Appendix B

CLINICAL DOCUMENTATION IMPROVEMENT (CDI) CHECKLISTS

Introduction

Appendix B provides bulleted lists that can be used for clinical documentation improvement. These are different from the Documentation and Coding Checklists in that they are designed to be used by clinical documentation improvement (CDI) specialists and would be used primarily in the inpatient setting for chart review to help identify missed diagnoses or underdocumented conditions.

Physicians often don’t realize that coding specialists need a specifically documented diagnosis to assign a code especially if the physician believes that the documentation clearly identifies the reason for the admission and any concurrent conditions or complications affecting the patient’s medical care. For example, if the discharge diagnosis is pneumonia and laboratory results of sputum cultures and the medications administered clearly indicate a specific bacterial infection as the cause of the pneumonia, the coding specialist cannot assign a code for bacterial pneumonia without this being specifically documented by the physician. Physicians may not recognize that coders cannot interpret information in the medical record. Codes must be assigned based solely on the physician’s documentation. However, coding specialists and CDI specialists can review the documentation for specific clinical indicators to determine whether a condition may be present and then they can query the physician regarding the condition to determine if the condition does in fact exist. CDI specialists work with physicians and coders to ensure that the documentation supports the assignment of a more specific code.

Appendix B provides clinical documentation improvement bulleted lists for three conditions that are often lacking sufficient documentation in the inpatient setting. The information in these lists identifies common indicators of the condition so that the physician can be queried to determine if the condition should be included as a diagnosis or a more specific diagnosis in the medical record.

CDI Checklist – Chronic Obstructive Pulmonary Disease (COPD)

Definitions

•COPD may also be referred to as: Chronic Obstructive Lung Disease (COLD), Chronic Obstructive Airway Disease (COAD), Chronic Airflow Limitation (CAL) or Chronic Obstructive Respiratory Disease (CORD). An individual may have chronic bronchitis, a long-term cough with mucus production or emphysema, destruction of lung tissue that occurs over time. Most people diagnosed with COPD will have a combination of both

•Forced expiratory volume in one second (FEV1)–The amount of air forcibly exhaled in the first second of a forced exhalation

•Forced volume vital capacity (FVC)-The amount of air forcibly exhaled after taking in the deepest breath possible

Types

•Chronic bronchitis–Defined symptomatically as a cough with sputum production, on a majority of days, three months of the year, for 2 consecutive years. Clinically there are also:

–Increased number (hyperplasia) and increased size (hypertrophy) of goblet cells and mucus glands in the airway

–Scarring of airway walls from infiltration of inflammatory cells

–Squamous metaplasia, an abnormal change in the tissue lining of the airway causing fibrosis, thickening, and narrowing of the airway and limiting airflow

•Emphysema–Damage to the lung with inflammation of the air sacs (alveoli) and increase in the size of air space distal to the terminal bronchioles. The increased size of the air sacs:

–Reduces the surface area for gas exchange (oxygen and carbon dioxide)

–Inhibits the elasticity and support of the interstitial tissue

–Four types identified:

»Centriacinar/centrilobular: Disease is located in the proximal and central acini (air space close to bronchioles).

»Panacinar/panlobular: Disease is found in air spaces from bronchioles to alveoli. This type is most often associated with alpha-1-antitrypsin deficiency

»Distal/paraseptal: The proximal acinus is normal and disease affects the distal area

»Irregular: Scattered areas of the acini are affected. This type is most often associated with fibrosis

Stages

Stages are categorized by airflow limitation which is a measurement of forced expiratory volume in one second (FEV1)/forced volume vital capacity (FVC) < 0.70

•Stage I – Mild COPD

–Mild airflow limitations

–FEV1/FVC < 0.70; FEV1 ≥ 80% of predicted

–Other possible symptoms

»Chronic cough

»Sputum production

•Stage II – Moderate COPD

–Worsening airflow limitations

–FEV1/FVC < 0.70; FEV1 = 50-79% of predicted

–Shortness of breath (SOB), especially on exertion

–Other possible symptoms

»Chronic cough

»Sputum production

•Stage III – Severe COPD

–Worsening airflow limitations

–FEV1/FVC < 0.70; FEV1 = 30-49% of predicted

–Shortness of breath (SOB)

–Reduced exercise capacity

–Fatigue

–Exacerbations that affect quality of life

–Other possible symptoms

»Chronic cough

»Sputum production

•Stage IV – Very severe COPD

–Severe airflow limitations

–FEV1/FVC < 0.70

»FEV1 < 30% predicted

OR

»FEV1 < 50% with presence of chronic respiratory failure defined as PaO2 < 8.0 kPa (60 mm/Hg) with or without PaCO2 > 6.7 kPa (50 mm/Hg) while breathing air at sea levels

–Shortness of breath (SOB)

–Reduced exercise capacity

–Fatigue

–Quality of life significantly impaired

–Exacerbations life-threatening and requiring admission to intensive care unit of acute care facility

–Other possible symptoms

»Right heart failure (cor pulmonale)

»Elevated jugular venous pressure

»Pitting edema of lower extremities (ankles)

»Chronic cough

»Sputum production

Signs/Symptoms

•Chronic cough, dry or mucus producing

•Fatigue

•Frequent respiratory infections

•Shortness of breath (SOB, dyspnea), often worse with exercise/activity

•Wheezing

Risk factors

•Smoking

•Non-smokers with congenital absence of the protein, Alpha-1 antitrypsin

•Exposure to certain (workplace) chemicals (cadmium, isocyanates)

•Coal and gold mining, working in cotton textile plants, welding

•Exposure to second hand smoke and air pollution

•Exposure to cooking fires with poor ventilation

•Gastroesophageal reflux disease (GERD)

Diagnostic Indicators

•Positive history for risk factors

•Chronic cough with sputum production

•Dyspnea

•Rhonchi, wheezing, rales present with auscultation of breath sounds

•Use of accessory muscles (neck, abdomen) to help with breathing

•Change in chest shape/circumference (Barrel chest)

•Abnormal pulmonary function test that is not fully reversible and usually progressive

Treatment

•Stop smoking, reduce exposure to pollutants/chemicals

•Medications

–Bronchodilators-reduce airway constriction

»Albuterol (ProAir)

»Ipratropium (Atrovent)

»Tiotropium (Spiriva)

»Salmeterol (Serevent)

»Formoterol (Foradil)

–Inhaled corticosteroids-decrease inflammation

»Flunisolide (Aerobid)

»Budesonide (Pulmicort)

»Fluticasone (Flovent)

»Beclomethasone (Qvar)

»Mometasone (Asmanex)

»Ciclesonide (Alvesco)

–Oral anti-inflammatory-site specific to lungs

»Montelukast (Singulair)

»Roflimulast

•Pulmonary Rehabilitation–Learning to breath in ways that allow for exercise/physical activity and maintenance of muscle strength

•Surgery to remove damaged section of lung may allow other areas to work more effectively

•Lung transplant

Treatment-Severe COPD-In addition to above:

•Systemic corticosteroids (oral and/or intravenous)

•Antibiotics if infection is present

•Inhaled bronchodilators and/or corticosteroids delivered via nebulizer

•Supplemental oxygen

•Assisted breathing: Mask, BiPAP, endotracheal tube with mechanical ventilation

Complications

•Irregular heart rate (cardiac arrhythmias)

•Need for supplemental oxygen and/or mechanical ventilation

•Pulmonary hypertension–Elevated blood pressure in the arteries/blood vessels in the right side of the heart

•Cor pulmonale – Right side heart enlargement with subsequent pumping failure usually caused by pulmonary hypertension

•Pneumonia

•Pneumothorax

•Weight Loss/Malnutrition

•Osteoporosis due to decreased exercise/activity and corticosteroid use

CDI Checklist – Pneumonia

Definition

Pneumonia is a respiratory condition, usually due to an infection, which causes inflammation in the lungs and an accumulation of fluid, inflammatory cells and fibrin ultimately impairing oxygen/carbon dioxide exchange in the alveoli (air sacs).

Types

•Aspiration–Occurs when foreign material is inhaled causing inflammation of the airway (bronchial tubes) and lungs. Other names include: Anaerobic pneumonia, Aspiration pneumonitis (Mendelson’s syndrome), Necrotizing pneumonia

–Aspiration of vomit/gastric acid most often leads to a chemical pneumonitis

–Aspiration of oral/pharyngeal fluid most often results in bacterial pneumonia (anaerobic)

–Aspiration of oil (vegetable, cooking) causes an exogenous lipoid pneumonia

•Bacterial–This includes both gram negative and gram positive organisms

–Streptococcus pneumoniae (Pneumococcus), is most common type

–Staphylococcus aureus

–Haemophilus influenzae

–Enterococcus bacteriaceae

–Pseudomonas aeruginosa

–Bacteria-like organisms:

»Mycoplasma pneumoniae

»Chlamydophila pneumoniae

»Legionella pneumophila

»Pneumocystis jiroveci

•Community acquired–An infection that develops from commonplace germs encountered during an individual’s normal routine. The most common causative organisms of community acquired pneumonia are:

–Streptococcus pneumoniae (Pneumococcus)

–Staphylococcus aureus

–Haemophilus influenzae

–Enterococcus bacteriaceae

–Adenovirus

•Fungal–Certain areas of the United States have specific fungi that cause pneumonia in both healthy and immune compromised individuals. The three most commonly found are:

–Coccidioidomycosis (Coccidioides immitis), found in the Southwestern US and may be referred to as “San Joaquin fever” or “Valley Fever”.

–Histoplasmosis (Histoplasma capsulatum), most prevalent in the Midwest

–Blastomycosis (Blastomyces dermatitidis), found in the Southeast.

•Hospital acquired pneumonia (HAP)–Hospitalization, including residing in a long term care facility and/or receiving dialysis or infusion therapy in an outpatient center/clinic, places individuals at increased risk for developing pneumonia. The most common causative bacteria are:

–Pseudomonas aeruginosa

–Methicillin-resistant Staphylococcus aureus (MRSA).

•Pneumonia caused by opportunistic organisms–Opportunistic organisms most often cause illness in a host with congenital or acquired immune deficits or defenses, such as:

–Fungi

»Candida species

»Aspergillus species

»Mucor species

»Cryptococcus neoformans

–Bacteria-like organisms

»Pneumocystis jiroveci

»Mycobacterium avium.

•Ventilator-associated pneumonia (VAP)–VAP is a subtype of HAP and occurs in patients who have endotracheal tubes or a tracheostomy and receive respiratory support via mechanical ventilation

–Baseline respiratory cultures should be obtained at the initiation of ventilator support

–Signs/symptoms of pneumonia with subsequent cultures that contain bacteria different from baseline are determined to be VAP

–Common causative bacteria include:

»Pseudomonas aeruginosa

»Klebsiella pneumoniae

»Serratia marcescens

»Enterobacter

»Citrobacter

»Acinetobacter

»Stenotrophomonas maltophilia

»Burkholderia cepacia

»Methicillin-resistant Staphylococcus aureus (MRSA)

•Viral–Many viral infections can lead to pneumonia including:

–Influenza virus (“Flu”) which affects all population groups

–Respiratory Syncytial Virus (RSV) is most common in infants (especially infants born prematurely) and adults with impaired immunity

–Coronaviruses, which cause Severe Acute Respiratory Syndrome, or SARS-associated coronavirus pneumonia and the newly emerged COVID-19 respiratory disease

–Human Parainfluenza virus found most often in children, elderly and persons with impaired immunity

–Adenoviruses which are most common in children

–Herpes Virus

–Avian influenza

–Cytomegalovirus (CMV)

•Workplace acquired–Certain work environments may predispose an individual to pneumonia, such as:

–Manufacturing plant accidents may cause workers to inhale chemicals or other hazardous materials that lead to inflammation and fluid accumulation in the lungs

–Farming or slaughterhouses may expose workers to:

»Anthrax

»Brucella

»Coxiella burnetii

–Exposure to birds or bird droppings can cause Psittacosis pneumonia from Chlamydia psittaci

–Exposure to rodent droppings may cause Hantavirus infection of the lungs

Types Classified by Site

•Lobar pneumonia

–Acute onset

–Inflammation and consolidation affecting a large and continuous area of one or more lobes of the lung

–Causative organisms include:

»Streptococcus pneumoniae (Pneumococcus)

»Haemophilus influenzae

»Moraxella catarrhalis

»Mycobacterium tuberculosis

•Bronchial pneumonia (Bronchopneumonia)

–Inflammation of the walls of the bronchioles (air tubes) in multiple areas of one or both lungs

–Most often found in infants, children, elderly and persons with impaired immunity

–Rarely caused by the bacteria, Streptococcus pneumoniae (Pneumococcus)

•Acute interstitial pneumonia

–Fine, lace-like, vascular tissue found throughout the lungs as a support system for the alveoli (air sacs)

–Normally not visualized on X-ray or CT scans

–Bacteria, virus and fungi can cause pneumonia in this tissue

–Causative organism is most often the bacteria-like, Mycoplasma pneumoniae

Classification of Types in Children

•Non-severe

–Symptoms may include cough, difficulty breathing, increased respiratory rate (RR)

»<2 months=RR >60/minute

»2 – 12 months=RR >50/minute

»12 months-5 years=RR >40/minute

–One or more of the following on auscultation:

»Crackles (rales)

»Areas of decreased breath sounds

»Areas of bronchial breathing

–Infection can be treated with antibiotics as an outpatient

•Severe

–Include signs and symptoms of non-severe plus one or more of the following:

»Crackles (rales)

»Retractions

»Nasal flaring

»Grunting

–On auscultation includes findings from non-severe and may also have:

»Abnormal vocal resonance

»Pleural rub

–Admit to hospital for antibiotics and supportive therapy.

•Very severe

–Includes signs and symptoms of non-severe and severe plus one or more of the following:

»Central cyanosis

»Dehydration

»Lethargy

»Seizures

–Admit to hospital for antibiotics and supportive care including:

»Oxygen therapy

»Intravenous fluids

»Intubation and mechanical ventilation

Signs/Symptoms

•Cough, dry or productive (mucus producing) – Mucus is often thick and colored (brown, yellow, green and/or blood tinged)

•Chills – feeling suddenly cold, shivering and/or shaking

•Fever – Body temperature > 100.4° F (38° C)

•Difficulty breathing/shortness of breath (dyspnea)

•Sweating (diaphoresis), including night sweats

•Sharp/stabbing pain in chest especially with inspiration or cough

•Cyanosis (blue color to skin, nail beds, mucous membranes)

•Fatigue – Extreme tiredness

•Headache

•Vomiting, decreased appetite, weight loss

•Confusion, decreased level of consciousness

•Decreased blood pressure (↓BP)

•Increased heart rate (↑HR), respiratory rate (↑RR)

•In infants: grunting, retractions, poor perfusion

General Risk Factors

•Recent surgery or trauma (injury)

•General anesthesia

•Serious chronic or acute illness/disease, such as diabetes mellitus, renal failure, cirrhosis of the liver, heart failure/cardiac disease, cancer

•Chronic or acute respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis, cystic fibrosis

•Impaired immunity from HIV/AIDS, chemotherapy

•Cigarette, cigar or pipe smoking/smoke inhalation

•Residing in a hospital, long term care facility, shelter, receiving dialysis or infusions at an outpatient treatment center.

•Impaired swallowing due to conditions such as stroke, dementia, Parkinson’s disease, degenerative muscular or neurological diseases (muscular dystrophy, multiple sclerosis, myasthenia gravis)

•Esophageal strictures or reflux

•Impaired mobility such as cerebral palsy, spinal cord injuries

•Altered level of consciousness caused by drugs/alcohol, neurological diseases, brain injury/tumor, seizure disorder

•Recent upper respiratory infections such as influenza, laryngitis, common cold

Risk Factors For Increased Morbidity/Mortality

•Age > 65 or <5 years

•Severely underweight or obese

•Malnourished/poor nutritional status

•Concurrent chronic or acute disease or condition

Other Factors That Predispose To Certain Types of Pneumonia

•Admitted from SNF

–Aspiration pneumonia

–Bacterial pneumonia

–Hospital acquired pneumonia (HAP)

–Opportunistic

•History of cerebral vascular accident (CVA) w/dysphagia

–Aspiration pneumonia

–Opportunistic

•Alzheimer’s or other type of dementia

–Aspiration pneumonia

–Opportunistic

Diagnostic Tests/Procedures

•Chest X-ray or CT scan

•Arterial blood gases

•CBC w/differential

•Culture and gram stain of sputum

•Blood cultures

•Culture of pleural fluid

•Swallowing studies

•Bronchoscopy

Complications

•Acute respiratory distress syndrome (ARDS)

•Pleural effusion (fluid/inflammation in the lining around the lung)

•Lung abscess

•Respiratory failure (requiring intubation and ventilator assistance)

•Sepsis or severe sepsis with septic shock or organ failure

•Myelodysplastic syndromes

•Fungal infection (specific) complications

–Mediastinal fibrosis

–Broncholithiasis (histoplasmosis)

–Dissemination to other organs, blood vessel invasion causing:

»Emboli and infarction

»Fistula formation

»Sepsis syndrome

Treatment

Common Antibiotics, Antiviral, Antifungal Medications

•Aspiration Pneumonia

–Antibiotics may be prescribed following aspiration because of the increased risk that bacteria may proliferate in the area of inflammation. See list under Bacterial pneumonia

•Bacterial Pneumonia

–Often treated with a combination of antibiotics until the causative organism has been identified by culture and the specific antibiotic(s) have been identified by sensitivity testing

–Macrolides

»Azithromycin (Zithromax)

»Clarithromycin (Biaxin)

»Erythromycin

–Tetracyclines

»doxycycline

–Fluoroquinolones

»Gemifloxacin (Factive)

»Levofloxacin (Levaquin)

»Moxifloxaccin (Avelox)

–Cephalosporins

»Cefaclor

»Cefadroxil

»Cefprozil

»Cefuroxime (Ceftin)

»Cephalexin (Keflex)

–Penicillins

»Amoxicillin

»Amoxicillin with clavulanate (Augmentin)

»Ampicillin

»Piperacillin

»Ticarcillin with clavulanate (Timentin)

–Vancomycin (Vancocin)

•Fungal Pneumonia

–Amphotericin B-Fundamental drug for severe/life threatening infections. Effective against:

»Aspergillus

»Cryptococcosis

»Systemic candidiasis

»Histoplasmosis

»Blastomycosis

»Coccioidomycosis

»Zygomycosis.

–Triazoles

»Itraconazole, effective against:

◦Aspergillus

◦Mucosal candidal infections

◦Histoplasmosis

◦Blastomycosis

◦Coccidioidomycosis

»Fluconazole, effective against:

◦Candida albicans (mucosal and invasive)

◦Cryptococcosis

◦Coccidioidomycosis

»Voriconazole

◦Invasive aspergillosis

◦Other molds

»Posaconazole

◦Oral candidiasis

◦Aspergillus

◦Coccidioidomycosis.

–Echinocandin

»Caspofungin

◦Candida species

◦Aspergillus species

»Micafungin

◦Candida species

◦Aspirgillus species

»Anidulafungin

◦Candida

◦Aspergillus species.

•Viral Pneumonia–Antiviral drugs may lessen the severity and shorten the length of time an individual has symptoms. Although antibiotics are not effective in killing viruses, some physicians will prescribe them because of the high incidence of secondary bacterial infection.

–Antiviral medications include:

»Amantadine (Symadine)

»Rimantadine (Flumadine)

»Oseltamivir (Tamiflu)

»Zanamivir (Relenza).

–For varicella pneumonia:

»Acyclovir (Zovirax).

–For Respiratory Syncytial Virus (RSV):

»Ribavirin (Rebetol)

Other Treatment

•Breathing treatments

–Usually administered by a Respiratory Therapist and may include:

»Medication to thin/loosen mucus so it can be removed by suction (if intubated) or coughed up by the patient

»A patient who has underlying respiratory disease such as COPD or asthma, and is experiencing airway constriction may further benefit from inhaled bronchodilator medication such as albuterol

»Percussion (gentle tapping on chest over lungs to loosen mucus) and postural drainage (positioning to help drain mucus/fluids into bronchial tubes to be suctioned out or coughed up)

•Humidifier or vaporizer

–Warm or cold moisture added to the air to help thin and loosen mucus

•Supplemental oxygen delivered by nasal cannula/prongs or a mask

•Ventilator support for patients with:

–Respiratory failure

–ARDS

CDI Checklist – Sepsis, Severe Sepsis, Septic Shock, and SIRS

Definitions

The definitions of sepsis, severe sepsis, septic shock and systemic inflammatory response syndrome have changed in ICD-10-CM. The signs/symptoms below reflect the conditions as they are defined for ICD-10-CM coding purposes. Physicians may not use the same terms in their documentation. For example, physicians may use the term SIRS or sepsis interchangeably to describe sepsis due to an infection. However, for coding purposes when SIRS is due to an infection, the code for sepsis is reported even if the physician used SIRS to describe the disease process.

Sepsis Signs and Symptoms

A documented infection (by culture, stain or polymerase chain reaction) with two or more of the following signs/symptoms may be indicative of sepsis:

•Temperature

–Elevated – 100.4°F/38°C

OR

–Decreased – 96.8°F/36°C

•Tachycardia/elevated heart rate (HR)

–> 90 BPM

•Respiratory rate (RR) or PaCO₂

–RR > 20 breaths per minute

OR

–PaCO < 32 mm Hg (4.3 kPa)

•White Blood Cell (WBC) Count

–>12,000 (mm3)

OR

–<4,000 (mm3)

OR

–10% bands (immature WBCs)

»White blood cells in (normally) sterile fluid (i.e., urine, cerebral spinal fluid)

»Evidence of free air in abdomen (perforated viscus) by x-ray or CT scan

»Focal opacification consistent with pneumonia on chest x-ray

Additional signs/symptoms of sepsis:

•Peripheral vasodilation

•Change in mental status, such as lack of attention, confusion/disorientation, agitation

•Hemorrhagic skin rash (petechiae, purpura)

•Hypotension, dizziness

•Decreased platelet counts

Signs/symptoms of severe sepsis:

•Reduced urine output (oliguria) or no urine output (anuria)

•Reduced oxygen levels in the blood (hypoxemia)

•Increased lactic acid levels (>4 mmol/L) in blood (lactic acidosis)

•Altered mental status (cerebral function)

•Acute organ dysfunction, such as

–Acute kidney failure (oligoria, anuria, serum electrolyte imbalance, volume overload)

–Acute respiratory failure-Acute lung injury (ALI) PaO2/FiO2 <300 OR acute respiratory distress syndrome (ARDS) PaO2/FiO2 <200

–Critical illness myopathy/polymyopathy (widespread muscle weakness and neurological dysfunction that can delay recovery and cause prolonged ventilator dependence)

–Disseminated intravascular coagulopathy (DIC) (elevated fibrin degradation products from clot disintegration

–Encephalopathy (agitation, confusion or coma due to ischemia, hemorrhage, microthrombi, microabscesses, multifocal necrotizing leukoencephalopathy)

–Hepatic failure (disruption in the function of protein synthesis leading to bleeding disorders from low levels of clotting factors and a disruption of bilirubin metabolism with a subsequent elevation of indirect bilirubin levels)

–Acute cardiac failure (systolic or diastolic heart failure due to cytokines and decreased myocyte function or cellular damage manifested as a troponin leak)

Signs/symptoms of septic shock

•Same symptoms as severe sepsis

AND

•Systolic blood pressure < 90 mm/HG (hypotension) that

–Does not return to normal with intravenous hydration (>6 L or 40mg/kg crystalloid fluid)

–Requires the use of medication to maintain blood pressure (vasopressors/inotropes)

SIRS Signs and Symptoms

A documented injury or trauma with the following signs/symptoms may be indicative of systemic inflammatory response (SIRS):

•Temperature

–Elevated – 100.4°F/38°C

OR

–Decreased – 96.8°F/36°C

•Tachycardia/elevated heart rate (HR)

–> 90 BPM

•Respiratory rate (RR) or PaCO

–RR > 20 breaths per minute

OR

–PaCO < 32 mm Hg (4.3 kPa)

•Elevated WBC (leukocytosis) or severely decreased WBC levels (leukopenia)

A diagnosis of SIRS with acute organ failure requires documentation of one or more of the following:

•Acute kidney failure (oligoria, anuria, electrolyte abnormalities, volume overload)

•Acute respiratory failure-Acute lung injury (ALI) PaO2/FiO2 <300 OR acute respiratory distress syndrome (ARDS) PaO2/FiO2 <200

•Critical illness myopathy/polymyopathy (widespread muscle weakness and neurological dysfunction that can delay recovery and cause prolonged ventilator dependence.

•Disseminated intravascular coagulopathy (DIC) elevated fibrin degradation products from clot disintegration

•Encephalopathy (agitation, confusion or coma due to ischemia, hemorrhage, microthrombi, microabscesses, multifocal necrotizing leukoencephalopathy

•Hepatic failure (disruption in the function of protein synthesis leading to bleeding disorders from low levels of clotting factors and a disruption of bilirubin metabolism with a subsequent elevation of indirect bilirubin levels)

•Other acute organ failure-acute cardiac failure (systolic or diastolic heart failure due to cytokines and decreased myocyte function or cellular damage manifested as a troponin leak)

Diagnostic Tests

The following tests are commonly performed to establish or rule-out a diagnosis of sepsis:

•White Blood Cell (WBC) count w/differential

•Gram stain

•Urinalysis for bacteria/infectious agents (sterile catheterization or bladder tap)

•Urine for gram stain and culture

•Blood cultures

•Platelet count, bleeding time, fibrin degradation studies

•Lumbar puncture (spinal tap) for examination of cerebral spinal fluid

•Catheter tip culture for suspected central line sepsis

•Arterial blood gases to monitor metabolic or respiratory acidosis/alkalosis

•Chest x-ray to evaluate for pneumonia

•Abdominal x-ray or CT to evaluate for perforated viscus (free air in abdomen)

•Ultrasound exam may be performed for suspected biliary sepsis.

Therapeutic Measures

To treat sepsis the following measures are often employed:

•Intravenous antibiotics (empiric monotherapy or combination of antimicrobial agents are given until culture and sensitivity have been reported, then the most therapeutic drug(s) are continued for a minimum of 2 weeks)

•Intravenous fluids – well defined (500 mL) and rapidly infused colloid and crystalloid fluid boluses

•Transfusion of platelets or red blood cells if coagulopathy is present.

•Supplemental oxygen with continuous monitoring by pulse oximetry.

•Intubation and Mechanical ventilation – necessary due to increased work of breathing and as airway protection due to encephalopathy or decreased level of consciousness

•Central venous catheter for central venous pressure (CVP) monitoring (normal range 8-12 mmHg)

•Vasopressors (norepinephrine or phenylephrine) to maintain mean arterial pressure (MAP) > or = to 65

•Inotropes (Dobutamine) if vasopressors do not stabilize MAP

•Dialysis if urine output is >0.5 ml/kg/hr and there is evidence of kidney damage in blood chemistries (elevated BUN, creatine, potassium) or fluid overload from fluid bolus

•Surgical treatment of the underlying infection, such as incision and drainage