1. بنام خدا

2. کيس
بيماردختر 17 ساله است اهل گيلا ن بعلت تب ولرز تکان دهنده دربيمارستان بستری ميگردددرشرح حال بيمار سابقه تالاسمی واسلپکتومی رادر سال قبل ذکر می کند بيمار از 6 روز قبل بطورناگهانی دچار تب ولرز تکان, تنگی نفس شدن , بيمار اسهال نيز دارد سوزش ادرار وتکررادرار ندارد.
درمعاينه:
T= 39/5 , BP = 110/80 .PR= 140, RR=45

3. درمعاينه بيمار فوالعاده توسيک است کم لنفوژپوری دارد رودوگردن ندارد
درمعاينه بيمار فوالعاده توسيک است کم لنفوژپوری دارد رودوگردن ندارد .درمعاينه ريه کراکل ودرريه ودسمع قلب تاکيکاردی شديددارد , درمعاينه شکم تندرنس در هيپوکنوراست دارد
آزمايش اوليه:
راديوگرافی ريه : انفليتراسيون وسيع دوطرفه ريه دارد.
WBC = pog =80% Band =%10
SGT = 250
Hb = SLM =140
HCT = PT = 15
RBS = NU = 135
R = 4/5

4. Sepsis SIRS Two or more of the following conditions
1- Fever > 38 or hypothermia<36
2- Tachypnea >24
3- Tachycardia>90
4- Leukocytosis >12000, or<40000, band>10%

5. Sepsis syndrome Sepsis with one or more sign of organ dysfunction
1- Cardiovascular: BP90 or mean arterial pressure≤70
2- Renal urine out put <0/5ml/Kg per hours
3- Respiratory:
4- Haematologic :platelet <80000 or 50%decrease in platelet count

6. Sepsis syndrome
5- Unexplained Metabolic acidosis PH≤7.30 or base deficit ≥5meq /L
Or plasma lactate Level >1/5 times upper Limit of normal
6- Adequate fluid resuscitation :pulmonary artery wedge pressure ≥12 mmHg or CVP≥ 8mmHg

7. Septic shock 1- Sepsis with hypotension BP<90
Or 40 mmhg less than patients normal blood pressure for at least 1hr despite adequate fluid
resuscitation Or
2- Need for vasopressors to maintain systolic blood pressure ≥90 mmHg
Mean arterial pressure ≥70 mmHg

8. Refractory septic shock
Septic shock that lasts for >1hr and does not respond to fluid or pressor administration

9. Multiple – organ dysfunction
Dysfunction of more than one organ , requiring intervention to maintain homeostasis

10. Etiology Gram – Negative bacteria 40% Gram – positive bacteria 31%
Fungi 6%
Poly microbial 16%

11. Condition that may predispose to Infections
Gram- negative bacilli
Diabetic mellitus
Lymphoproliferative diseases
Cirrhosis
Burns
Invasive procedures or devices
Neutropenia
Indwelling urinary catheter
Diverticulitis , perforated viscous

12. Conditions that may predispose to infections
Gram – positive bacteria
Intravascular catheters
Indwelling mechanical devices
Burns
Neutropenia
Intra venous drug use
Infection with super antigen – producing streptococcus pyogenes

13. Condition that may predispose to Infections
Fungi
Neutropenia
Broad – spectrum antimicrobial therapy

14. Diagnosis There is no specific diagnostic test
1- blood culture and other culture
2- Leukocytosis
3- Thrombocytopenia
4- Leukopenia
5- Hyperbilirubinemia
6- proteinuria
7- D- dimer
8- decreased fibrinogen

15. Treatment 1- Hemodynamic support 2- Antibiotic therapy 3- Vasopressors
4- Steroids
5- Human Activated protein C
6- Glucose control
7- Renal Replacement
8- Bicarbonate therapy
9- Deep vein thrombosis prophylaxis
10 - Stress ulcer prophylaxis

16. Treatment 1- Hemodynamic support (goals )
Central venous pressure mmHg
Mean arterial pressure ≥65 mmHg
Urine output ≥0/5 ml .kg .hr
Central venous mixed venous oxygen saturation≥70%

17. Treatment 2- Antibiotic therapy Immunocompetent adult Ceftriaxone
Tazocin
Imipenem
Meropenem
Cefepime

18. Antibiotic therapy Allergic to ß lactam agents
Ciprofloxacin (IV) plus Clindamycin

19. Antibiotic therapy Neutropenia Imipenem Meropenem + Aminoglycoside
Cefepime
Tazocin
Vancomycin?

20. Antibiotic Therapy Spelenectomy Ceftriaxone ± Vancomycine
Allergic to ß lactam
Vancomycine ± Plus Ciprofloxacin

21. Antibiotic Therapy IV Drug User Nafcillin Or } + Gentamycin Oxacillin
MRSA or Allergic to ß- Lactam
Vancomycin + Gentamycin