SEPSIS IN A BURN PATIENT
Sepsis is the systemic response to infection and is defined as the presence of Systemic Inflammatory Response Syndrome {SIRS} in addition to a documented or presumed infection. SIRS is usually indicative of invasive bacteria from the Burn wound or catheter sepsis getting into the bloodstream sensitizing receptor organs prior to septic shock. In burn patients in the unit with an infection that has a fever and a leucocyte count has greater than 12000 we consider sirs.
SIRS SYMPTOMS are as follows:
1. Body temperature over 38 or under 36 degrees Celsius.
2. Heart rate greater than 90 beats/minute
3. Respiratory rate greater than 20 breaths/minute or partial pressure of
CO2 less than 32 mm Hg
4. Leucocyte count greater than 12000 or less than 4000 /microliters or over
10% immature forms or bands.
Two or more symptoms must be present for it can be called sirs. In the pediatric population, the definition is modified to a mandatory requirement of abnormal leukocyte count or temperature to establish the diagnosis, as abnormal heart rate and respiratory rates are more common in children.{1}
How do we manage sirs? There are 6 key points for the management of sirs.
1. Ensuring hemodynamic stability
– In severe sepsis and septic shock, the surviving sepsis guidelines recommend an initial administration of isotonic crystalloids at a rate of 30 ml/kg bolus.
2. Vasopressors and inotropes-
-In our experience the choice of vasopressors is dopamine. Low doses of 1 to 2 mcg/kg/min, dopamine acts predominantly on dopamine-1 receptors in the renal, mesenteric, cerebral, and coronary beds, resulting in selective vasodilation. It acts on Low cardiac output (e.g. decompensated heart failure, cardiogenic shock, failed septic shock with resuscitation with IV fluids and vasopressors)
3. Primary source control
-means that we should manage burns accordingly with dressing and debridement.
4. Broad-spectrum antibiotics
-Suspicion of community vs. hospital-acquired infection
-Prior microbiology patterns in the individual
-Antibiogram for the facility
One week after the burn, there is a change in the flora of the wound. So it is important that a gram stain and culture and sensitivity of them would be taken.
5. Glucocorticoids in low doses (200 to 300 mg hydrocortisone or equivalent )
– have been shown to improve survival and help in the reversal of shock in patients with persistent shock despite fluid resuscitation vasopressor use. But in our case, we have not tried to use them.
6. Blood glucose control
– Van den Berghe et al., in their landmark study in surgical ICU patients, reported a reduction of in-hospital mortality rates with intensive insulin therapy (maintenance of blood glucose at 80 to 110 mg/dL) by 34%. The surviving sepsis guidelines recommend blood glucose control less than 180 mg/dl.[2]
Bibliography
- Chakraborty R,Burns B. Systemic Inflammatory Response Syndrome.Statpearls Publishing. 2021 January.
- Bellomo R. Acute glycemic control in diabetics. How sweet is oprimal? Pro: Sweeter is better in diabetes. J Intensive Care. 2018;6:71. [PMC free article: PMC6225577] [PubMed: 30455957]
Michelle Marie P. Aportadera M.D.
Plastic Surgery
Diplomate in General Surgery
Master of the Arts Hospital Administration
Administrator, RD Aportadera MD SPMC BURN CENTER
