12.12.03 Sepsis teaching

Indications for dialysis

• • AKI: AEIOU

    • Acidemia

      • From metabolic acidosis

      • In situations in which correction with sodium bicarbonate is impractical or may result in fluid overload

    • Electrolyte abnormality

      • e.g. Severe hyperkalemia

    • Intoxication

      • Acute poisoning with a dialyzable substance: SLIME

        • Salicylic acid

        • Lithium

        • Isopropanol

        • Magnesium-containing laxatives

        • Ethylene glycol

    • Overload of fluid

      • Not expected to respond to treatment with diuretics

    • Uremia complications

      • Pericarditis, encephalopathy, gastrointestinal bleeding

  • Chronic indications for dialysis:

    • Symptomatic renal failure

    • GFR of less than 10-15 mls/min/1.73m2

      • In diabetics, dialysis is started earlier

    • Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low

Indications for ventilation

• • Acute lung injury

    • ARDS, trauma

  • Apnea with respiratory arrest

    • Including cases from intoxication

  • COPD

  • Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 6.65 kPa and pH < 7.25

    • e.g. Paralysis of the diaphragm due to Guillain-Barré syndrome, Myasthenia Gravis, spinal cord injury, or the effect of anaesthetic and muscle relaxant drugs

  • Increased work of breathing

    • As evidenced by significant tachypnea, retractions, and other physical signs of respiratory distress

  • Hypoxemia with arterial partial pressure of oxygen (PaO2) < 7.3 kPa on 100% oxygen

  • Hypotension

    • Including sepsis, shock, congestive heart failure

  • Neurological diseases

    • e.g. Muscular Dystrophy, Amyotrophic Lateral Sclerosis

Indications for extended courses of antibiotics

• • Rheumatic fever

  • Post-Strep GN

CURB-65 score

• • Items

    • Confusion of new onset (AMTS of 8 or less)

    • Urea greater than 7 mmol/l

    • Respiratory rate > 30

    • Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less

    • age 65 or older

  • Admit if score >1

Hospital-acquired pneumonia

• • Two classes:

    • MRSA

    • Gram negatives

      • E. coli

      • Klebsiella

      • Psudomonas

  • Can travel up lymphatics from the gut

Treatment of pneumonia

• • CURB-65 >2

    • Tazocin

  • CURB-65 1 or 2

    • Ampicillin

  • Atypicals

    • Clarythromycin or tetracycline

HACEK endocarditis (Kids)

• • Haemophilus

    • Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus

  • Actinobacillus

    • Actinobacillus actinomycetemcomitans, Aggregatibacter aphrophilus

  • Cardiobacterium hominis

  • Eikenella corrodens

  • Kingella

    • Kingella kingae

Indications for transfusion

• • Hb <7

  • Hb <9 if ischaemic heart disease

NIV

• • CPAP is for type I respiratory failure

    • Also useful in pulmonary oedema - Drives fluid out of alveoli

  • BiPAP is for type II failure

Monitoring fluid challenges

• • Stroke volume variation

  • CVP

  • Mixed venous sats

  • Urine output

  • BP

Inotropes

• • Inodilators

    • Dobutamine

    • Dopexamine

  • Inoconstrictors

    • Noradrenaline

    • Vasopressin

Multiple myeloma

• • Diagnostic criteria

    • Symptomatic myeloma:

      • Clonal plasma cells >10% on bone marrow biopsy or (in any quantity) in a biopsy from other tissues (plasmacytoma)

      • Paraprotein in either serum or urine (except in cases of true non-secretory myeloma)

      • Evidence of end-organ damage felt related to the plasma cell disorder (CRAB):

        • HyperCalcemia (corrected calcium >2.75 mmol/L)

        • Renal insufficiency attributable to myeloma

        • Anemia (hemoglobin <10 g/dL)

        • Bone lesions

    • Asymptomatic (smoldering) myeloma:

      • Serum paraprotein >30 g/L AND/OR

      • Clonal plasma cells >10% on bone marrow biopsy AND

      • NO myeloma-related organ or tissue impairment

    • Monoclonal gammopathy of undetermined significance (MGUS):

      • Serum paraprotein <30 g/L AND

      • Clonal plasma cells <10% on bone marrow biopsy AND

      • NO myeloma-related organ or tissue impairment

  • Complications

    • Infection, due to immune paresis

Neurogenic shock

• • Distributive shock, featuring hypotension, occasionally with bradycardia

  • Due to disruption of the autonomic pathways within the spinal cord

    • Hypotension occurs due to decreased systemic vascular resistance resulting in pooling of blood within the extremities lacking sympathetic tone

    • Bradycardia results from unopposed vagal activity

C. diff

• • "Treatment-associated infection"

  • Treatment

    • Metronidazole

    • Oral vancomycin

    • Stool transplant

    • Fidaxomycin?

    • IVIG

    • Toxin binders

  • Rectal catheter

  • Complications

    • Diarrhoea

    • Pseudomembranous colitis

Sepsis bundles

• • Sepsis Resuscitation Bundle

    • Measure serum lactate

    • Obtain blood cultures prior to antibiotic administration

    • Administer broad-spectrum antibiotic within 3 hours of ED admission and within 1 hour of non-ED admission

    • Treat hypotension and/or elevated lactate with fluids; Apply vasopressors for ongoing hypotension

    • Maintain adequate central venous pressure and central venous oxygen saturation

  • Sepsis Management Bundle

    • Administer low-dose steroids for septic shock in accordance with a standardized ICU policy.

    • Maintain glucose control lower limit of normal, but <10 mmol/L

    • Maintain a median inspiratory plateau pressure (IPP) <30 cm H20 for mechanically ventilated patients

Notes

• • 1/3 of the world has TB

    • So check for it, even if something else has been isolated!

  • Staph pneumonia

    • IVDUs

    • Secondary infection on top of 'flu

  • Hypercalcaemia => Nephrogenic diabetes insipidus

  • Liver perfusion can drop to 1% in sepsis

  • Anticoagulation (warfarin) required if albumin is <20

  • Fusidic acid is good for penetrating bone and pus

  • Carbohydrates in ORT / Rice water reactivates gut wall cells

  • ITU: Brush their teeth!

  • > 60% O2 damages lungs

    • Permissive hypercapnia

  • Surviving sepsis campaign

  • Acinetobacter = New, deadly, resistant

  • ESBL organisms

    • Plasmid-spread

  • New Delhi metalo-beta lactamase

    • Breaks down carbapenams

  • Linezolid

    • Last-line, vs Gram +ve organisms

    • VRSA, Vancomycin resistant enterococcus

  • Sentinel flocks for bird flu

  • Smallpox is the most infectious thing ever

  • Clinical sign of thrombocytopaenia = Bleeding from mouth / blood blisters