SEPSIS Dr.

Hanan El-Halaby

Epidemiology:
 It is estimated that more than 40,000 children develop severe sepsis each year in the United States, an
annual incidence of 0.56 cases per 1000 population.
 The incidence of severe sepsis was highest in infants (5.16 cases per 1000 population per year) and
decreased sharply among children ages 10 to 14 (0.2 cases per 1000 population per year).

Infection: A local inflammatory response to the presence of microorganisms or to the invasion of

normally sterile host tissue by those organisms.
Bacteremia: The presence of viable bacteria in the blood

Low-grade bacteremia High-grade bacteremia

(<100–CFU/mL) (>100–1,000 CFU/mL)
Not associated with disease Serious extension of an invasive bacterial
e.g., bacteremia following instrumentation of the infection e.g., meningitis, Osteomyelitis,
respiratory, gastrointestinal, or genitourinary tracts. Endocarditis, Epiglottitis and Facial cellulitis.

Systemic inflammatory response syndrome (SIRS):

 SIRS is a widespread inflammatory response that may or may not be associated with infection.
 Presence of ≥ 2 of the following criteria defines SIRS:
(One of which must be abnormal temperature or leukocyte count)
1- Core temperature of >38.5ºC or <36ºC (measured by rectal, bladder, oral, or central probe).
2- Tachycardia/Bradycardia
o Tachycardia: defined as a mean heart rate >2 standard deviations above normal for age in the
absence of external stimulus, chronic drugs or painful stimuli; or otherwise unexplained
persistent elevation over a 0.5hr time period, or, for children <1 year of age
o Bradycardia: defined as a mean heart rate <10th percentile for age in the absence of external
vagal stimulus, beta-blocker drugs or congenital heart disease; or otherwise unexplained
persistent depression over a 0.5-hr time period.
3- Mean respiratory rate >2 standard deviations above normal for age
4- Leukocyte count elevated or depressed for age or >10 percent immature neutrophils.

Edited by: Ahmed Gamal

Infectious SIRS [Sepsis]:
 Sepsis is the systemic inflammatory response to infection with
bacteria, viruses, fungi, protozoa, or rickettsiae.

 it is defined as Infectious SIRS i.e.

SIRS plus clinical and microbiological evidences of infection.
 Grades of sepsis:

It is defined as the presence of sepsis without manifestations of

Uncomplicated sepsis inadequate organ perfusion or function.
It is defined as sepsis with
at least one organ dysfunction or hypo-perfusion variable
Sepsis syndrome
 Organ dysfunction variables
(Severe Sepsis)  Tissue hypoperfusion variables
Hyperlactatemia >1 mmol/L
Delayed capillary refill or mottling
Severe sepsis with hypotension, despite adequate fluid
Septic shock resuscitation in the absence of other causes for hypotension.
Cardiovascular
 Hypotension <5th percentile for age or systolic BP >2 SD below
normal for age OR
 Need for vasoactive drug to maintain BP in normal range
(dopamine >5 mcg/kg/min or dobutamine, epinephrine, or
norepinephrine at any dose) OR
 Two of the following:
1) Unexplained metabolic acidosis: base deficit >5.0 mEq/L
2) Increased arterial lactate >2 times upper limit of normal
3) Oliguria: urine output <0.5 mL/kg/hr
4) Prolonged capillary refill: >5 secs
5) Core to peripheral temperature gap >3°C
Respiratory
 PaO2/FiO2 <300 in absence of cyanotic heart disease or preexisting
lung disease OR
Multiple organ system  PaCo2 >65 or 20 mmHg over baseline PaCo2 OR
failure  Need for >50% Fio2 to maintain oxygen saturation 92% OR
 Need for non-elective mechanical ventilation
Neurologic
 Glasgow coma score 11 OR
 Acute change in mental status with a decrease in GCS >3 points from
abnormal baseline
Hematologic
♣ Platelet count <80,000/microL or decline of 50% from highest
value recorded over the past three days OR
♣ INR >2
Renal
Serum creatinine 2 times upper limit of normal for age or
two-fold increase in baseline creatinine
Hepatic
 Total bilirubin ≥4 mg/dL (not applicable to newborn) OR
 ALT 2 times upper limit of normal for age
Edited by: Ahmed Gamal
 EARLY SEPTIC SHOCK:
Sepsis syndrome plus hypotension or poor capillary refill time that responds promptly to
IV fluids and/or pharmacologic interventions.
 REFRACTORY SEPTIC SHOCK:
Sepsis syndrome plus hypotension or poor capillary refill time that lasts > 1 hr despite
IV fluids and pharmacologic interventions, and requires vasopressor support.

Management of sepsis & septic shock

Sepsis syndrome or Septic Shock

EGDT
Sepsis

Early Goal Directed Therapy (EGDT)

 EGDT emphasizes:
1. Early recognition of patients with potential sepsis in the ED, support ABC
2. Early broad-spectrum antibiotics, and
3. Goal-directed therapy for those patients who remain hypotensive or severely ill after this initial
therapy.
Edited by: Ahmed Gamal
 The selection of specific antibiotics depends on:
 The presumed site of infection.
 Gram's stain results.
 Suspected or known organisms.
 Resistance patterns of the common hospital microbial flora.
 Patient’s immune status (especially neutropenia and immunosuppressive drugs), allergies,
renal dysfunction and hepatic dysfunction.
 Antibiotic availability, hospital resistance patterns, and clinical variables of patient to be treated.

ICU INFECTIONS
 25% of infections are confirmed gram negative:
♣ E.coli (25%)
♣ Klebsiellla/citrobacter (20%)
♣ Pseudomonas (15%)
♣ Enterobacter (10%)
♣ Proteus (5%)
♣ The remaining 25% is made up of different bacteriae.
 25% Gram positive: the common is:
 Staphylococcus aureus (35%), followed by
 Enterococcus (20%)
 Coagulase negative staphylococcus (15%)
 Streptococcus pneumoniae (10%)
 20% mixed gram positive/gram negative
 3% fungal: The vast majority of fungal infections are candida.

HOW TO APPLY EGDT?

1) Address A and B of the ABCs:
 Supplemental oxygen should be administered to all patients with suspected sepsis.
 Early intubation and mechanical ventilation should be strongly considered for patients with an
oxygen requirement, dyspnea or increased respiratory rate, hypotension or those with evidence
of poor peripheral perfusion.
 Patients with suspected sepsis should receive initial crystalloid fluid bolus of 20-30 mL/kg (1-2 L)
as well as broad-spectrum antibiotics.
2) Fluid Resuscitation
3) Hemodynamic Support
4) No improvement with catecholamines
5) Hydrocortisone Therapy
 Adrenal insufficiency should be suspected in
1- Catecholamine-resistant hypotensive shock.
2- History of CNS abnormality.
3- Chronic steroid use.
4- Purpura fulminans.
 Dose recommendations:
 Shock dose is 25 times higher than stress dose.
 50 mg/kg for shock, followed by the same dose as a 24-hr infusion.
Edited by: Ahmed Gamal