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

1. At the end of this presentation participants will have an understanding of the patho - physiology of sepsis, leading to early recognition and treatment

2. The importance of the first 2 hours will be emphasized

Definitions

Infection

Is the invasion of normally sterile tissue by organisms

Bacteremia

Is the presence of viable bacteria in the blood

Sepsis

Is defined as the presence [probable or documented] of infection together with systemic manifestations of infection

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

Leukocytosis [WBC count > 12,000 ] or leukopenia [WBC count <4000]

Plasma C reactive protein, Procalcitonin

Hemodynamic variables

Arterial hypotension [systolic BP < 90 mmHg]

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

Hyperlactatemia Decreased capillary refill or mottling

Symptoms of Malaria

Meningitis

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

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

Urgent empirical antimicrobials Antibiotics Antimalarials Influenza – specific antiviral if suspect

influenza

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

Every 30 minutes until stable then every hour

SBP pulse Respiratory rate SpO2

Mental status JVP, auscultate for crackles

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 SpO2]

Check oxygen supply If JVP elevated and/or increasing crackles

– consider fluid overload

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.

Thank you for your attention