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What is Sepsis ?
SIRS
Sepsis
Severe Sepsis
SIRS + presumed or
confirmed infectious process
2 of the following:
BT >38 or <36
HR > 90bpm
RR > 20bpm or PaCO2 <32mmHg
WBC >12,000, <4,000, or >10% bands
Septic
Shock
Severe Sepsis
Sepsis-induced
tissue hypoperfusion or organ dysfunction
Septic shock
Sepsis-induced hypotension persisting
despite adequate fluid resuscitation
Sepsis (n=1063)
Infection no SIRS (n584)
Total n=3608
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Crit Care Med 2008; 36: 1394 1396
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Crit Care Med 2008; 36: 1394 1396
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Crit Care Med 2008; 36: 1394 1396
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Crit Care Med 2008; 36: 1394 1396
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2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definition Conference. CCM 2003;31:1250-1256
Ventilation
Infection
Perfusion
Supportive care
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Index
//
Bicarbonate
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A Problematic Measurement
It should be recognized that
systemic hypo-perfusion
usually precedes
hypotension, especially in
patients with sepsis
Rackow, JAMA, 1991
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20
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0.3
28.4%
0.3
28 Day In-hospital Mortality
22.4%
0.2
0.2
9.0%
0.1
4.9%
0.1
4.5%
1.5%
0.0
0.0-2.4
2.5-3.9
>4.0
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Where to measure ?
Normal value ?
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Low DO2
High VO2
High DO2
Low VO2
Hypoxia, Suctioning
(low SaO2)
Exercise
Hyperoxia
(high FiO2)
Hypothermia
Pain
Erythrocytosis
(high Hb)
Anesthesia,
Pharmacologic
paralysis
Anemia,
Hemorrhage
(low Hb)
Cardiac dysfunction,
Hypovolemia, Shock,
Arrythmia
(low CO)
Hyperthermia,
Shivering, Seizure
Arterio-venous
shunting,
Hyperdynamic state
Mitochondrial defect,
(high CO)
Terminal Shock
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DO2
Cardiac Output
Heart Rate
Oxygen Content
Stroke Volume
Afterload
Preload
Contractility
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EGDT Results
28-day Mortality
60
50
49.2%
40
P = 0.01*
33.3%
30
20
10
0
Standard Therapy
n=133
EGDT
n=130
.
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EGDT in ER
sepsis induced hypotension or Lactate 4 mmol/L
6
1.
2.
3.
4.
2
(48hr)
(
):
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1
()
Kreger BE. Am J Med 1980;68:344-355.
Ibrahim EH. Chest 2000;118:146-155.
Hatala R. Ann Intern Med 1996;124-717-725.
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48-72
Optimize efficacy
Prevent resistance
Avoid toxicity
Minimize costs
7-10
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Maximal efficacy & minimal physiologic upset
Jimenez MF. Intensive Care Med 2001;27:S49-S62.
Bufalari A. Acta Chir Belg 1996;96:197-200.
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Drainage
- Intra-abdominal abscess
- Thoracic empyema
- Septic arthritis
- Pyelonephritis, cholangitis
Debridement
- Necrotizing fasciitis
- Infected pancreatic necrosis
- Mediastinitis
- Intestinal infarction
Device Removal
- Infected vascular catheter
- Urinary catheter
- Colonized endotracheal tube
Definitive Control
- Sigmoid resection for diverticulitis
- Amputation for clostridial myonecrosis
- Cholecystectomy for gangrenous cholecystitis
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Total n=6997
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:
colloidscrystalloids
(volume of distribution)
Choi PTL. Crit Care Med 1999;27:200-210.
Cook D. Ann Intern Med 2001;135:205-208.
Schierhout G. BMJ 1998;316:961-964.
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:
Goal: CVP 8 mmHg ( or 12 mmHg)
500 - 1000 mL of crystalloids over 30 mins
300 - 500 mL of colloids over 30 mins
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Goal: MAP 65 mmHg
norepinephrine
dopamine
Norepinephrinedopamine
Dopa ;
dopamine
Vasopressin
: 0.01-0.04 units/min
(stroke volume)
Hollenberg SM. Crit Care Med 1999; 27:639-660.
Bellomo R. Lancet 2000; 356: 2139-2143.
Kellum J. Crti Care Med 2001; 29: 1526-1531.
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dobutamine
dobutamine
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100%
100%
28-day Mortality
P=0.04
80%
P=0.96
80%
63%
60%
40%
53%
N=114
61%
53%
60%
N=115
40%
20%
20%
0%
0%
Low-dose Steroids
N=36
Placebo
N=34
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: CortisolACTH30-60min
>9 mcg/dL
ACTH
(tapering)
fludrocortisone
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Hydrocortisone >300 mg
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PROWESS study
ARR: 6.1%
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rhAPC
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rhAPC
rhAPC (drotrecogin alfa [activated])rhAPC
:
Active internal bleeding
- Recent (within 3 months) hemorrhagic stroke
- Recent (within 2 months) intracranial or intraspinal surgery, or
severe head trauma
- Trauma with increased risk of life-threatening bleeding
- Presence of an epidural catheter
- Intracranial neoplasm or mass lesion or evidence of cerebral
herniation
See labeling instructions for relative contraindications (i.e. warnings)
rhAPC30,000
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< 7 g/dL
:
:
Hb 7 9 g/dL
Erythropoietin(EPO)
EPO
(FFP)
Corwin HL. JAMA 2002;288:2827-2835.
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Antithrombin
5000/mm3
5000 - 30,000/mm3
/ 50,000/ mm3
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ALI/ARDS
39.8
Mortality (%)
40
31
30
20
Low Tidal
Volume
* death before
discharge home
and breathing without
assistance
Traditional
Tidal
Volume
10
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Traditional: 12mL/kg; Pplateau <50 cmH20
Protective: 6mL/kg; Pplateau <30 cmH20
ALI/ARDS
:
High tidal volumes, > 6 ml/kg
High plateau pressures, > 30 cm H2O
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ALI/ARDS
FiO2plateau
pressure
(prone position)
(mechanical ventilation)
45%,
(ventilator associated
pneumonia)
Drakulovic M. Lancet 1999;354:1851-1858.
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ALI/ARDS
ALI/ARDS
ALI/ARDS
ALI
60
ALI/ARDS
:
FiO2
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//
(Protocols)
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Mortality (%)
20.0%
20. 20%
15.0%
10. 60%
10.0%
5.0%
8. 00%
10. 90%
7. 20%
4. 60%
0.0%
ICU
In-hospital
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NICE-SUGAR trial:
Goal 150mg/dl
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check
q1~2 hours
< 150 mg/dL
()
5% or 10% dextrose
van den Berghe G. N Engl J Med 2001;345:1359-1367.
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CVVHHD
CVVH
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Bicarbonate
(lactic acidosis) pH 7.15
bicarbonate
Bicarbonate NS
pH 7.13
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The Surviving Sepsis Campaign: results of an international guideline69 performance improvement program targeting severe sepsis
based
Intensive Care Med (2010) 36:222231
Strategies to Timely
Obviate the Progression
of Sepsis
STOP Sepsis
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Goal
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http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Tools/SepsisBundleIHITool.htm
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http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Tools/SepsisBundleIHITool.htm
Heads of Sepsis
hypotension, hypoperfusion, and organ dysfunction
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The End
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