Transcript Sepsis and Septic Shock 2011 - st. james healthcare education

Sepsis and Septic Shock
Dr. John Pullman
St. James Healthcare
Butte, Montana
2011
Microbiology of Sepsis
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Common gram-positive cocci are Strep pneumonia,
Staph aureus (MSSA & MRSA), gp A & B strep, gp G
strep; strep anginosis.
Aerobic gram-negatives are E. coli, Klebsiella, and
other Enterobacteriacae (Lipid A)
Gram-positive anerobes are Clostridia (toxinproducing) & rarely Fusobacterium
CAP and Sepsis
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37 yr old woman presents with 5 day h/o fever, cough, dysnea
and pleuritic chest pain. No hx of prior lung disease or
pneumonia. No major medical illnesses or surgeries.
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Temp 104.6 BP 70/45, HR 130, RR 40, O2 sat 76% RA. Exam
and CXR reveal RLL, RML, LLL consolidation & large R pleural
effusion. pH 7.12, pCO2 56, pO2 56.
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What most likely would a gram stain of sputum show?
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What are the most likely organisms to cause CAP?
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What guides antibiotic choices initially?
Purpura Fulminans
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26 yr old woman with a history of ‘congenital splenic dysplasia’
presents with temp 104 F, BP 88/50, HR 124, RR 36. Recent
URI and cough.
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She develops purpuric lesions on the acral points of her body.
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WBC is 4200, Hgb 11, platelet count is 15,000.
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CXR shows lobar pneumonia.
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What is her most likely condition?
Fever, Rash, and Hypotension
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30 yr old woman referred for evaluation of a perineal cellulitis
culture + for MRSA.
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Rash developed on oral TMP/SMX and pt transferred to your
hospital. Steroids started.
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Temp is 104 F, BP 92/56, HR 128, RR 32; there is a diffuse
macular rash on trunk and extremities; perineum is red and
ulcerated.
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Is this shock? What kind? What else is wrong?
Fever, Limb Pain, and Hypotension
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18 yr old man with hep C cirrhosis from infancy presents with temp
103 F, BP 92/54, HR 120, RR28. He has chronic lymphedema of both
legs but has severe pain in his right calf.
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WBC is 20,000, Hgb 11, platelet count is 52000. CPK is 4200. BUN is
65 and creatinine is 3.2. Last creatinine 3 months ago was 1.0.
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What type(s) of septic shock is this likely to be ?
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Is this a surgical disease?
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What antibiotics should be ordered? What principles guide your
selection?
Fever & Hypotension NOS
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65 yr old man presents with fever, BP 84/52, HR 116, RR 30. There
are no focal symptoms or signs. After 24 hours, temp is still 104 F on
vancomycin and ceftriaxone. What next?
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32 yr old woman brought to ER by ambulance confused, febrile, and
hypotensive. Minimal findings on exam; has a dorsal laceration of her
hand with minimal redness. What history is pertinent? What requests
do you make of micro?
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80 yr old woman brought to ER from SNF for acute confusion, temp
101 F, and BP 96/60, HR 110. No hx available and CXR is ‘clear’. After
blood work is drawn, what next?
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56 yr old man with rheumatoid arthritis presents with fever and
hypotension. He is on TNF antagonist. Why does that matter?
Vasopressors and Septic Shock
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Recent prospective MC/DB randomized trial found no difference in 28
day mortality between dopamine (DA) and norepinephrine (NE) in
treatment of shock.
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Dysrhythmias were more common with DA. DA-induced tachycardia
was associated with increased ischemic events; cardiogenic shock
had higher mortality rate with DA.
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Norepinephrine should be first line in septic shock
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After adequate volume resuscitation, if NE-treated patients have
MAP<65-70, add fixed dose vasopressin (0.03 units/min) and IV
hydrocortisone (50 mg q6hrs).
Sepsis and Respiratory Failure
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72 yr old man presents with abdominal pain, temp 102 F, BP 70/44,
HR 120, RR 40. Abd/Pelvic CT confirms peri-diverticular abscesses
with air-fluid levels and percutaneous catheter drainage is performed.
Arterial lactate level is high, creatinine is 3.0 after volume
resuscitation.
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On AM of his third day, he develops increasing confusion and dysnea
despite CPAP mask. ABGs: pH 7.20, pCO2 38, pO2 84 on high flow
O2.
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CXR shows new ‘bibasilar and perihilar’ lung infiltrates.
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Is this hospital-acquired pneumonia? What else could it be?
Serum Cortisol and Sepsis
Surviving Sepsis Campaign
Goal-Directed Rx in the First 6 Hours
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Blood cultures before antibiotic therapy
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Volume resuscitation
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Imaging studies promptly to confirm source of infection
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Administration of broad-spectrum antibiotics within 1 hour of diagnosis
of septic shock and for 7-10 days
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Source control after R/B analysis of methods needed
Surviving Sepsis Campaign
Goal-Directed Rx in the First 6 Hours
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Vasopressor followed by stress dose corticosteroids
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Low TV/ low peak pressure ventilation with PEEP if ALI/ARDS
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Targeting blood glucose 140-180 after stabilization
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VAP prevention bundle
Don’t Let It Sneak Up On You!
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17 yr old girl goes to walk-in clinic with 5-7 day h/o sore throat, fever,
swollen cervical LN and myalgias. Rapid strep test + and amoxacillin
prescribed.
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A diffuse macular rash develops on her trunk. What lab test would you
order now?
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She is re-assured, given analgesics, and sent home.
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3 days later she presents with Temp 104, BP 80/40, HR140, RR 36.
WBC 4000, plt count 45,000
SEPSIS
True or False
True or False
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Sepsis and septic shock are synonymous.
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Bacteremia is always followed by sepsis.
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Gram positive sepsis has replaced gram negative sepsis in frequency
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Septic emboli to the lungs should be treated with antibiotics and full
anti-coagulation
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Pneumonia, soft tissue infx, UTIs, and intra-abdominal infx are
common causes of sepsis
True or False
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MRSA sepsis is more common than Strep pneumonia sepsis.
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E. coli sepsis is often from an intra-abdominal or urinary tract source.
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Klebsiella more often than E coli can cause pneumonia –associated
sepsis.
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Vasopressor preferences in sepsis are absolutely defined by practice
guidelines.
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Norepinephrine is generally preferred over dopamine for septic shock
refractory to fluid resuscitation.
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Vasopressin can play a role as an adjunctive Rx in shock.
True or False
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Source control of infection can often wait until Monday if a patient in
septic shock is admitted on a preceding Friday.
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Bactericidal antibiotics are preferred over bacterostatic antibiotics for
patients with sepsis or septic shock.
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Vancomycin is often the antibiotic of choice in the ICU for suspected
gram positive infections.
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Azithromycin in combination with ceftriaxone is recommended in CAP
over ceftriaxone alone on the basis of prospective randomized
controlled multi-center trials.
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CAP patients admitted to ICU should get the same antibiotics
recommended for medical floor CAP patients if on telemetry.
True or False
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Group A streptococcal toxic shock and necrotizing fasciitis is a
purely medically managed condition.
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Staphylococcal toxic shock syndrome is always associated with
staphylococcal bacteremia or necrotizing fasciitis.
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Positive blood cultures for Staph aureus (MSSA or MRSA) after 48-72
hours of high-dose vancomycin are a poor prognostic sign.
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E coli has been cultured from the urinary tract after 3 days of high
dose levofloxacin in cases of septic shock from E coli pyelonephritis.
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Surviving sepsis guidelines work best when a team approach is
respected by everyone involved in the care of a septic pt.