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Sepsis

New Definition 3 International Consensus


rd

Definitions for Sepsis and Septic Shock


(2016)

Presenter :
Dr Vidit Joshi
MD, FCCM
Consultant Intensivist
Krishna Shalby hospital
Definition Sepsis
Life-threatening organ dysfunction caused by a dysregulated host
response to infection.

(Bodys response to infection, injures its own tissue)

Suspected or documented infection


Definition Septic shock
Sepsis with profound circulatory, cellular, and metabolic
abnormalities

Vasopressor requirement to maintain MAP > 65 mm Hg


(despite volume resuscitation)

Serum lactate level > 2 mmol/L (>18 mg/dL) in the absence of


hypovolemia.
Bedside quick assessment
Patients with suspected infection

quickSOFA (qSOFA): HAT


Hypotension: SBP < 100 mmHg
Altered mental status (any GCS < 15)
Tachypnoea: RR > 22
SOFA
Suspected infection
NO Monitor clinical condition
NO
qSOFA 2 Sepsis still suspected Re-evaluate for clinical
YES sepsis if clinically indicated

Assess for evidence of YES


organ dysfunction
NO Monitor clinical condition
SOFA 2 Re-evaluate for clinical
YES sepsis if clinically indicated
Sepsis

Despite adequate fluid resuscitation


1. Vasopressor required to maintain NO
MAP 65
2. Serum lactate level > 2 mmol/L
YES
Septic shock
Surviving Sepsis Campaign:
International Guidelines
for Management
of Sepsis and Septic Shock:
2016
INITIAL RESUSCITATION
Medical emergencies- Treatment and resuscitation begin
immediately
At least 30 mL/kg of IV crystalloid in 3 hours
Additional fluids : frequent reassessment of hemodynamic status.
Reassessment
1. Clinical Examination (HR, BP, SpO2, RR, Temp., urine output, Skin turgor)
2. Cardiac Monitor (Invasive or non-invasive : Dynamic preferred over static)
Target MAP > 65 mm Hg
Guiding resuscitation to normalize lactate
DIAGNOSIS
Appropriate routine microbiologic cultures (including blood) be
obtained before starting antimicrobial therapy

Include at least two sets of blood cultures (aerobic and anaerobic).


ANTI MICROBIAL THERAPY
IV antimicrobials as soon as possible(within 1 hour)
Empiric broad-spectrum therapy
Antimicrobial therapy be narrowed once pathogen identification
and sensitivities are established
Empiric combination therapy
Against combination therapy for the routine treatment of
neutropenic sepsis
ANTI MICROBIAL THERAPY
Against sustained systemic antimicrobial prophylaxis

Antimicrobial treatment duration of 7 to 10 days

Daily assessment for de-escalation

Procalcitonin levels based shortening the duration of


antimicrobial
SOURCE CONTROL

Source control as soon as medically and logistically practical

Prompt removal of intravascular devices (CVP ART line) that


are a possible source
FLUID THERAPY
Fluid administration continue till hemodynamic improvement

Fluid of choice - Balanced crystalloids or saline

Albumin in addition to crystalloids (when patients require


substantial amounts of crystalloids)

Against using hydroxyethyl starches and crystalloid over


Gelatin
VASOACTIVE MEDICATIONS
Norepinephrine as the first-choice
Addition : Vasopressin (up to 0.03 U/min) or Epinephrine (for
targeting MAP or Decreasing NorAD dose)
Dopamine as - alternative to Norepinephrine (absolute or
relative bradycardia)
Against using low-dose dopamine for renal protection
Dobutamine - persistent hypoperfusion despite fluid and
vasopressor
Arterial catheter
CORTICOSTEROIDS
IV Hydrocortisone at a dose of 200 mg per day
(if hemodynamic instability persists despite IV fluids and
vasopressors use)
BLOOD PRODUCTS
RBC transfusion if Hb < 7.0 g/dL
Against the use of erythropoietin for anemia
Against FFP use in the absence of bleeding or invasive
procedure
Platelet transfusion :
Prophylactic <10,000/mm3
Risk of bleeding <20,000/mm3
Active bleeding, surgery, or invasive procedures <50,000/mm3
MECHANICAL VENTILATION
Target TV of 6 mL/kg predicted body weight
Plateau pressures of < 30 cm H2O
Higher PEEP, Prone ventilation and recruitment maneuvers
Neuromuscular blocking agents for 48 hours
Conservative fluid strategy
Against the routine use of the PAC
Head elevation 30 and 45 degrees
Daily spontaneous breathing trials with sedation brake
GLUCOSE CONTROL
Target BSL between 110 180 mg/dl

Arterial blood or plasma glucose values preferred over capillary


blood

BSL @ 1-2 hr on insulin infusion


RENAL REPLACEMENT THERAPY
Either continuous or intermittent RRT for AKI

CRRT better for haemodynamically unstable


BICARBONATE THERAPY
Against the use of sodium bicarbonate therapy for pH 7.15
THROMBOEMBOLISM PROPHYLAXIS
UFH or LMWH for VTE

LMWH preferred

Mechanical prophylaxis when pharmacological contraindicated


STRESS ULCER PROPHYLAXIS
Only for patients with risk factors for gastrointestinal bleeding

Either proton pump inhibitors or histamine-2 receptor


antagonists
NUTRITION
Early Enteral feeding
Against the of early PN alone or PN + enteral feedings
Initiate IV glucose and advance enteral feeds in first 7 days if
enteral feed not tolerated
Trophic/hypocaloric feeding is the initial strategy
Against the use of omega- 3 fatty acids, Glutamine, IV
selenium, Argenine
Against routinely monitoring gastric residual volumes
Use prokinetic agents
THANK YOU