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    The following terrminology may be used when dealing with a septic patient.

    Infection 1: Infection
    A collection / accumulation of pathogenic organisms

    Definition 2: Systemic Inflammatory Response Syndrome (SIRS):

    By definition is present if any two of the following are present -
                    - Tachycardia > 90
                    - Tachypnoea with RR > 20 OR PaCO2 < 4.25
                    - Temperature > 38C or < 36C
                    - WCC > 12 or < 4 OR less than 10% immature neutrophils in the blood
                    
    Definition 3: Sepsis
                    

    SEPSIS = INFECTION + SIRS



    Definition 4: Severe sepsis: This term is distinct from septic shock.
                    

    Severe sepsis = Sepsis + Hypotension



    Definition 5: Septic shock:
    Septic shock by definition is severe sepsis (i.e. sepsis with hypotension) which does not respond to aggressive fluid resuscitation, thus requiring inotropic support within a ITU/HDU environment.

    Clinical features in the septic patient:
    Tachycardia, tachypnea, raised WCC and inflammatory markers, pyrexia/hypothermia
    Symptoms and signs related to the organ system affected infection:
                 - UTI: pain, foul smelling dark urine etc
                 - Chest: SOB, low saturations, cough
                 - Wound infection: discharge, pain, dehiscence
    Clammy, Warm peripheries (The latter is a distinct feature from other types of shock where peripheral vasoconstriction leads to cold peripheries. Whereas in sepsis vasodilatation due to bacterial toxins leads to warm peropheries. This in turn leads to reduced venous return, preload and reduced cardiac output leading to low blood pressure in severe sepsis and septic shock)
    Metabolic acidosis, raised lactate
    Hypotension and reduced urine output


    Management:
    Based on parameters above establish how unwell the patient is.
    - IV access, bloods, blood cultures, venous blood gas/arterial blood gas
    - Fluids (establish pre-resus fluid status clinically, i.e. check JVP, pitting oedema, crepts in the chest, mucus membranes, skin turgor, check fluid balance chart if available, check recent CXR, ECHOS, patients medication)
            - Choice of fluid: In sepsis crystalloid (normal saline Hartmann´┐Żs) or colloid may be used.
            - Catheterisation: If patient unable to move, has severe sepsis, low urine output, deranged U&Es
            consider catheterisation inorder to enable more intensive monitoring. However, this should not be carried out
            routinely in all patients as the catheter may also be an important source of sepsis.
    - Culture everything: blood, urine, sputum, wound swabs
    - Routine investigations - CXR, ECG
    - Antibiotics: Choice dependent on most likely presumed source. Use local protocols and guidelines when choosing antibiotics and check recent microbiology results/organisms grown and sensitivity profiles.
    - Regular observations
    - Critical care outreach input or a more formal ITU review should be requested if condition deteriorating or in septic shock. In patients with comorbidities especially those with cardiac problems who require close fluid status monitoring will benefit from early intensive care input where appropriate.


Author: Mr Kasun Wanigasooriya MBCHB, MRCS  | Speciality: General Surgery  | Date Added: 02/07/2011

   
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