Cor Pulmonale

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Introduction

Sepsis is the systemic response to infection, and is a common cause of death in hospitalized patients. Rates of sepsis have increased dramatically. It is now the 13th most common cause of death in the US, with approximately 600,000 cases per year. Disease of increasing severity includes:

bacteremia: bacteria in bloodstrea; may be asymptomatic or transient
sepsis syndrome: SIRS - altered organ perfusion, leading to hypoexia, decreased urine output, or altered mental status, or elevated lactate levels
septic shock: hypotension, despite IV fluids

The Case of...

a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.

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Causes and Risk Factors

The most commonly identified bloodstream pathogens include:

staphylococci
Streptococci
E coli
Enterobacter
Pseudomonas aeruginosa

Fungal causes are less likely but increasing in frequency.

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Pathophysiology

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Signs and Symptoms

Signs and symptoms of sepsis are non-specific. They include:

tachypnea and respiratory alkalosis (early sign)
fever, chills
hypothermia (poor prognosis)
tachycardia
hypotension
mental status changes or delirium
end-organ failure

Fever does not always occur, especially in the elderly and those with renal or liver failure.

Some organisms, especially gram-negatives, can cause ecthyma gangrenosum.

Assess underlying diseases, previous infections and antimicrobial therapy, and symptoms of local infection.

Inquire into travel, occupational exposure, or encounters with infectious sources.

Two or three sets of blood cultures have a sensitivity of 89% and 99%, respectively, in people with bacteremia.

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Investigations

lab investigations
diagnostic imaging

Lab Investigations

leukocytosis
leukopenia (common in overwhelming bacteremia, severe viral infections, alcoholics, elderly)

Diagnostic Imaging

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Differential Diagnosis

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Treatments

Early recognition and initiation of treatment is of paramount importance. Patients are best served in the ICU, especially if hypotensive.

Tissue perfusion can be maintained using crystalloid fluid recusitation, transfusion to kepp hematocrit >30%, and use of inotropes if necessary.

Antibiotics should be based on pathogen identified, local resistance patterns, and potential sites of infection. Early, broad-spectrum emperic therapy is necessary.

Glucose maintenance between 80-100 mg/dl can prevent death.

Activated protein C (drotrecogin-alpha) can reduce risk of mortality, but does increase risk of bleeding.