Download Sepsis-Case

‫بنام خدا‬
‫کيس‬
‫بيماردختر ‪ 17‬ساله است اهل گيال ن بعلت تب ولرز‬
‫تکان دهنده دربيمارستان بستری ميگردددرشرح‬
‫حال بيمار سابقه تاالسمی واسلپکتومی رادر سال‬
‫قبل ذکر می کند بيمار از ‪ 6‬روز قبل بطورناگهانی‬
‫دچار تب ولرز تکان‪ ,‬تنگی نفس شدن ‪ ,‬بيمار‬
‫اسهال نيز دارد سوزش ادرار وتکررادرار ندارد‪.‬‬
‫درمعاينه‪:‬‬
‫‪T= 39/5 , BP = 110/80 .PR= 140, RR=45‬‬
‫درمعاينه بيمار فوالعاده توسيک است کم لنفوژپوری دارد‬
‫رودوگردن ندارد ‪.‬درمعاينه ريه کراکل ودرريه ودسمع‬
‫قلب تاکيکاردی شديددارد ‪ ,‬درمعاينه شکم تندرنس در‬
‫هيپوکنوراست دارد‬
‫آزمايش اوليه‪:‬‬
‫راديوگرافی ريه ‪ :‬انفليتراسيون وسيع دوطرفه ريه دارد‪.‬‬
‫‪WBC = 2500 pog =80% Band =%10‬‬
‫‪SGT = 250‬‬
‫‪Hb = 8‬‬
‫‪SLM =140‬‬
‫‪HCT =24‬‬
‫‪PT = 15‬‬
‫‪RBS =150‬‬
‫‪NU = 135‬‬
‫‪R = 4/5‬‬
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 <0/5ml/Kg per hours
3- Respiratory:
4- Haematologic :platelet <80000 or 50%decrease
in platelet count

Sepsis syndrome
5- Unexplained Metabolic acidosis PH≤7.30
or base deficit ≥5meq /L
Or plasma lactate Level >1/5 times upper
Limit of normal
6- Adequate fluid resuscitation :pulmonary
artery wedge pressure ≥12 mmHg or
CVP≥ 8mmHg
Septic shock
1- Sepsis with hypotension BP<90
Or 40 mmhg less than patients normal blood
pressure for at least 1hr despite adequate fluid
resuscitation
Or
2- Need for vasopressors to maintain systolic
blood pressure ≥90 mmHg
Mean arterial pressure ≥70 mmHg
Refractory septic shock
 Septic
shock that lasts for >1hr
and does not respond to fluid or
pressor administration
Multiple – organ dysfunction
 Dysfunction
of more than one
organ , requiring intervention to
maintain homeostasis
Etiology
 Gram
– Negative bacteria 40%
 Gram – positive bacteria 31%
 Fungi 6%
 Poly microbial 16%
Condition that may predispose to Infections
Gram- negative bacilli
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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
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Intravascular catheters
Indwelling mechanical devices
Burns
Neutropenia
Intra venous drug use
Infection with super antigen – producing
streptococcus pyogenes
Condition that may predispose
to Infections
Fungi
Neutropenia
 Broad – spectrum antimicrobial therapy

Diagnosis

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 )
Central venous pressure 8- 12 mmHg
 Mean arterial pressure ≥65 mmHg
 Urine output ≥0/5 ml .kg .hr
 Central venous mixed venous oxygen
saturation≥70%
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Treatment
2- Antibiotic therapy
Immunocompetent adult
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Ceftriaxone
Tazocin
Imipenem
Meropenem
Cefepime
Antibiotic therapy
Allergic to ß lactam agents
Ciprofloxacin (IV) plus Clindamycin
Antibiotic therapy
Neutropenia
 Imipenem
 Meropenem + Aminoglycoside
 Cefepime
 Tazocin
 Vancomycin?
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Antibiotic Therapy
Spelenectomy
 Ceftriaxone ± Vancomycine
Allergic to ß lactam
 Vancomycine ± Plus Ciprofloxacin
Antibiotic Therapy
IV Drug User
Nafcillin
Or
} + Gentamycin
Oxacillin
MRSA or Allergic to ß- Lactam
Vancomycin + Gentamycin