February 27, 2010

Infection, SIRS and Sepsis

This lady has developed sepsis due to necrotizing fasciitis involving the lower abdomen and inguinal region. The diseased part is removed up until the external oblique muscle and daily dressing is done with poviderm and chlorhexidine.

Infection is a Colonization of exogenous agent that is introduced into host from environment or when endogenous agent overcomes innate host immunity to cause disease.

Systemic Inflammatory Response Syndrome (SIRS) is a collection of syndrome characterized as presence of two or more of the following

a) Hyper/ hypothermia (temperature > 380C or <360C)

b) Tachycardia (heart rate >90 bpm)

c) Tachypnoea (Respiratory rate > 20 breath per minutes) or PaCO2 <32>

d) White cell count > 12X109l-1 or less than 4X109l-1

And without the evidence of infection.

Sepsis is a Systemic manifestation of SIRS with a documented infection.

Severe sepsis is the presence of sepsis with one or more (Multiple Organ Dysfunction syndrome) organ failure. Organ failure may be

a) Acute respiratory distress syndrome (lung)

b) Septic shock (heart)

c) Acute tubular necrosis (kidney)

d) Liver failure

e) DIVC (failure of blood coagulation system)

f) Disorder of central nervous syndrome.

Management of sepsis

1) Recognize the sepsis or impending sepsis

2) Establish the aetiology based on signs and symptoms

a. Blood culture and sensitivity

b. Urine culture and sensitivity

c. Throat swab for culture and sensitivity

d. Lumbar puncture for culture and sensitivity

e. Swab from abscess or wound.

3) Removal of causes of infection (abscess, necrotizing fasciitis)

4) Appropriate antibiotic therapy which is empirical broad spectrum antibiotic to cover gram negative, gram positive and anaerobs pathogen (Zinacef + flagyl). Once the pathogen is identified, then it is changed to antibiotic that is sensitive to the pathogen.

5) Prevention or treatment of shock (target urine output is at least 0.5-1 ml/kg/hour)

a) Insertion of at least 2 large bore IV canulla

b) Bladder catherization

c) Insertion of Long line with CVP measurement.

d) Fluid resuscitation

e) Close monitoring of vital sign.

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