Systemic Inflammatory Response Syndrome SIRS and Septicemia

Systemic Inflammatory Response Syndrome SIRS and Septicemia - SOFA score APACHE score MODS Failure DIC

1. SYSTEMIC INFLAMMATORY RESPONSE SYNDROME(SIRS) AND SEPTICEMIA SUBJECT SEMINAR GUIDE: DR AMEET KATAWKAR STUDENT: DR GANESH

2. Sepsis (derived from the Greek word sepo meaning “ decay or putrefaction ”), septic shock (derived from the French word choquer meaning ‘to collide with ’)

3. Sepsis Defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock I s a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality

4. Q SOFA as a screening tool for mortality Prediction and takes less time as compared to SOFA • >2 of the following criteria – Hypotension Systolic BP<100mmHg – Altered mentation-GCS<15 – Tachypnea -RR>22/min

5. Why the new definition? • 1 out of 8 patients with sepsis were missed with the SIRS definition • “SIRS criteria lacked sensitivity and specificity ” • Why the focus on organ dysfunction? – In-hospital mortality > 10% ( more than mortality for STEMI)

6. Drawbacks of newer definitions • Older definitions – Do not require organ failure to be present – May capture patients earlier before organ failure takes place • New algorithm – Does not encourage early diagnosis – False re-assurance

7. Specificity also not great • Mortality predictors and NOT tests to detect sepsis • Positive qSOFA not always means Sepsis • Must not miss other diagnosis ! -May over-admit patients in icu …resource limited settings

8. COMPENSATORY ANTI-INFLAMMATORY REACTION SYNDROME (CARS) Patients during the later ( > 72 hours) and recovery phases of sepsis frequently acquire new infections N ot exhibit the overwhelming vascular responses as seen in ‘ new’ episodes of sepsis . Relative immunosuppression may derive from a change in the balance of pro-inflammatory and anti-inflammatory cytokines Catecholamine-induced immunosuppression alteration in the T helper cell responses

9. EPIDIMIOLOGY Worldwide , 13 million people become septic each year and 4 million die . In I ndia , this accounts for 1750 000 cases per year 215 000 resultant deaths, and annual costs of 16.7 billion dollars .

10. Microbial invasion of the bloodstream is not essential because local inflammation can also elicit distant organ dysfunction and hypotension. In fact, blood cultures yield bacteria or fungi in only ~20–40% of cases of severe sepsis and 40–70% of cases of septic shock. In a prevalence study of 14,414 patients in intensive care units (ICUs) from 75 countries in 2007, 51% of patients were considered infected.

11. Respiratory infection was most common (64%). Microbiologic results were positive in 70% of individuals considered infected; 62 % were gram-negative bacteria ( Pseudomonas species and E coli were most common), 47 % were grampositive bacteria ( Staphylococcus aureus was most common), 19 % were fungi ( Candida species)

12. OTHER THAN INFECTION/ mimics . Trauma , burns and pancreatitis . Inhalation injuries. Massive blood loss/transfusion. Drug related(including overdose ) Myocardial infarction, drowning, hyperthermia , pulmonary embolus.

13. HMGB1, high-mobility group box 1 protein; PAI-1, plasminogen activator inhibitor-1 ; PAMP, pathogen-associated molecular pattern; STNFR, soluble tumor necrosis factor receptor; TF, tissue factor; TFPI, tissue factor pathway inhibitor .

14. SPRECTUM OF SEPSIS

15. IN LUNGS

16. CLUES TO IDENTIFY CAUSITIVE AGENT • FEVER AND THROMBOCYTOPENIA : – Dengue fever – Malaria – Leptospirosis – Rickettsial infections – Viral infections

17. FEVER WITH HEPATORENAL DYSFUNCTION : – Falciparum malaria – Leptospirosis – Scrub typhus – Hepatitis E or A (with fulminant hepatic failure)

18. FEVER WITH PULMONARY-RENAL SYNDROME: – Falciparum malaria acute respiratory distress syndrome (ARDS) – Leptospirosis (ARDS or alveolar hemorrhage ) – Hantavirus infection – Scrub typhus – Severe pneumonias (due to Legionella / Pneumococcus

19. FEVER WITH ALTERED SENSORIUM: – Cerebral malaria – Encephalitis – Meningitis – Typhoid fever – Septic encephalopathy

20. Meningococcal rash

21. INVESTIGATIONS

22. ROUTINE INVESTIGATIONS 1.Complete haemogram 2.RFT and serum electrolytes 3.Urine analysis 4.ABG Analysis 5.Chest xray 6.ECG 7.GRBS 8.LFT

23. BLOOD CULTURE

24. BLOOD CULTURE : • 10ml from each blood sample drawn is inoculated into an aerobic bottle and 10 mL into an anaerobic bottle. • An isolator tube of 10 mL of blood should be drawn if any of the following are suspected. Bartonella , Bordetella , Francisella , Histoplasma capsulatam , Legionella , Mycobacterium sp. These will be incubated for longer than 4 days before being considered negative .

25. BIOMARKERS C-REACTIVE PROTEIN correlated with an increased risk of organ failure and death. The study of CRP trends may be helpful to evaluate the response to therapy in septic patients. PRESEPSIN predicting mortality as compared to acute physiology and chronic health evaluation (APACHE) 2 and PCT .

26. PROCALCITONIN I ncreases the expression of proinflammatory cytokines by leukocytes and reduces neutrophil migration, augments sepsis-induced increases in nitric oxide release, and increases mortality in septic animals

27. HEPARIN BINDING PROTEIN It is an early marker of circulatory failure in sepsis. Combination of PCT, CRP and lactate levels may be more useful than any biomarker individually. TREM The plasma concentration of soluble TREM-1 (Triggering receptor expressed on myeloid cells) a member of immunoglobulin

28. Blood film showing “toxic” neutrophils, with coarse cytoplasmic granules and vacuolation of the cytoplasm.

29. A chest radiograph in an intravenous drug abuser with sepsis demonstrating multiple small peripheral opacities.that these opacities represent cavities, typical of staphylococcal abscesses .

30. Chest radiograph of a right lower lobe pneumonia with collapse , loss of lung volume manifest as a shift of the mediastinum to the right.

31. A plain abdominal radiograph showing gas in the wall of the gallbladder in the right upper quadrant in a diabetic patient with sepsis and right upper quadrant pain: the diagnosis is emphysematous cholecystitis .

32. A transvaginal ultrasound image of the uterus in a patient with an intrauterine contraceptive device (IUCD) in situ and a foul-smelling vaginal discharge . The endometrial cavity is distended by reflective pus ( pyometria ),

33. An ultrasound image of a grossly hydronephrotic kidney. Specular internal echoes within the fluid raise the possibility of pyonephrosis . In the context of sepsis, urgent nephrostomy is required .

34. MRI showing an infective discitis of the L2–L3 disc. Low-signal oedema is seen in the vertebral bodies either side of the disc on the T1-weighted image (arrows), high signal pus is seen in the disc space on the T2-weighted image, with destruction of the vertebral endplate on either side (dotted arrows). The infected disc bulges posteriorly to compress the lumbar thecal sac.

35. Computerized tomography (CT )-showing a pelvic collection in the rectovesical fossa .

36. coronal reformats of CT of the thorax reveal the primary source of infection – a pleural empyema containing a pocket of gas seen laterally in the right hemithorax . The coronal section demonstrates the convex medial border indenting the lung

37. Contrasted axial computerized tomography (CT) of the head shows a biconvex low-density collection with rim enhancement (arrows) in the left frontal region representing an extradural empyema in this patient with sepsis

38. VERIGENE SYSTEM

39. INITIAL ASSESMENT

40. SURVIVING SEPSIS CAMPAIGN: INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEPSIS AND SEPTIC SHOCK: 2016

41. A. INITIAL RESUSCITATION 1.Rescuscitation should be started asap 2.At least 30 mL/kg of IV crystalloid fluid be given within the first 3 hours 3.Additional fluids be guided by frequent reassessment of hemodynamic status . Reassessment should include a thorough clinical examination and evaluation of available physiologic variables as well as other non-invasive or invasive monitoring, as available .

42. Ability to predict a response to a fluid challenge when the CVP is within a relatively normal range is limited . The same holds true for other static measurements of right or left heart pressures or volumes. Dynamic measures of assessing whether a patient requires additional fluid have been proposed in an effort to improve fluid management and have demonstrated better diagnostic accuracy at predicting those patients who are likely to respond to a fluid challenge by increasing stroke volume .

43. 4. F urther hemodynamic assessment (such as assessing cardiac function) to determine the type of shock 6.An initial target mean arterial pressure of 65 mm Hg in patients with septic shock requiring vasopressors . 7 . Suggested guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

44. SUGGESTED GOALS FOR RESUSCITATION ENDPOINTS ARE AS FOLLOWS: • Mean arterial blood pressure > 65 mmHg • Improving capillary refill time • Warming of extremities • Urine output > 0.5 ml/kg/hour • Improving mental status • Decreasing lactate

45. B. SCREENING FOR SEPSIS AND PERFORMANCE IMPROVEMENT I ncluding sepsis screening for acutely ill, high risk patients C . DIAGNOSIS Appropriate routine microbiologic cultures (including blood) be obtained before starting antimicrobial therapy in patients with suspected sepsis or septic shock Appropriate routine microbiologic cultures always include at least two sets of blood cultures ( aerobic and anaerobic).

46. D. ANTIMICROBIAL THERAPY 1 . A dministration of IV antimicrobials should be initiated as soon as possible after recognition and within one hour for both sepsis and septic shock. 2 . E mpiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens (including bacterial and potentially fungal or viral coverage ) 3.Empiric antimicrobial therapy be narrowed once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted

47. a) The anatomic site of infection b ) Prevalent pathogens within the community, hospital, and even hospital ward c ) The resistance patterns of those prevalent pathogens d ) The presence of specific immune defeciency status e)Age and patient comorbidities including chronic illness (e.g ., diabetes) and chronic organ dysfunction (e.g., liver or renal failure) f)Presence of invasive devices (e.g ., central venous lines or urinary catheter) that compromise the defense to infection. SELECTION OF ANTIBIOTICS DEPENDS ON

48. clinician must assess risk factors for infection with multidrug-resistant pathogens including prolonged hospital/chronic facility stay, recent antimicrobial use, prior hospitalization, prior colonization or infection with multidrug- resistant organisms

49. IMMUNOCOMPETENT ADULT The many acceptable regimens include piperacillin-tazobactam (3.375 g q4–6h ); imipenem-cilastatin (0.5 g q6h), ertapenem (1 g q24h), or meropenem (1 g q8h); or ( 3) cefepime (2 g q12h ). If the patient is allergic to β-lactam agents, use ciprofloxacin (400 mg q12h) or Levofloxacin (500–750 mg q12h) plus clindamycin (600 mg q8h ). Vancomycin (15 mg/kg q12h) should be added to each of the above

50. SPLENECTOMY Cefotaxime (2 g q6–8h) or ceftriaxone (2 g q12h) should be used. If the local prevalence of cephalosporinresistant pneumococci is high, add vancomycin . If the patient is allergic to β- lactam drugs, vancomycin (15 mg/kg q12h) plus either moxifloxacin (400 mg q24h) or levofloxacin (750 mg q24h) should be used.

51. IV DRUG USER Vancomycin (15 mg/kg q12h) is essential. AIDS Cefepime alone (2 g q8h) or piperacillintazobactam (3.375 g q4h) plus tobramycin (5–7 mg/kg q24h) should be used . If the patient is allergic to β- lactam drugs , ciprofloxacin (400 mg q12h) or levofloxacin (750 mg q12h) plus vancomycin (15 mg/kg q12h) plus tobramycin should be used.

52. NEUTROPENIA (<500 NEUTROPHILS/ Μ L) ( 1) imipenem cilastatin (0.5 g q6h) or meropenem (1 g q8h) or cefepime (2 g q8h) or ( 2) piperacillin-tazobactam (3.375 g q4h ) plus tobramycin (5–7 mg/kg q24h ). Vancomycin (15 mg/kg q12h) added if patient have chances of getting MRSA infections; Antifungals should be added if the patient is hypotensive, has been receiving broad-spectrum antibacterial drugs , or remains febrile 5 days after initiation of empirical antibacterial therapy .

53. 4. Antimicrobial prophylaxis in patients with severe inflammatory states of non-infectious origin (e.g., severe pancreatitis, burn injury ) not adviced 6. S uggest empiric combination therapy (using at least two antibiotics of different antimicrobial classes) aimed at the most likely bacterial pathogen(s) for the initial management of septic shock

54. 7 . S uggest that combination therapy not be routinely used for ongoing treatment of most other serious infections, including bacteremia and sepsis without shock 8 . C ombination therapy for the routine treatment of neutropenic sepsis/ bacteremia not adviced

55. 9. De-escalation 10 . Suggested that an antimicrobial treatment duration of 7 to 10 days is adequate for most serious infections associated with sepsis and septic shock. 11 . Suggested longer courses are appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with Staphylococcus aureus , fungal and viral infections, or immunologic deficiencies, including neutropenia

56. uncomplicated S aureus bacteremia requires at least 14 days of therapy while complicated bacteremia requires treatment as an endovascular infection with 6 weeks of therapy. Uncomplicated bacteremia has been defined as: 1 ) exclusion of endocarditis , 2) no implanted prostheses, 3 ) negative results of follow-up blood cultures drawn 2 to 4 days after the initial set , 4 ) defervescence within 72 hours after the initiation of effective antibiotic therapy, 5 ) no evidence of metastatic infection

57. 12.Shorter courses are appropriate in some patients, particularly those with rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis and those with anatomically uncomplicated pyelonephritis 13.Daily assessment for de-escalation of antimicrobial therapy in patients with sepsis and septic shock. 14 . M easurement of procalcitonin levels can be used to support shortening the duration of antimicrobial therapy

58. E. SOURCE CONTROL 1.Specific anatomic diagnosis of infection requiring emergent source control should be identified or excluded as rapidly as possible in patients with sepsis or septic shock, and that any required source control intervention should be implemented as soon as medically and logistically practical after the diagnosis is made. 2 . P rompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established

59. F. FLUID THERAPY 1.Fluid challenge technique be applied where fluid administration is continued as long as hemodynamic factors continue to improve . 2 . Recommended crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock 3 . U sing either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock

60. 4. U sing albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock, when patients require substantial amounts of crystalloids . 5 . Recommended against using hydroxyethyl starches for intravascular volume replacement in patients with sepsis or septic shock. 6 . S uggested using crystalloids over gelatins when resuscitating patients with sepsis or septic shock

61. G. VASOACTIVE MEDICATIONS 1.Recommended norepinephrine as the first-choice vasopressor . 2. Suggested adding either vasopressin (up to 0.03 U/min)or epinephrine to norepinephrine with the intent of raising mean arterial pressure to target, or adding vasopressin (up to 0.03 U/min) to decrease norepinephrine dosage .

62. 3. U sing dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia ). 4 . Recommended against using low-dose dopamine for renal protection. 5 . S uggested using dobutamine in patients who show evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents.

63. If initiated, dosing should be titrated to an end point reflecting perfusion, and the agent reduced or discontinued in the face of worsening hypotension or arrhythmias. 6 . Suggested that all patients requiring vasopressors have an arterial catheter placed as soon as practical if resources are available

64. H. CORTICOSTEROIDS 1 . Suggested against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day I . IMMUNOGLOBULINS 1. S uggested against the use of IV immunoglobulins in patients with sepsis or septic shock

65. J . BLOOD PRODUCTS RBC transfusion occur only when hemoglobin concentration decreases to < 7.0 g/ dL in adults in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, or acute hemorrhage 2 . T he use of erythropoietin for treatment of anemia associated with sepsis not recommended. 3 . use of fresh frozen plasma not recommended to correct clotting abnormalities in the absence of bleeding or planned invasive procedures .

66. 4. Suggested prophylactic platelet transfusion when counts are < 10,000/mm3 ) in the absence of apparent bleeding when counts are < 20,000/mm3 ) if the patient has a significant risk of bleeding. Higher platelet counts ( ≥ 50,000/mm3 ) are advised for active bleeding, surgery, or invasive procedures

67. K. BLOOD PURIFICATION 1 . N o recommendation regarding the use of blood purification techniques. L . ANTICOAGULANTS 1 . U se of antithrombin for the treatment of sepsis and septic shock not recommended. 2 . N o recommendation regarding the use of thrombomodulin or heparin for the treatment of sepsis or septic shock

68. M. MECHANICAL VENTILATION 1. Use a target tidal volume of 6 mL/kg predicted body weight 2 . Recommended using an upper limit goal for plateau pressures of 30 cm H2O over higher plateau pressures in adult patients with sepsis-induced severe ARDS 3.Suggested using higher positive end-expiratory pressure (PEEP) over lower PEEP in adult patients with sepsis-induced moderate to severe ARDS .

69. 5 . R ecommended using prone over supine position in adult patients with sepsis-induced ARDS and a Pao2/Fio2 ratio < 150 6 . H igh-frequency oscillatory ventilation in adult patients with sepsis-induced ARDS not recommended 7. N o recommendation regarding the use of noninvasive ventilation for patients with sepsis-induced ARDS.

70. 8. Suggested using neuromuscular blocking agents for ≤ 48 hours in adult patients with sepsis-induced ARDS and a Pao2/Fio2 ratio < 150 mm Hg 9. We recommend a conservative fluid strategy for patients with established sepsis-induced ARDS who do not have evidence of tissue hypoperfusion 10. U se of b-2 agonists for the treatment of patients with sepsis-induced ARDS without bronchospasm not recommended 11. Recommended against the routine use of the pulmonary artery catheter for patients with sepsis-induced ARDS

71. 12.Suggested using lower tidal volumes over higher tidal 13 . M echanically ventilated sepsis patients be maintained with the head of the bed elevated between 30 and 45 14 . Recommended using spontaneous breathing trials in mechanically ventilated patients with sepsis who are ready for weaning.

72. N. SEDATION AND ANALGESIA 1 . Recommended that continuous or intermittent sedation be minimized in mechanically ventilated sepsis patients, targeting specific titration end points o . BICARBONATE THERAPY 1.Use of sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements in patients with hypoperfusion -induced lactic acidemia with pH ≥ 7.15 not recommended

73. P . GLUCOSE CONTROL Recommended a protocolized approach to blood glucose management in ICU patients with sepsis, commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/ dL . This approach should target an upper blood glucose level ≤ 180 mg/ dL rather than an upper target blood glucose level ≤ 110mg/dl 2. B lood glucose values be monitored every 1 to 2 hours until glucose values and insulin infusion rates are stable , then every 4 hours thereafter in patients receiving insulin infusions

74. 3.Glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution because such measurements may not accurately estimate arterial blood or plasma glucose values . 4 . Suggested the use of arterial blood rather than capillary blood for point-of-care testing using glucose meters if patients have arterial catheters

75. Q . RENAL REPLACEMENT THERAPY Suggested that either continuous or intermittent renal replacement therapy (RRT) be used in patients with sepsis and acute kidney injury. 2 . S uggested using continuous therapies to facilitate management of fluid balance in hemodynamically unstable septic patients 3. Suggested against the use of RRT in patients with sepsis and acute kidney injury for increase in creatinine or oliguria without other definitive indications for dialysis .

76. R. VENOUS THROMBOEMBOLISM PROPHYLAXIS Recommended LMWH rather than UFH for VTE prophylaxis in the absence of contraindications to the use of LMWH in case of contraindication UFH can be used. 2 . Suggested combination pharmacologic VTE prophylaxis and mechanical prophylaxis, whenever possible. 3 . M echanical VTE prophylaxis when pharmacologic VTE is contraindicated

77. S. STRESS ULCER PROPHYLAXIS Recommended that stress ulcer prophylaxis be given to patients with sepsis or septic shock who have risk factors for gastrointestinal (GI) bleeding . 2. Suggested using either proton pump inhibitors or histamine-2 receptor antagonists. 3 . Recommended against stress ulcer prophylaxis in patients without risk factors for GI bleeding .

78. T. NUTRITION Recommended against the administration of early parenteral nutrition alone or parenteral nutrition in combination with enteral feedings 2. I nitiate IV glucose and advance enteral feeds as tolerated over the first 7 days in critically ill patients with sepsis or septic shock for whom early enteral feeding is not feasible rather than TPN

79. 4. S uggested either early hypocaloric or early full enteral feeding in critically ill patients with sepsis or septic shock ; 5 . Recommended against the use of omega-3 fatty acids as an immune supplement in critically ill patients with sepsis or septic shock 6 . R outinely monitoring gastric residual volumes in critically ill patients with sepsis or septic shock not advised . However , we suggest measurement of gastric residuals in patients with feeding intolerance or who are considered to be at high risk of aspiration.

80. 7. Advised to use of prokinetic agents in critically ill patients with sepsis or septic shock and feeding intolerance . 8 . S uggested placement of post-pyloric feeding tubes in critically ill patients with sepsis or septic shock with feeding intolerance or who are considered to be at high risk of aspiration . 9 . u se of IV selenium to treat sepsis and septic shock not recommended .

81. 10.Use of arginine,carnithine and gliutamine to treat sepsis and septic shock not recommended . U. SETTING GOALS OF CARE Goals of care and prognosis be discussed with patients and families Goals of care be incorporated into treatment and end-of-life care planning, utilizing palliative care principles where appropriate Goals of care be addressed as early as feasible, but no later than within 72 hours of ICU admission..

82. MULTI-RESISTANT INFECTIONS BACKGROUND TO MULTI-RESISTANCE A major problem is the increasing incidence of infections caused by multi-resistant organisms. Gram-positive organisms, notably methicillin-resistant S. aureus ( MRSA) and vancomycin -resistant Enterococcus (VRE). Gram-negative bacteria, e.g. multi-resistant Acinetobacter and Pseudomonas , carbapenem -resistant Klebsiella pneumoniae . Fungi , e.g. non- albicans Candida species that are increasingly fluconazole-resistant. Atypical organisms

83. MANAGEMENT When prescribing antibiotics consider the likelihood of multi-resistance in the following patients: Inpatient for ≥3 days. Recently hospitalised. Recently in an area with known high resistance rates, e.g. penicillin resistant meningococcus from Spain. Patients colonised/infected with multi-resistant organisms should, in general, be placed in source isolation to protect other patients. However , strong evidence for efficacy is lacking. Source isolation is probably more relevant

84. Strict hand hygiene, glove and gown wearing, and other local infection control policies should be observed. Decolonisation regimens may be considered for MRSA, e.g. chlorhexidine bodywashes and topical antibiotics (e.g. mupirocin ) nasally and/or orally.

85. STAFF MEASURES (UNIVERSAL PRECAUTIONS) Remove watches and jewellery, remove long-sleeved white coats and jackets , roll shirt sleeves up to elbow. Hand washing before and after touching patient. Use alcohol-based gel after skin contact, but soap and water for body fluid contact Wear disposable aprons and gloves if in contact with patient. Wear gloves and aprons when handling any body fluid and eye protection when there is any danger of fluid or droplet splash .

86. Use strict aseptic technique for invasive procedures Bedside equipment ( infusion and syringe pumps , ventilators) should be cleaned regularly. Immunization. Stethoscopes should be cleaned between patients. Clear signposting of precautions to be taken on access doors

87. VISITORS Non-ICU medical and paramedical staff, relatives, and friends should adhere to the policies in force, e.g. handwashing , aprons, and gloves. Traffic through the ICU should be minimised .

88. CROSS-INFECTION Inform the Infection Control team should cross-infection arise It may be worthwhile typing the microorganism to confi r m an outbreak. Source isolate the patient for multi-resistant or virulent organisms. If cross-infection persists/spreads, other sources should be sought, e.g . taps, sinks, reusable equipment (rebreathing bags, ventilators ).

89. ISOLATION Source isolation—for patients carrying potentially contagious, virulent or multiresistant organisms, e.g. tuberculosis. Protective isolation—for immunosuppressed patients at risk of acquiring infection, e.g. when neutropaenic following chemotherapy

90. MICROBIOLOGICAL SURVEILLANCE Policies vary; some routinely screen sputum, bronchoalveolar lavage, blood , urine, and drain fluid every 2–4 days while others screen only on clinical indication, e.g. deteriorating gas exchange, pyrexia, neutrophilia . Some perform routine MRSA surveillance with rapid PCR-based technologies where results are available within 6h

91. FREQUENT CHANGING

92. CONCLUSION The incidence of patients with infection and a related inflammatory response is significant, and is associated with high morbidity/ mortality. The monitoring and management of these patients are complex, and require a multidisciplinary, multispecialty approach ideally in a critical care environment. As with all acute illness the ABCDE framework is an ideal assessment tool, which can lead to early identification of these patients , resulting in prompt treatment and management and transfer to a higher level of care

93. REFERENCES 1.Harrisons textbook of medicine 2.ABC of sepsis 3.Cecills textbook of medicine 4.Robins textbook of basic pathology 5 sepsis survivalance guidelines 2016