Sepsis

SIRS (SYSTEMIC INFLAMMATORY RESPONSE SYNDROME)

Systemic Inflammatory Response Syndrome (SIRS) is defined as an “abnormal, generalized inflammatory reaction remote from the initial insult.”

In severe sepsis, the body's balance between inflammatory and anti-inflammatory chemical responses gets out of whack. A massive release of pro-inflammatory mediators creates an uncontrolled inflammatory response. This systemic inflammatory response is known as SIRS (systemic inflammatory response syndrome).

Once SIRS is underway, impaired fibrinolysis interrupts the body's normal clotting cascade, and the blood begins to clot abnormally. Critical microvasculature, essential to supplying oxygen to the body's organs, begins to clog and fail. Systemic inflammation, vasodilatation and capillary leakage contribute to hypotension and the rapid slide into end-organ hypoxia and failure.

PURPOSEThis protocol is to be used on patients suspected of being severely septic. Sepsis is a clinical syndrome that results from the human body’s response to

infection.

While bacteria probably account for most cases, sepsis can also be the result ofinfection by fungi, viruses and parasites.

CLINICALLY, IT IS THE PRESENCE OF TWO OR MORE OF THE FOLLOWING:

Temperature less than 96.8°F or greater than 100.4°F. Heart rate greater than 90 bpm. Respiratory rate greater 20 or a ETCO2 ≤ 25 mmHg. White blood cell count less than 4,500 or greater than

10,000 l/mm.

SEPSIS IS MORE LIKELY TO OCCUR IN SEVERAL HIGH-RISK POPULATIONS.

Always have a higher index of suspicion when evaluating the elderly or the very young, patients who are bed confined or immobile, and patients who have had recent surgeries or invasive medical procedures.

Also, be highly suspicious of patients receiving immunosuppressive treatments like chemotherapy or post-organ transplant medications.

Recognize that some disease processes leave the patient naturally immuno-compromised. This is the case with diabetes, liver cirrhosis, autoimmune disease and HIV/AIDS populations.

SEVERE SEPSIS

Severe sepsis is characterized by poor perfusion, leading to a buildup of serum lactate and resulting metabolic acidosis. EtCO2 levels decline in the setting of both poor perfusion and metabolic acidosis. To compensate for metabolic acidosis, patients increase their minute ventilation. This increased respiratory rate “blows off” carbon dioxide and lowers EtCO2. At the same time, poor tissue perfusion decreases the amount of blood flow to the alveoli of the lungs, reducing the amount of carbon dioxide that can be exhaled—the most dramatic demonstration of this process is during cardiac arrest. Therefore, EtCO2 is inversely proportional to lactate: As lactate levels rise in septic patients, EtCO2 levels drop.

Previous studies have shown that low EtCO2 levels correlate with elevated lactate levels and predict mortality in patients with suspected sepsis, severe sepsis and septic shock. In fact, low pre-hospital EtCO2 levels predict metabolic acidosis and mortality across a wide spectrum of patient complaints.

SEPTIC SHOCK

Septic shock is low blood pressure due to sepsis that does notimprove after reasonable amounts of intravenous fluids are given.

In severe sepsis and septic shock, broad-spectrum antibiotics (usually two or a β-lactam antibiotic with broad coverage) are recommended. Some recommend they be given within 1 hour of making the diagnosis stating that for every hour delay in the administration of antibiotics, there is an associated 7.6% rise in mortality.Approximately 20–35% of people with severe sepsis and 30–70% of people with septic shock die.

IS THIS SEPTIC SHOCK WITH PNEUMONIA?

BASIC LEVEL: EMT AND PARAMEDIC Initial Patient Assessment Protocol 2.1.1 Airway Assessment/Management Protocol 2.1.2. Oxygen via nasal cannula @ 2 - 4 LPM to maintain pulse ox ≥ 94% (non-rebreather

@15LPM if SpO2 < 90%). If sepsis is suspected, use nasal cannula capable of measuring end tidal CO2.

Attach cardiac monitor and pulse oximeter. Measure and/or record patient’s temperature. Assess for possible source of infection:

Ask about recent illnesses, surgeries, invasive procedures or trauma. Has the patient had arespiratory infection or been feeling ill? Ask about symptoms of gastrointestinal or bladder infections, abdominal discomfort and unusual body or joint pain. Also ask about current or past prescriptions for antibiotics, steroids or immuno-suppressants.

ALS LEVEL 1: PARAMEDIC ONLY

Notify receiving hospital of a possible sepsis patient (call sepsis alert ifapplicable) if patient meets the following three criteria: Suspected infection based on history and physical exam. Two or more of the following:

Temp > 100.4 F or < 96.8 FRespiratory Rate > 20 breaths/minHeart Rate > 90 beats/min

EtCO2 ≤ 25 mmHg Initiate IV of Normal Saline. If BP Systolic ≤ 90 mm Hg, bolus with 250

ml IV fluid and repeat prn up to 2 liters. Check vital signs and breath sounds in-between each bolus.

ALS LEVEL 2: MEDICAL CONTROLContact Medical Control or Medical Director for any questions

orProblems.

CAPNOGRAPHYCapnography, a well-known tool in EMS, provides valuable

information not only about ventilation but perfusion as well. As long as the body is metabolizing glucose and oxygen, waste products will be eliminated into the bloodstream. They can only be released into the alveolus if there’s normal perfusion of the lung with blood.

As perfusion decreases, so does the EtCO2. This results in elevation of the metabolic waste, which is comprised mainly of lactic acid. Therefore, EtCO2 level is inversely proportional to lactate levels. As we see lactate levels rise in septic patients, we see EtCO2 levels drop. EtCO2 readings of less than 25 mmHg in the clinical setting of shock are associated with significant increase in mortality. Patients with EtCO2 of 25 mmHg may have lactate levels as high as 6.1 mmol/L. Capnography can be monitored and helpful in assessing the impact of therapies designed to improve perfusion.

This method of sepsis detection, however, is being underused.

ETCO2

IMMUNOSUPPRESSANTSImmunosuppressants are drugs or medicines that lower the

body's ability to reject a transplanted organ. Another term for these drugs is anti-rejection drugs. There are 2 types of immunosuppressants:Induction drugs: Powerful antirejection medicine used at the time of transplant.Maintenance drugs: Anti-rejection medications used for the long term.

There are usually 4 classes of maintenance drugs:•Calcineurin Inhibitors: Tacrolimus and Cyclosporine.•Anti-proliferative agents: Mycophenolate Mofetil, Mycophenolate Sodium and Azathioprine.•mTOR inhibitor: Sirolimus.•Steroids: Prednisone.

COMMON IMMUNOSUPPRESSANT DRUGS

STEROIDS

A steroid is an organic compound with four rings arranged in a specific configuration. Examples include the dietary lipid cholesterol, the sex hormones estradiol and testosterone and the anti-inflammatory drug dexamethasone. Steroids have two principal biological functions: certain steroids are important components of cell membranes which alter membrane fluidity, and many steroids are signaling molecules which activate steroid hormone receptors.

SEPSIS EVEN MORE DEADLY FOR STEROIDS USERSDoctors say that sepsis has occurred when a pathogen – usually a bacteria –

gets into the bloodstream. Extremely aggressive bacteria can cause fatal septic shock, which means that organs close off their blood supply and die off through lack of oxygen.

In theory, anabolic hormones raise the chance of septic shock occurring. IGF-1 activates the molecular switches extracellular-signal-regulated kinases 1 and 2 and nuclear factor kappa B in the body's cells. These molecular switches are involved in anabolic processes, but also in inflammatory reactions, which cells use to protect themselves against pathogens. In extreme cases of exposure to these substances, the immune reactions that occur cause septic shock.

So if a pathogenic bacteria ends up in the bloodstream of a steroids user, you would expect his body to react more severely than that of a non-user.

ANTIBIOTICSAntibiotics, also called anti-bacterials, are a type of

antimicrobial drug used in the treatment and prevention of bacterial infections. They may either kill or inhibit the growth of bacteria.

Antibiotics are not effective against viruses such as the common cold or influenza and may be harmful when taken inappropriately.

ANTIBIOTICS

Penicillin Metronidazole

Erythromycin

Amoxicillin

Cephalosporin Tetracycline

Ciprofloxacin

JEMS ASSESSING $ MANAGING SEPSIS IN THE PREHOSPITALSETTINGThu Oct 29, 2015 By Keith Widmeier, BA< NRP< FP-C, Keith Wesley, MD, FACEP

Ergo-log.com 02-28-2015Kaohsiung J Med Sci June 27, 2011