Updated: 12/19/2019


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  • A 44-year-old woman is brought to the emergency department by her husband for 2 days of generalize malaise, fatigue, and altered mental status. Her husband reports that she has been having a fever for the past 5 days with pain on urination and foul smelling urine. Medical history is significant for renal transplantation 4 years ago and is on tacrolimus and amlodipine. Her temperature is 101°F (38.3°C), blood pressure is 98/65 mmHg, pulse is 112/min, and respirations are 27/min. On physical exam, she is oriented to self but not place or time. Cardiopulmonary exam is unremarkable. Abdominal exam is notable for suprapubic tenderness upon palpation. She has costovertebral angle tenderness. She is immediately started on intravenous fluids and antibiotics and blood and urine studies are obtained. She is being transferred to the medical intensive care unit. (Urosepsis)
  • Definition
    • a dysregulated host response to infection that results in organ dysfunction
      • if untreated, can result in septic shock
  • Epidemiology
    • most common bacteria include
      • Escherichia coli
      • Staphylococcus aureus
      • Klebsiella pneumoniae
      • Streptococcus pneumoniae
    • risk factors
      • admission to the intesive care unit 
      • bacteremia
      • advanced age (≥ 65 years of age)
      • immunosuppression
      • diabetes
      • obesity
      • malignancy
      • previous hospitalization
  • Etiology
    • gram-positive and -negative organisms are responsible for most cases
  • Pathogenesis
    • pathogen results in the activation of the host's immune system, resulting in systemic inflammation and the release of pro-inflammatory mediators
      • increased heart rate => hyperdynamic circulation
        • low wedge pressure
      • decreased SVR
      • impaired tissue utilization of oxygenation => high SvO2 
        • from inability of tissue to extract oxygen + hyperdynamic circulation
  • Quick Sequential Organ Failure Assessment (qSOFA) score 
    • used to promptly triage infection in patients who may develop sepsis
    • the qSOFA score is:
      • respiratory rate ≥ 22/minute
      • altered mentation
      • systolic blood pressure ≤100 mmHg
  • Prognosis
    • increased mortality in patients who are not treated
  • Symptoms
    • nonspecific and include
      • fever
      • symptoms from an infectious source, for example
        • cough and dyspnea in pneumonia
        • purulent exudate in abscesses
    • often associated with hyperventilation and altered mental status
  • Physical exam
    • arterial hypotension
    • tachycardia and tachypnea
    • warm and flushed skin (in early phases of sepsis)
    • cool skin (in the late phases of sepsis, where blood flow becomes redirected to core organs
  • Laboratory findings are nonspecific and can include
    • leukocytosis or leukopenia
    • elevated C-reactie protein
    • arterial hypoxemia
    • acute oliguria and worsening creatinine
    • elevated lactate
    • respiratory alkalosis with a metabolic acidosis
    • thrombocytopenia
    • hyperbilirubinemia
  • Management approach
    • perform a detailed history and physical to properly triage patients to the intensive care unit (ICU) who require it and to determine the likely organism causing sepsis
    • initiate intravenous fluids and empiric antibiotic promptly and tailored to the patient
    • monitor the treatment response
      • can be accomplished by measuring mean arterial pressure, urine output, and trending lactate levels
  • Conservative
    • admit to the ICU
    • ensure we have a secure airway
    • establish venous access for fluid, obtain labs, and antibiotic administration
    • obtain an arterial blood gas
    • obtain cultures
    • remove source of infection (e.g., catheter)  
  • Medical
    • intravenous fluid administration
      • types
        • normal saline
        • Ringer lactate 
          • the preferred fluid for renal and mortality outcomes
      • central line for vascular access and if pressors needed
        • confirm placement with a chest radiograph 
    • empiric antibiotics
      • indication
        • administered preferably within the first hour once a presumed diagnosis of sepsis has been made
      • medications
        • carbapenem
        • piperacillin-tazobactam
        • vancomycin
        • third or fourth generation cephalosporins
  • Septic shock
  • Disseminated intravascular coagulation
  • Acute respiratory distress syndrome
  • Acute renal failure
  • Cardiomyopathy

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2

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