SEPSIS   80A

A 65-year-old woman is admitted to the hospital with community-acquired pneumonia. She is treated with intravenous (IV) antibiotics and oxygen. A Foley catheter is inserted. On hospital day 3, she is switched to oral antibiotics. However, she then develops fever and tachycardia. Blood and urine cultures are ordered. The following morning, she is difficult to arouse. Her temperature is 35°C, blood pressure 85/40 mm Hg, heart rate 110 beats/min, and respiratory rate 25 breaths/min. Lung examination is unchanged from admission, with rales at the left base. Cardiac examination reveals a rapid but regular rhythm without murmurs, gallops, or rubs. Abdominal examination is normal. Extremities are warm. Neurologic examination is nonfocal. The patient is transferred to the intensive care unit with presumed sepsis and given IV fluids and broad-spectrum antibiotics. Blood and urine cultures are positive for gram-negative rods.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Foley catheter; hypotension; hypothermia, tachycardia, tachypnea; warm extremities (suggest decreased systemic vascular resistance [SVR]); positive blood and urine cultures

How to think through: First, consider other causes of shock (hypovolemic, cardiogenic, obstructive, other distributive). What physical finding makes blood loss or cardiogenic shock less likely? (These are states of increased SVR, but her skin is warm.) A high suspicion for sepsis is important since early intervention improves outcomes. What are the key components of management of septic shock? (Restore perfusion; ensure adequate oxygenation; identify and treat the infection [use broad-spectrum antibiotics initially and then narrow coverage based on blood cultures].) Replete intravascular fluids aggressively. If the patient remains hypotensive, use vasopressors. What end-organ effects of poor perfusion can one monitor? (Mental status; urine output; lactic acidemia, cardiac ischemia or arrhythmia; peripheral perfusion [pulses, capillary refill].) What are important complications of sepsis? (Disseminated intravascular coagulation; renal and hepatic hypoperfusion; acute respiratory distress syndrome.)

SEPSIS   80B

What are the essentials of diagnosis and general considerations regarding sepsis?

Essentials of Diagnosis

Fever, tachycardia, elevated white blood cell (WBC) count, or increased respiratory rate

Proven or probable source of infection; bacteremia with positive blood cultures

Elevated lactate or end-organ dysfunction in severe disease; hypotension in septic shock

General Considerations

Sepsis is defined as meeting SIRS criteria with a known source of infection

SIRS is two or more of the four following criteria: temperature <36°C or >38°C; heart rate >90 beats/min; respiratory rate >20 beats/min or PaCO₂ <32 mm Hg; WBC count <4000/mcL or >12,000/mcL or differential with >10% bands

Gram-negative bacteremia usually originates from the genitourinary system, hepatobiliary tract, gastrointestinal tract, and lungs but may also be from wounds and decubitus ulcers

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