3. Objectives
Define SIRS / sepsis / severe sepsis - MODS septic
shock
Delineate difference between sepsis SIRS and
MODS
Early recognition of Sepsis
Prophylaxis
Early Goal Directed Therapy
4. Lay out of immune responses
A continuum of severity describing the host
systemic inflammatory response……………
To external trauma
Internal physiological uncompensated trauma
External or internal source of infection.
7. SIRS RESPONSE OF BODY TO STRESS
Defined as ≥2 of the following:
Temperature abnormality
>38°C or <36°C
Hemodynamic distress
tachycardia
Respiratory distress
tachypnea, hypercarbia >32mmol, or hypoxia <70%
Inflammatory marker
WBC >12k, <4k, .
8. Sepsis
SIRS plus…
confirmed infectious process
or strongly suspected infection or established by culture
or clinical examination
Severe Sepsis
Sepsis plus…
organ dysfunction
various organ-failures due to hypoperfusion
9. Septic shock
Definition: sepsis plus ≥1 of the following:
decreased peripheral pulses (compared to central
pulses)
capillary refill:
>2 seconds
mottled or cool extremities (cold shock)
flash capillary refill (vasodilated / warm shock)
decreased urine output (< 1 mL/kg/hr
MAP <60 mm Hg (<80 mm Hg if previous hypertension)
after adequate fluid resuscitation
Need for pressors to maintain BP after fluid resuscitation
Adequate fluid resuscitation = 40 to 60 mL/kg saline
solution (NS 5L-10L)
10. MODS
Definition
progressive reversible dysfunction of ≥2 organs from
acute disruption of normal homeostasis requiring
intervention
Primary MODS
immediate systemic response to injury or insult
Needs mostly<1 week in ICU, better prognosis,
Secondary MODS
progressive decompensation from host response &
2nd hits
Needs >1week in ICU, worse prognosis
11. A Typical Sequence of Organ System Dysfunction…
Circulatory insufficiency
Tachycardia
hypotension,
myocardial depression,
CHF,
arrhythmia
19. What actually is happening
MODS is comprised of the activation and
dysregulation of multiple complex overlapping
physiologic systems
Overall: hormonal, cytokine, and immunologic
changes leading to systemic inflammation, a
procoagulant state, & organ dysfunction
25. Feed-Forward Cycle
metabolic/inflammatory/immunologic responses become
generalized & persistent (even in absence of original stimulus)
increased demand on organ function promotes failure (CO,
ventilation, oxygenation, nutrition, fluids, excretion of waste)
Organ Failure
causes metabolic/inflammatory/immunologic responses
hypoxia ischemia cell death inflammation
26. Imbalance between
Proinflammatory Cytokines
e.g., IL-6, IL-8 & interferon-γ
promote immune cell-mediated killing
Anti-inflammatory Cytokines
e.g., soluble TNF receptor, IL-1 receptor antagonist
protein, IL-4, and IL-10
turn off the immune response when infection/stimulus
has been cleared
27. Cytokines out of control…
Peroxynitrite (ONOO−) can cause DNA
damage
Cell program and function deranged
Activation of poly ADP-ribose synthetase
depletes cells of NAD+ & ATP
leads to secondary energy failure
overactivated immune cells release Fas &
Fas ligand
prevents activated immune cell apoptosis
promotes ongoing inflammation
ineffective and unresolving inflammation
leads to systemic organ failure
28. MODS- VARIETIES
THROMBOCYTOPENIA ASSOCTIATED MODS- DIC
PROLONGED MONOCYTE DEACTIVATION
PROLONGED LYMPHOPENIA WITH SUPER INFECTION
VIRAL INFECTION WITH SEQUENTIAL ORGAN FAILURE
FIBROPROLIFERATIVE LUNG DISEASE WITHOUT INFECTION.
30. Cultures / Antibiotics / Labs
Cultures PRIOR to Antibiotics ( 2 Sets, one peripheral and one from any line
older than 48hrs)
IV Abx within 3 hrs in the ED, within 1 hr in the ICU
Broad Spectrum, combination therapy for neutropenic and patients with
pseudomonas risk factors
Consider need for Source Control !
Drainage of abscess or cholangitis, removal of infected catheters,
debridement or amputation of osteomyelitis
31. Central Line Access (Fluid hydration +/- pressor)
1st line therapy – fluids
Crystalloid equivalent to colloid
Initial 1-2 Liters (20mg /kg) crystalloid or 500 ml
colloid
Careful in CHF patients !!
32. Use in Septic Shock, if NO response to vasopressors
and fluids
HYDROCORTISONE 200mg -300mg / day
Divided doses (Q6hrs)
Initial Dose 100mg IV x1
Wean Steroids QUICKLY once off pressors
33. Recognize Sepsis EARLY and determine SEVERITY
EARLY Antibiotics are critical to resolution of shock
RESUSCITATE severe sepsis and septic shock
34. MODS PREVENTION
General:
rapidly identify and eliminate inciting stimulus before host
response becomes own feed-forward stimulus
Primary MODS:
Measures to decrease multisystem injury/trauma/illness through
avoidance of 1st hit in a vulnerable demographic
e.g., protective gear, immunizations, etc.
Secondary MODS:
Measure to forestall progression of SIRS or Sepsis to MODS
through avoidance of 2nd hits in a primed system
e.g., rapid medical access (EMT), special teams
35. MODS TREATMENT
Severe infection in MODS
Appropriate antimicrobials
early empiric antimicrobials
timely conversion to infection-specific therapy
antibiotics with best MIC
Early goal-directed hemodynamic & O2-delivery therapy
normal BP w/ IVF and SVC O2 sat >70%
achieve with oxygen + PRBC + inotropes
Activated protein C
Adjunctive immune therapy
GCSF / GM-CSF for neutropenic patients (esp. newborns)
steroids/IVIG/etc in selected cases
36. Septic Shock in MODS
Use of hydrocortisone plus fludrocortisone
for patients with a minimal cortisol response to corticotropin
stimulation
Careful vasopressor selection in patient population
ECMO in selected cases
benefit greatest in neonates > children > adults
41. 0 points: ICU Mort 0%, Hosp Mort 0%, ICU Stay 2 Days
1-4 points: ICU Mort 1-2%, Hosp Mort 7%, ICU Stay 3 Days
5-8 points: ICU Mort 3-5%, Hosp Mort 16%, ICU Stay 6 Days
9-12 points: ICU Mort 25%, Hosp Mort 50%, ICU Stay 10 Days
13-16 points: ICU Mort 50%, Hosp Mort 70%, ICU Stay 17 Days
17-20 points: ICU Mort 75%, Hosp Mort 82%, ICU Stay 21 Days
21-24 points: ICU Mort 100%, Hospital Mortality 100%
42. Antibiotic prophylaxis for surgery
Risk of infection The risk of SSI depends on a number of factors; these can be
related to the patient or the operation and some of them are modifiable • Age
• Nutritional status • Diabetes • Smoking • Obesity • Coexistent infections at a
remote body site • Colonization with microorganisms (e.g. Staph. aureus) •
Immunosuppression (inc. taking glucocorticoid steroids) • Length of
preoperative stay • Coexistent severe disease Patient
Risk of infection Operation • Duration of surgical scrub • Preoperative shaving/
preoperative skin prep. • Length of operation • Appropriate antimicrobial
prophylaxis • Operating room ventilation • Inadequate sterilization of
instruments • Foreign material in the surgical site • Surgical drains • Surgical
technique inc. haemostasis, • poor closure, tissue trauma • Post-operative
hypothermia
43. The risk is also related to the amount of contamination with microorganisms which is called
“class” of the operation
Clean Operations in which no inflammation is encountered and the respiratory, alimentary
alimentary or genitourinary tracts are not entered. There is no break in aseptic operating
theatre technique.
Clean-contaminated Operations in which the respiratory, alimentary or genitourinary
tracts are entered but without significant spillage.
Contaminated Operations where acute inflammation (without pus) is encountered, or
where there is visible contamination of the wound. Examples include gross spillage from a
hollow viscus during the operation or compound/open injuries operated on within four
hours
Dirty Operations in the presence of pus, where there is a previously perforated hollow
viscus, or compound/open injuries more than four hours old.
Prophylactic antibiotics • Prophylaxis with antibiotics has decreased the high incidence
of wound infection after head and neck operations that involve incisions through oral or
pharyngeal mucosa. • Prophylactic administration of antibiotics can decrease
postoperative morbidity, shorten hospitalization, and reduce overall costs attributable to
infections. • Additional doses during the procedure are advisable if surgery is prolonged
(i. e, >4 h), major blood loss occurs, or an antimicrobial with a short half-life is used
44. The aim of prophylaxis
The aim of prophylaxis is to augment host defense mechanisms at the time of
bacterial invasion.
Prophylaxis is an attempt to attack organisms before they have a chance to
induce infection.
Antibiotic Prophylaxis
Timing for Administration
Additional Intra-operative doses
Post-operative antibiotic prophylaxis
Timing for Administration Antibiotic prophylaxis administered too early or too
late increases the risk of SSI. Studies suggest that antibiotics are most effective
when given 30 minutes before skin is incised.
For operations lasting more than 4 hours re-dosing may be necessary.
Antibiotic Recommended re-dosing interval/dose to give Cefuroxime 4 hours,
750mg IV Clindamycin 4 hours , 300mg IV Co-amoxiclav 4 hours, 1.2g IV
Metronidazole 8 hours, 500mg IV
45. FOUR GUIDLINES
Safety
An appropriate NARROW specrum of coverage of relevant pathogens
Little or no reliance on the agent for therapy of infection-to prevent
resistence
Administration of drug at appropriate time before incision and for defined
period thereof mostly single dose no longer than 24hrs
46. Risks of prophylaxis
Drug allergy- anaphylaxis
Steven Johnson syndrome TENS
Antibiotic induced dirrhoea
Coolonisation by opportunistic flora
Antibiotic resistance
Multiresistance carriage and spread.
Catheter related infections
47. Is prophylaxis mandatory?
Facial surgeries without implant
Gall bladder surgery with no risk of bile leak
Uncomplicated inguinal, femoral, incisional, either laparoscopic or open
with mesh or without
Diagnostic endoscopy except ercp
Tonsillectomy,adenoidectomy,
Splenectomy in immunocompetent patient
CAN BE MANAGED WITH OUT PROPHYLAXIS AND PROPHYLAXIS IS NOT
RECOMMENDED AS A ROUTINE
48. ALL OTHER surgical procedures including
Therapeutic endoscopy, shockwave lithotripsy routinely prophylaxis is
recommended
Soft tissue surgery of hand can be considered for prophylaxis on need
basis depending on type of wound
49. Antimicrobials May be:
Bacteriostatic – inhibits growth of Bacteria, so acts by preventing bacteria
from multiplying and then hosts defences deal with the small number of
bacteria left
Bactericidial – kills Bacteria, so eliminates bacteria
53. If vancomycin is selected it must be used in institutions with established
MRSA infection risk
54. First generation cephalosporin can be used for
CTVS-median sternotomy(clindamycin) pacemaker insertion defibrillators
vascular procedures.(except carotid endarterectomy)
Pulmonary resection
Lower limb amputation(gentamycin and metronidazole)
Cholecystectomy high risk (gentamycin)
Gastrectomy, hepatobilliary(G M)
Malor debridement(G)
Genito urinary(ciproflox)
Hysterectomy(doxycycline) LSCS- STAT DOSES (M OR Doxy)
55. Surgery in oral or pharyngeal cavity with mucosal breach(G C or M)
CRANIOTOMY(C,V)
ORTHROPLASTY(V)
Appendicectomy- colonsurgery-prenetating trauma abdomen SECOND
generation cephalosporins(Metronidaz plus gentamycin)
60. Superficial Incisional SSI: Occurs within 30 days postoperatively and
involves skin or subcutaneous tissue of the incision and at least one of the
following: (1) purulent drainage from the superficial incision, (2) organisms
isolated from an aseptically obtained culture of fluid or tissue from the
superficial incision, (3) at least one of the following signs or symptoms of
infection: pain or tenderness, localized swelling, redness, or heat, and
superficial incision is deliberately opened by surgeon and is culture-
positive or not cultured (a culture-negative finding does not meet this
criterion), and (4) diagnosis of superficial incisional SSI by the surgeon or
attending physician
61. Deep Incisional SSI: Occurs within 30 days after the operative procedure if no
implant is left in place or within one year if implant is in place and the infection
appears to be related to the operative procedure, involves deep soft tissues
(e.g., fascial and muscle layers) of the incision, and the patient has at least one
of the following: (1) purulent drainage from the deep incision but not from the
organ/space component of the surgical site, (2) a deep incision spontaneously
dehisces or is deliberately opened by a surgeon and is culture-positive or not
cultured and the patient has at least one of the following signs or symptoms:
fever (>38 °C) or localized pain or tenderness (a culture-negative finding does
not meet this criterion), (3) an abscess or other evidence of infection involving
the deep incision is found on direct examination, during reoperation, or by
histopathologic or radiologic examination, and (4) diagnosis of a deep
incisional SSI by a surgeon or attending physician
