This presentation was prepared by me during my placement under medicine department in 2012.

1. Septicemia
Dr. Mashfiqul Hasan
Resident (Phase A)
Endocrinology & metabolism

2. Terminology to describe septic
patient
2

3. Infection
• Invasion of normally sterile host tissue by
microorganisms
3

4. Bacteremia
• Presence of bacteria in blood
• Evidenced by positive blood culture
4

5. Septicemia
• Presence of microbes or toxins in blood
5

6. SIRS
• Two or more of the following conditions:
– Fever or hypothermia
– Tachypnea
– Tachycardia
– Leukocytosis or leukopenia or >10% bands
• Infectious / Noninfectious
6

7. Sepsis
• SIRS with proven or suspected microbial
etiology
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8. Severe sepsis
• Sepsis with signs of one or more organ dysfunction
– Cardiovascular: hypotension that responds to
administration of IV fluids
– Renal
– Respiratory
– Hematologic
– Unexplained metabolic acidosis
8

9. Septic shock
• Sepsis with
– Hypotension, for at least 1 h, despite adequate fluid
resuscitation
– Need for vesopressor
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10. Refractory septic shock
• Last for >1 hour
• Does not respond to fluid or pressor administration
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11. MODS
• Dysfunction of >1 organ
• Requiring intervention to maintain homeostasis
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12. 12

13. Inflammatory response to sepsis
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14. 14

15. 15

16. APPROACH TO SEPTIC
PATIENT
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17. 17

18. 18

19. 19

20. Treatment: Severe Sepsis &
Septic Shock

21. Antimicrobial agents
• Without delay
• Appropriate
• IV
• Maximal recommended dose
• Local microbial susceptibility 21

22. Immunocompetent patient
• Any of the following
– Piperacillin-tazobactam
– Imipenem-cilastin or meropenem
– Cefepime
• If allergic to ß lactam agents
– Ciprofloxacin or levofloxacin plus clindamycin
• Vancomycin should be added to each of
the above regimen 22

23. Neutropenic patient
• Imipenem-cilastin or meropenem or cefepime
• Piperacillin-tazobactam plus tobramycin
• Vancomycin should be added if indicated
• Empirical antifungal therapy if hypotensive or
has been receiving broad spectrum antibiotic
23

24. Other special situations
• Splenectomy
– Cefotaxime or Ceftriaxone
– Vancomycin plus either moxifloxacin or
levofloxacin or aztreonam
• IV drug user
– Vancomycin
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25. Other special situations: cont
• AIDS
– Cefepime or peperacillin-tazobactam
plus tobramycin
– Ciprofloxacin or levofloxacin
plus vancomycin
plus tobramycin
25

26. Source Control
• Evaluation for a focused infection
• Abscess drainage or tissue debridement

27. Management of hypotension
• Fluid challenge over 30 min
• 500–1000 ml crystalloid
• 300–500 ml colloid
• Repeat based on response and tolerance
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28. Management of hypotension
• Vasopressor therapy
– Titrating dose of norepinephrine or dopamine
– Dobutamine if myocardial dysfunction
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29. Steroid
• CIRCI: inadequate corticosteroid activity for the
severity of the illness
• Hypotension that does not respond to fluid
replacement therapy
• Hydrocortisone, 50 mg IV q6h
• If clinical improvement, continue for 5-7 days,
slowly taper
• Hastens recovery from septic shock
• No increase in long term survival
29

30. Activated protein C
• Approved by USFDA
• Indicated for
– Very sick patient (APACHE II)
– Low risk of hemorrhage
• Complex anti-inflammatory, anti-apoptotic,
anticoagulant effect
• Trials going on 30

31. Glucose control
– Insulin to lower blood glucose to 100-120
mg/dl is potentially harmful
– Needed only to maintain blood glucose below
150 mg/dl
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32. Other measures
• Nutritional supplementation
• Prophylactic heparinization
• Erythrocyte transfusion
– When Hb <7 g/dl
– Target level 9 g/dl
32

33. Other measures: cont…
• Bicarbonate
• Fresh frozen plasma and platelets
• Ventilator support
• Hemodialysis or hemofiltration
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34. Ongoing trials
• IV Ig
• Endotoxin antagonist (eritoran)
• GM CSF
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35. 35

36. 36

37. 37