Sepsis SIRS Two or more of the following

Sepsis SIRS Two or more of the following conditions 1 - Fever > 38 or hypothermia<36 2 - Tachypnea >24 3 - Tachycardia>90 4 - Leukocytosis >12000, or<40000, band>10%

Sepsis syndrome Sepsis with one or more sign of organ dysfunction 1 - Cardiovascular: BP 90 or mean arterial pressure≤ 70 2 - Renal urine out put <0/5 ml/Kg per hours 3 - Respiratory: 4 - Haematologic : platelet <80000 or 50%decrease in platelet count n

Sepsis syndrome 5 - Unexplained Metabolic acidosis PH≤ 7. 30 or base deficit ≥ 5 meq /L Or plasma lactate Level >1/5 times upper Limit of normal 6 - Adequate fluid resuscitation : pulmonary artery wedge pressure ≥ 12 mm. Hg or CVP≥ 8 mm. Hg

Septic shock 1 - Sepsis with hypotension BP<90 Or 40 mmhg less than patients normal blood pressure for at least 1 hr despite adequate fluid resuscitation Or 2 - Need for vasopressors to maintain systolic blood pressure ≥ 90 mm. Hg Mean arterial pressure ≥ 70 mm. Hg

Refractory septic shock n Septic shock that lasts for >1 hr and does not respond to fluid or pressor administration

Multiple – organ dysfunction n Dysfunction of more than one organ , requiring intervention to maintain homeostasis

Etiology n Gram – Negative bacteria 40% n Gram – positive bacteria 31% n Fungi 6% n Poly microbial 16%

Condition that may predispose to Infections Gram- negative bacilli n n n n Diabetic mellitus Lymphoproliferative diseases Cirrhosis Burns Invasive procedures or devices Neutropenia Indwelling urinary catheter Diverticulitis , perforated viscous

Conditions that may predispose to infections Gram – positive bacteria Intravascular catheters n Indwelling mechanical devices n Burns n Neutropenia n Intra venous drug use n Infection with super antigen – producing streptococcus pyogenes n

Condition that may predispose to Infections Fungi n Neutropenia n Broad – spectrum antimicrobial therapy

Diagnosis n There is no specific diagnostic test 1 - blood culture and other culture 2 - Leukocytosis 3 - Thrombocytopenia 4 - Leukopenia 5 - Hyperbilirubinemia 6 - proteinuria 7 - D- dimer 8 - decreased fibrinogen

Treatment 1 - Hemodynamic support 2 - Antibiotic therapy 3 - Vasopressors 4 - Steroids 5 - Human Activated protein C 6 - Glucose control 7 - Renal Replacement 8 - Bicarbonate therapy 9 - Deep vein thrombosis prophylaxis 10 - Stress ulcer prophylaxis

Treatment 1 - Hemodynamic support (goals ) n Central venous pressure 8 - 12 mm. Hg n Mean arterial pressure ≥ 65 mm. Hg n Urine output ≥ 0/5 ml. kg. hr n Central venous mixed venous oxygen saturation≥ 70%

Treatment 2 - Antibiotic therapy Immunocompetent adult n Ceftriaxone n Tazocin n Imipenem n Meropenem n Cefepime

Antibiotic therapy Allergic to ß lactam agents Ciprofloxacin (IV) plus Clindamycin

Antibiotic therapy n Neutropenia n Imipenem n Meropenem + Aminoglycoside n Cefepime n Tazocin n Vancomycin?

Antibiotic Therapy Spelenectomy n Ceftriaxone ± Vancomycine Allergic to ß lactam n Vancomycine ± Plus Ciprofloxacin

Antibiotic Therapy IV Drug User Nafcillin Or } + Gentamycin Oxacillin MRSA or Allergic to ß- Lactam Vancomycin + Gentamycin