SEPSIS

Diagnosis Criteria of Sepsis

General Variables
Fever ( >38,30C) or Hypothermia ( <360C)
Heart Rate >90x/min or more than 2 SD above the
normal value of age

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130 x/min

Tachypnea

28 x/min

Altered mental status

Anxious

Significant edema or positive fluid balance ( 20

ml/kgBW/24 hr)
Hyperglycemia (plasma glucose >140 mg) in the
absence of diabetes
Inflammatory Variables

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Leukocytosis ( > 12000) or Leukopenia ( <4000)

41000

Normal WBC count with > 10% immature forms

Plasma CRP > 2 SD above the normal value

Plasma PCT > 2 SD above the normal value

Inflammatory Variables
Hypotension (SBP < 90 mmHg, MAP < 70 mmHg, or
an SBP > 40 mmHg or less than 2 SD below

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Diagnosis Criteria of Sepsis

Organ Dysfunction Variables

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Arterial hypoxemia (PaO2/FiO2 < 300)

Acute oliguria (urine output < 0,5 ml/kg/hr for at
least 2 hours despite adequate fluid rescucitation)
Creatinine increase > 0,5 mg/dl

3.3

Coagulation abnormalities (INR > 1,5 or aPTT > 60s)

Ileus (absent bowel sounds)

Thrombocytopenia (platelet count < 100000)

Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL)
Tissue Perfusion Variables
Hyperlactatemia ( > 1 mmol/L)
Decreased capillary refill

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12.7

State of
patient

We concluded that this pts was also suffering of severe preeclampsia

The sepsis was due to intrauterine infection proved by physical
examination: foul odor baby and amniotic fluid
The sepsis process was comorbid by the PE also the long period of
hypoxia bad condition and irreversible

APACHE II SCORE

MANAGEMENT OF SEVERE SEPSIS

Management of Severe Sepsis

Initial
Resuscitation

Diagnosis

Antibiotic
Therapy

Source Control

Fluid Therapy

Vasopressors

Corticosteroids

Recombinant
Human Activated
Protein C (rhAPC)

Inotropic Therapy

Blood Product
Administration

Sepsis Guidelines 2008

EARLY GOAL-DIRECTED
THERAPY

Supplemental oxygen +/Endotracheal intubation and

Mechanical ventilation
Central venous and
Arterial catheterization
Sedation,paralysis
(if intubated)
Or both

CVP

Minimize VO2

<8-12mmHg

>65 and>90mmHg

ScvO2
>70%

No

Goals
achieved

Volume load

colloid

8-12 mmHg

MAP

crystalloid

<65mmHg
<90mmHg
<70%

vasoactive agents
Transfusion of red cells
Until hematocrit >30%

Inotropic agents

>70%
<70%

Vasoactive drugs

O2 carrying
capacity

&
Inotrope

Initial Resuscitation
(First 6 hrs)

Begin resuscitation immediately

in patients with hypotension
or serum lactate > 4 mmol/L;
do not delay pending ICU
admission

Resuscitation goals:

CVP 812 mm Hg
MAP 65 mm Hg
Urine output 0.5 mL/kg/hour
Central venous O2 saturation
70%,
or mixed venous 65%

If venous O2 saturation target not

achieved:
consider further fluid
transfuse pRBC to Hct 30%

Early Goal-Directed Therapy Results

28-day Mortality

60
50

49.2%

40

P = 0.01*
33.3%

30
20
10
0

Standard Therapy
EGDT
n =133
n=130
*Key difference was in sudden CV collapse, not MODS

Rivers E. N Engl J Med 2001;345:1368-77.

Before the initiation of antimicrobial therapy, at least two

blood cultures should be obtained
At least one drawn percutaneously
At least one drawn through each vascular access device if inserted longer
than 48 hours

Other cultures such as urine, cerebrospinal fluid,

wounds, respiratory secretions or other body fluids
should be obtained as the clinical situation dictates

Antibiotic
Therapy
Begin antibiotics as
early as possible, and
always within the first
hour of recognizing
severe sepsis and
septic shock.

Start intravenous antibiotic therapy within the first hour of recognition

of severe sepsis after obtaining appropriate cultures

Empirical choice of antimicrobials should include one or more drugs with

activity against likely pathogens, both bacterial or fungal

Penetrate presumed source of infection

Guided by susceptibility patterns in the community and hospital

Continue broad spectrum therapy until the causative organism

and its susceptibilities are defined

Reassess after 48-72 hours to narrow the spectrum of antibiotic

therapy

Duration of therapy should typically be 7-10 days and guided by

clinical response

Stop antimicrobials promptly if clinical syndrome is determined to

be noninfectious

Source Control
Drainage

Examples
Intra-abdominal abscess
Thoracic empyema
Septic arthritis

Debridement

Pyelonephritis, cholangitis
Infected pancreatic necrosis
Intestinal infarction
Mediastinitis

Device removal

Infected vascular catheter

Urinary catheter
Infected intrauterine contraceptive device

Definitive control Sigmoid resection for diverticulitis

Cholecystectomy for gangrenous cholecystitis
Amputation for clostridial myonecrosis

Fluid
Therapy

Fluid-resuscitate using
crystalloids or colloids.

Target CVP 8 mmHg

( 12 mmHg if
mechanically
ventilated)
Give fluid challenges of
1000 ml of crystalloids
or 300500 ml of
colloids over 30 min.

VASOPRESSOR

Initiate vasopressor therapy if appropriate fluid challenge fails to

restore adequate blood pressure and organ perfusion
Vasopressor therapy should also be used transiently in the
face of life-threatening hypotension, even when fluid
challenge is in progress
Either norepinephrine or dopamine are first line agents to correct
hypotension in septic shock
Norepinephrine is more potent than dopamine and may be
more effective at reversing hypotension in septic shock
patients
Dopamine may be particularly useful in patients with
compromised systolic function but causes more tachycardia
and may be more arrhythmogenic

VASOPRESSOR

Low dose dopamine should not be used for renal

protection in severe sepsis
An arterial catheter should be placed as soon as
practical in all patients requiring vasopressors
Arterial catheters provide more accurate and
reproducible measurement of arterial pressure in
shock states when compared to using a cuff
Vasopressin may be considered in refractory shock
patients that are refractory to fluid resuscitation and
high dose vasopressors
Infusion rate of 0.01-0.04 units/min in adults
May decrease stroke volume

INOTROPIC

In patients with low cardiac output despite

adequate fluid resuscitation, dobutamine may
be used to increase cardiac output
Should be combined with vasopressor therapy in
the presence of hypotension

It is not recommended to increase cardiac

index to target an arbitrarily predefined
elevated level
Patients with severe sepsis failed to benefit from
increasing oxygen delivery to supranormal levels by
use of dobutamine

STEROIDS
Low-Dose Steroids: 28-day Mortality

28-day Mortality

100%
80%

Patients with Relative Adrenal

Insufficiency (ACTH Test Nonresponders) (77%)

100%

P=0.04

40%

53%

60%

N=114

N=115

20%

0%

0%

Annane, D. JAMA, 2002; 288 (7): 868

61%
N=36

40%

20%

Low-dose Steroids

P=0.96

80%

63%
60%

Patients Without Relative Adrenal

Insufficiency (ACTH Test
Responders) (23%)

Placebo

53%
N=34

STEROIDS

Doses of hydrocortisone >300 mg daily

should NOT be used in septic shock or
severe sepsis for the purpose of treating
shock
In the absence of shock, corticosteroids
should not be used for treatment of sepsis

Blood Product
Administration
Give RBC when Hb < 7.0
g/dl to target HB 7.09.0
g/dl in adults.
Administer platelets
when:
platelet counts are <
5,000/mm3 regardless of
bleeding.
platelet counts are 5000 to
30,000/mm3 and there is
significant bleeding risk.
platelet counts
50,000/mm3 are required for
surgery or invasive

Glucose Control
Use IV insulin to control
hyperglycemia in severe
sepsis
Keep blood glucose < 150
mg/dl
Best results obtained when blood glucose was
maintained between 80 and 110 mg/dL
Minimize the risk of hypoglycemia by providing a
continuous supply of glucose substrate (D5/D10)
followed by initiation for enteral feeding

Glucose Control Intensive

Insulin
Mortality During Intensive
Care

Mortality (%)

15%

p < 0.04
(adjusted)

In-Hospital Mortality

15%

p = 0.01
10,9%

10%

7,2%
4,6%

5%

0%

10%

8,0%

n=783

n=765

Conventional
van den Berghe G. N Engl J Med 2001;345:1359-1367.

5%

0%

n=783

Intensive Insulin

n=765

Renal Replacement
Continuous venovenous hemofiltration and
intermittent hemodialysis are considered
equivalent in acute renal failure (in the absence
of hemodynamic instability)
Continuous hemofiltration
offers easier management
of fluid balance in
hemodynamically
unstable septic patients

Stress Ulcer Prophylaxis

Stress ulcer prophylaxis should be given to all patients
with severe sepsis

H2 receptor blockers are more efficacious than sucralfate

and are the preferred agents
Proton pump inhibitors compared to H2 blockers have not
been assessed

Deep Vein Thrombosis

(DVT) Prophylaxis
DVT prophylaxis with either low-dose unfractionated heparin
or low molecular weight heparin should be used in severe
sepsis patients
Use a mechanical prophylactic device or
intermittent compression in patients with
contraindications to heparin
Use a combination of pharmacological and
mechanical therapy in very high risk patients
(eg, severe sepsis and history of DVT)