptoms

    General:

    Fever

    Tachycardia

    Tachypnea

    Hypothermia (poor prognosis)

    Hypoxemia

    Diaphoresis

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    Cardiovascular:

    BP

    Normal early in sepsis

    Hypotension when septic shock occurs

    Poor perfusion with septic shock:

    Prolonged capillary refill

    Cool and clammy extremities

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    Gastrointestinal/Genitourinary: Abdominal pain Nausea, vomiting Diarrhea

    Dysuria/Frequency Reduced urine output Abdominal tenderness:

    Diffuse Localized to right upper quadrant (liver or gallbladder source) Right lower quadrant (appendicitis with or without abscess) Suprapubic area or lower quadrants (urinary tract or pelvic source or

    diverticulitis)

    Flank pain: With pyelonephritis or retroperitoneal abscess

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    Pulmonary:

    Shortness of breath

    Tachypnea:

    Present even when the lungs are not the source ofsepsis

    Productive cough

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    CNS:

    Change in mental status

    Confusion

    Delirium

    Coma

    Neck stiffness (meningitis)

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    Dermatologic: Any rash is important. Localized erythema with lymphangitis (streptococcal or

    staphylococcal cellulitis) Rash involving palms of hands and soles of feet (rickettsial

    infection) Petechiae scattered on the torso and extremities

    (meningococcemia) Ecthyma gangrenosum (pseudomonas septicemia) Round, indurated, painless lesion with surrounding erythema

    and central necrotic black eschar Decubitus ulcers Indwelling catheter:

    Surrounding skin erythematous with or without purulent drainage

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    Hematocrit:

    Needed to determine whether adequate oxygen

    delivery can be achieved Patients should be maintained with a hematocrit >30%

    and hemoglobin >10 g/dl.

    Platelets:

    May be elevated in the presence of infection or sepsis-induced volume depletion

    Low platelet count is a significant predictor ofbacteremia and death.

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    Electrolytes, blood urea nitrogen, creatinine,glucose: Low bicarbonate suggests inadequate perfusion. Renal dysfunction or failure indicates a worse

    prognosis. Ca, Mg, Ph C-reactive protein Cortisol level International normalized ratio/prothrombin

    time/partial thromboplastin time

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    Type and screen Liver function tests Arterial blood gas:

    Mixed acidbase abnormalities: respiratory alkalosiswith metabolic acidosis

    Blood cultures: From two different sites

    One may be drawn through an indwelling central line(i.e., Broviac).

    Urine analysis and culture

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    (B) Imaging

    Chest radiograph:

    Determine whether pneumonia is the infectioussource.

    Fluffy, bilateral infiltrates may indicate that ARDSis already present.

    Free air under the diaphragm indicates the sourceof the infection in intraperitoneal and a surgicalintervention

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    CT scan of the abdomen and pelvis Suspicion of abdominal source of infection:

    Diverticulitis, appendicitis, necrotizing pancreatitis,microperforation of the stomach or bowel, or formation of anintra-abdominal abscess

    Abdominal ultrasound: Indicated for suspected cholecystitis

    Pelvic ultrasound: Tubo-ovarian abscess or

    MRI: May be useful to identify soft tissue infections or epidural

    abscess

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    (C) Diagnostic Procedures/Surgery

    Lumbar puncture: Indicated when meningeal signs are present or altered

    mental status without a source of infection Cerebrospinal fluid analysis:

    Cell count and differential, tube 1

    Total protein and glucose, tube 2

    Culture and gram stain, tube 3 Cell count and differential, tube 4

    Depending on the clinical situation: cytology, venerealdisease research laboratory, AFB stain/culture, fungal stain

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    Central venous access:

    Central venous pressure (CVP) and ongoingmeasurement of central venous oximetry catheter

    may be helpful in guiding resuscitation

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    6. Treatment

    Pre Hospital Aggressive fluid resuscitation for hypotension

    Initial Stabilization

    ABCs Supplemental oxygen to maintain PaO2>60 mm

    Hg

    Intubation and mechanical ventilation if shock orhypoxia are present

    Administer 0.9% NS IV

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    ED Treatment

    Early goal-directed therapy: 500 cc boluses of 0.9% saline up to 12 liters empirically

    Place central line

    Continue 500 cc saline boluses until CVP >8 cm H2O

    If the mean arterial pressure 8, theninitiate pressors:

    Dopamine or norepinephrine to raise blood pressure

    Norepinephrine is preferred if tachycardia or dysrhythmias arepresent.

    Phenyl epinephrine for cases where shock is refractory to otherpressors

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    If the ScvO230, then adddobutamine.

    Administer antibiotics early based on the mostlikely organisms or site of infection.

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    If no source identified after initial assessment:

    Normal immune function:

    Second- or third-generation cephalosporin and gentamicin

    Nafcillin and gentamicin Add vancomycin if there is a history of methicillin resistant

    staphylococcus aureous or the patient resides in a nursingfacility or there is a history of recent hospitalizations.

    Immunocompromised host: Piperacillin and gentamicin

    Ceftazidime and either nafcillin or vancomycin andgentamicin

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    If source identified, or highly suspected, treatthe most likely organisms: Pulmonary source:

    Second- or third-generation cephalosporin andgentamicin, and possibly erythromycin

    Intra-abdominal source: Ampicillin and metronidazole and gentamicin

    Cefoxitin and gentamicin Urinary tract source:

    Ampicillin or piperacillin and gentamicin

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    Pediatric Considerations

    Antibiotic therapy based on age:

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    Admission Criteria

    Sepsis with toxicity, septicemia, or septicshock requires admission generally to anintensive care unit.

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    6. Differential Diagnosis

    Pancreatitis Trauma Toxic shock syndrome

    Anaphylaxis Adrenal insufficiency Drug or toxin reactions Heavy metal poisoning Hepatic insufficiency Neurogenic shock