Sepsis Management

Septicemia, unspecified
1 10
1 10 Refer

 . 8
Sepsis

2553
51.28
33.33
10.26
5.13
0
0

2554
47.92
27.28
8.33
12.5
0
4.17

2555
55.17
20.69
10.34
10.34
3.45
0

 . Sepsis
2553

2554

2555

10.07

11

11.18

10.43

11

8.82

2.52

3.44

4.12

2.52

1.72

4.12

7.19

3.78

2.94

11.51

10.31

8.82

6.12

5.5

9.41

10.07

10.31

7.06

1.08

4.12

3.53

3.96

6.87

6.47

4.32

4.47

5.88

7.19

4.81

9.41

1.44

2.75

2.35

11.15

9.28

5.88

4.32

3.09

4.12

0.72

3.09

1.76

5.4

4.47

4.12


30
25

26.36
22.75

24.3

20

21.79

24.2
20.3

22.21

15

10
5
0

2549

2550

2551

2552

2553

2554

2555

26.36

22.75

24.3

21.79

24.2

20.3

22.21

 sepsis

 sepsis







Source control
Resuscitation

Sepsis Golden period

STEMI/Stroke

Sepsis Golden period

Antibiotics 1
Resuscitate 6
Source control 12


sepsis

Ibrahim EH, et al. Chest 2000; 118: 146-155

- Central line
- Aggressive fluid
- PRC
- ScvO2

 fluid 5 vs 3.5 6

 46 30%

Fluid 5 litre/6hr

13 litre/72hr

 fluid 3 3

Sepsis Pathogenesis
Vasodilate
Fluid
Leakage

Fluid
Leakage

Organ hypoxia & failure

 dopamine
fluid

fluid dopamine
BP

Sepsis
Leakage
Vasodilate
Fluid
Resuscitate

Vasopressor

Save Organ and Life

 source control
necrotizing
fasciitis


2 4
BT > 37.8 c
> 20/min

BP < 90/60mmHg



NSAIDS steroid

Common Pitfall


6
fluid resuscitate vasopressor
antibiotic
transfer golden period


.

Key to decrease sepsis

mortality
Early diagnosis
sepsis
cause of sepsis.

Early appropriate
Antibiotic & source control
Resuscitation.

http://www.survivingsepsis.org

Systemic inflammatory response

syndrome (SIRS)
2 4
Body Temperature > 38 C or < 36 C
Heart rate > 90 beats/min
Respiratory rate > 20 /min or Paco2 < 32 mmHg
WBC > 12,000 cells/mm3 or
< 4,000 cells/mm3, or
> 10% band forms

Lab

 sepsis

2 4



BP < 90/60 or MAP < 70mmHg

notify

 sepsis
Body temp > 38C < 36C
> 20/min Kussmauls breathing

BP < 90/60 20%
Hypotension shock ( hypovolemic,
cardiogenic)
Metabolic acidosis
Alteration of conscious
SIRS criteria

 sepsis

wbc >12,000 cell/mm3

Band form >10%
Hypoglycemia
platelet <100,000

INR > 1.5, PTT >60s

TB > 4
AKI
Acute oliguria

Acute ischemic stroke

99.99% 1-2

/ sepsis

 poor tissue
perfusion
hypotension, oliguria, wide gap
metabolic acidosis ( lactic)
fluid 30cc/kg
Early goal directed therapy
5 litre 6
CVP guide fluid challenge


sepsis

Antimicrobial Therapy
1 sepsis
(De-escalation)

Antimicrobial Therapy
710 days;

/
S.aureus, B.pseudomallei

CNS

non-infection eg post-op day 1

= Ceftriaxone

 generic ???

 hemoculture??


Streptococcus Viridans, S.aureus echo
Streptococcus bovis Colonoscope
N.meningitidis prophylaxis
B.pseudomallei co-trimoxazole prevent
relapse
Antifungal Rx

Source Control

Source Control
/ 12 hr
off central line source

Source control
broader antibiotics

Resuscitation

Setting Goals of Care

1. aggressive Rx
2. aggressive end stage disease
further treatment

 Central line
1. Load IV fluid 2-3 BP < 90/60 mmHg
2. Urine output < 0.5 ml/kg/hr ( 2 )
3. vasopressor inotrope moderate dose
4. underlying congestive heart failure, cardiomyopathy, renal
failure
5. clinical leakage crepitation both lungs BP
< 90/60 mmHg

Initial resuscitation
(first 6 hours)
resuscitation hypotension
wide gap metabolic acidosis
30cc/kg

Initial resuscitation
(first 6 hours)
Resuscitation goals
CVP 812 mmHg
12-15 mmHg if mechanical ventilation
(x1.36 for cmH2O)
Mean arterial pressure 65 mm Hg
Urine output 0.5 ml/kg/hr
Central venous oxygen saturation 70%

Which fluid can be used in

severe sepsis treatment?

Crystalloids

Hydroxyethyl starches

Albumin

ry
1

outcome

Fluid therapy
1. Crystalloids (NSS) colloid

2. hydroxyethyl starches
3. albumin colloid NSS
4. hypotension, acidosis crystalloid
30 mL/kg

Norepinephrine

Dopamine
stroke volume
heart rate
MAP and cardiac output

vasoconstrictive effects
VS

MAP
Little change in heart rate
and
less increase in stroke
volume

Norepinephrine better than dopamine

in severe sepsis

De Backer D. N Engl J Med 2010; 362:779789;

Marik PE. JAMA 1994; 272:13541357;
Mathur RDAC. Indian J Crit Care Med 2007; 11:186
191;
Martin C. Chest 1993; 103:18261831;
Patel GP. Shock 2010; 33:375380;
Ruokonen E. Crit Care Med 1993; 21:12961303

Not statistical significant

Vasopressor
1. Target MAP > 65 mmHg
2. Norepinephrine : 1st choice
3. Dopamine : only in patients with low risk of
tachyarrhythmias and bradycardia

Vasopressor
Dopamine (2:1) v 10ud/min
Max if BW 50kg = 30ud/min (20ug/kg/min)

Levophed (4:100) v 10ud/min

Max if BW 50kg = vary 75-150ud/min
(1-2ug/kg/min)

Adjust q 10mins
Dose (ug/kg/min) = (conc) x (ud/min)
(BWx0.06)

Steroids
- on prednisolone stress
septic shock hydrocortisone 200-300mg/d
- adrenal insufficiency eg ,
Cushing cortisol hydrocortisone 200300mg/d

Steroids
- adrenal insufficiency :
fluid moderate-high dose
vasopressor MAP < 65mmHg
hydrocortisone 200 mg/day

BLOOD TRANSFUSION
838 critically ill patients

Restrictive strategy
Target Hb 7-9 g/dL

Liberal strategy
Target Hb 10-12 g/dL

Mortality rate in cardiac disease was

not sig. different
(20.5% in restrictive vs 22.9% in
liberal; P=0.69).
Mortality rate during hospitalization was
lower in the restrictive-strategy group
(22.2% vs 28.1%, P=0.05).
Hbert PC, et al. N Engl J Med 1999; 340:409417

Blood products in severe

sepsis
1. Initial resuscitate keep Hct > 30% if low ScvO2
keep Hb 7.0 9.0 g/dL except IHD, severe
hypoxemia, acute hemorrhage
2. FFP bleed or plan invasive procedures
3. platelets
<10,000/mm3
< 20,000/mm3 if significant risk of bleeding.
50,000/mm3 for active bleeding, surgery, or
invasive procedures

Intensive versus Conventional Glucose Control

in Critically Ill Patients
Intensive glucose control 81-108 mg/dL
Conventional glucose control 180 mg/dL

OR 1.14; 95%CI 1.02-1.28; P = 0.02)

The NICE-SUGAR Study Investigators. N Engl J Med
2009;360:1283-97

Glucose Control

target upper blood glucose

180 mg/dL

Bicarbonate Therapy
metabolic acidosis & pH <7.15
volume overload/CHF

Stress Ulcer Prophylaxis

omeprazole or ranitidine for patients with

coagulopathy or need ventilator > 48hrs

Nutrition
1. feed as tolerated within the first 48
hours
2. full caloric feeding

3. intravenous glucose &

enteral nutrition > total parenteral
nutrition (TPN)

Early = TPN within 48hr

Late = TPN not before
day8

 glutamine

Prevent nosocomial infection.

Hand hygiene
Off Line when no indication (Foley, Central
line)
Minimize use antibiotics

 sepsis fast track

 sepsis

2 4



BP < 90/60 or MAP < 70mmHg

notify

Parameter
. sepsis (
. sepsis )
fluid refer
fluid > 30cc/kg/hr
hemoculture
antibiotic 1

7
28

 hemoculture notify .

.

..

THANK YOU