Sepsis 

Definition: (Davidson)

• Sepsis: life threatening organ dysfunction due to dysregulated host response to infection.
• SIRS: caused by infection or noninfectious conditions like pancreatitis, trauma, vasculitis.

Diagnostic tool of sepsis:

1. qSOFA score (HAR)
2. SOFA score 

Sepsis management:

SSC

• SIRS, NEWS, MEWS are better than qSOFA to predict mortality in suspected infection

Recommendation:

• in sepsis induced hypoperfusion/septic shock→ 30 ml/kg, balanced crystalloid IV, in first 3 hours of resuscitation
• Capillary refill time→ measure of perfusion
• Infection

• Diagnosis of sepsis:

1. history
2. examination

• Timing of antimicrobials

1. initiation: antimicrobials given within 01 hour of recognition (suspected/probable infection)
2. stopping: if alternative noninfectious cause of illness is demonstrated/strongly suspected
3. monitoring and deescalation: procalcitonin level, clinical improvement

• Anti-microbial coverage

1. high risk of multi-resistant organism→ 2 antibiotic with gram negative coverage 
2. prolonged infusion of beta lactam for maintenance after initial bolus 

• Source control

1. identify/exclude any septic foci
2. manage septic foci accordingly

• Hemodynamic:

• fluid type: balanced crystalloid
• vasopressor: initially norepinephrine, then vasopressin, then dobutamine
• fluid strategy: IV fluid may be continued, if sign of hypoperfusion is still present 

• ECMO: extracorporeal membrane oxygenation for severe ARDS 
• IV corticoids in septic shock requiring vasopressor
• Vit-C: no role 
•  Ventilation: 

• low tidal volume ventilation strategy 
• prone positioning in moderate-to-severe ARDS

SAQ. A 50-year-old man presented with high grade fever for 7 days. He gave a history of dysuria and burning micturition for the same duration. On examination there are multiple purpuric spots on the back and extremities, BP 80/60 mmHg, Pulse 120 bpm, RR 28/min. Laboratory reports showed: Hb 7.8 gm/dl, TC 27,000, platelet 25,000, serum bilirubin 4.5 mg/dl, ALT-50 U/L, serum creatinine 3.5 mg/dl and lactate 8 mmol/L.

1. Mention immediate management steps for this patient. (OBALFU)

1. High flow oxygen
2. Take blood culture
3. Administer iv antibiotics
4. Send serum lactate and CBC
5. IV Fluid replacement
6. Accurate measurement of urine output

1. How will you monitor the response to treatment?

1. Mention the indications to send the patient to the ICU.

1. Patient requiring invasive mechanical ventilation
2. Persistent septic shock with vasopressors 
3. Confusion
4. Multi organ failure