FEVER / SEPTIC SHOCK

 

Etiology:

  1. 2ry to Gram (-)ve from GU > GI >Respiratory.
     
  2. Neutropenic pt (nadir sepsis) - common causes are S. aureus, streptococci, and G (-) including P. aeruginosa.  Also consider fungi (Candida, Aspergillus, Mucormycosis, Cryptococcus, Nocardia).
     
  3. Immunocompromised pt (AIDS, transplant, CA, steroid treatment) -  these pts are prone to:
      1. Bacteria - Listeria, Salmonella, TB
         
      2. Virus - CMV, HSV, EBV
         
      3. Fungi - as above
         
      4. Protozoa - Toxoplasma, PCP, Cryptosporidium
         
  4. Asplenic pt is prone to develop infections with encapsulated organisms- H. influenza , S. pneumoniae, Neisseria, Salmonella, E. coli.
     
  5. ETOH abusers are prone to aspirations.  Diabetics are prone to infections of lung, urine,  malignant otitis externa, cholecystitis.  ESRD pts have fevers that are commonly attributed to vascular catheter, infected grafts, trombophlebitis, peritonitis (if  pt is on PD). Pts with prosthetic valves are prone to - see above. Prosthetic orthopedic devices are prone to staphylococci, streptococci, Pseudomonas.  Skin wound - also requires staph, strep and Pseudomonas coverage. Fever post op on GI tract - as previous, in addition to anaerobic coverage (Clindamycin/Metronidazole).

S & S:

  1. Fever (may not be present), dec MS, tachypnea, dec in UO.
     
  2. Initially hyperdynamic state with inc CO 2ry to dec SVR = normal BP.
     
  3. In later stage hypodynamic state with dec CO and inc SVR = dec BP.
     
  4. Myocardial depression 2ry to lactic acidosis

DX:

  1. Hx & Clinical
     
  2. Increased WBC, fever, increased AG acidosis
     
  3. Nadir (neutropenic) sepsis is a specific type of sepsis in which pt's absolute neutrophil count is 500-1000/µL. Generally occurs s/p chemotherapy. These pts, just like any other pt with sepsis, shouldn't have instrumentation with Foley or rectal exam.  This shouldn't preclude from looking for possible perirectal abscess/infection since pt may or may not c/o pain.  Condom catheter (Texas cath) should be used for UO monitor. The source of infection may remain un-diagnosed (only 25% are identified after w/u), but GI/GU, oral, skin, lungs appear to be common sources.

Treatment:

  1. IVF, O2, cardiac monitor, UO
     
  2. If  IV fluids are not helpful, consider Dopamine, Dobutamine, Norepinephrine (Levophed).
     
  3. Antbx with synergism against Pseudomonas are used, e.g. Ticarcillin/Clavulanate + Gentamicin.
     
  4. Pt with severe rigors and chills can be treated with Meperidine 25 mg IV.

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