Aggressive volume replacement ideally is promptly followed by urinary output of at least 30 and preferably 50 mL/hr, as well as other indicators of improved perfusion. If not, then con sideration is given for vasoactive dtug therapy (Pacheco, 2014).
Mortality rates are high when sepsis is further complicated by respiratory or renal failure. With severe sepsis, damage to pul alveolar looding and pulmonary edema. This may occur even with low or normal pulmonary capillary wedge pressures, as with the ARDS discussed on page 918 and depicted in Figure 47-1.
Broad-spectrum antimicrobials are chosen empirically based on the probable source of infection. They are given promptly in maximal doses after appropriate cultures are taken of blood, urine, or exudates not contaminated by normal flora. In severe sepsis, appropriate empirical coverage results in better survival rates (Barochia, 2010; MacArthur, 2004). In obstetrics acute pyelonephritis is usually caused by Enterobacteriaceae, as discussed in Chapter 53 (p. 1028). For pelvic infections, empirical coverage with regimens such as ampicillin plus gentamicin plus clindamycin generally suices (Chap. 37, p. 668). Associated incisional and other soft-tissue infections are increasingly likely to be caused by methicillin-resistant S aureus, thus vancomycin therapy may be added (Klevens, 2007; Rotas, 2007). With a septic abortion, a Gram-stained smear may be helpful in identiying Clostridium species or group A streptococcal organisms. his is also true for deep fascial infections.
Continuing sepsis may prove fatal, and debridement of necrotic tissue or drainage of purulent material is crucial (Nelson, 2015; Pacheco, 2014). In obstetrics, the major causes of sepsis are infected abortion, pyelonephritis, and puerperal pelvic infections, which include metritis and infections of perineal lacerations or of hysterotomy or laparotomy incisions. With a septic abortion, uterine contents must be removed promptly by curettage as described in Chapter 18 (p. 351) . Hysterectomy is seldom indicated unless gangrene has resulted.
For women with pyelonephritis, continuing sepsis should prompt a search for obstruction caused by calculi or by a perinephric or intrarenal phlegmon or abscess. Renal sonography or "one-shot" pyelography can help diagnose obstruction and calculi. With obstruction, ureteral catheterization, percutaneous nephrostomy, or flank exploration may be lifesaving (Chap. 53, p. 1029). Computed tomography (CT) or magneticresonance imaging aids in identiying a phlegmon or abscess.
Puerperal Infections. Most cases of puerperal pelvic sepsis are clinically manifested in the first several days postpartum, and
FIGURE 47-6 Algorithm for evaluation and management of sepsis syndrome. Rapid and aggressive implementation is paramount for success. The three steps-Evaluate, Assess, and Manage-are carried out as simultaneously as possible.
intravenous antimicrobial therapy without tissue debridement cases, there is bacteremia and widespread tissue invasion, but with is generally curative. here are at least three exceptions. an intact uterus and abdominal incision. If uterine necrosis can