Professional Documents
Culture Documents
Advisor:
dr. H. Zulkifli, SpAn, KIC, M.Kes
Sepsis Severe sepsis Sepsis- induced
the presence sepsis + organ hypotension
(probable or dysfunction or SBP < 90 mm Hg
documented) of tissue or
infection together hypoperfusion (MAP) < 70 mmHg
with systemic or
manifestations of SBP decrease > 40
infection. mm Hg or
less than two SD
below normal for
age in the absence
of other causes.
PATHOGENESIS
INITIAL RESUSCITATION OF SEVERE SEPSIS
1. During the first 6 hrs of
resuscitation, the goals (grade 2. Normalize
1C):
a) CVP 812 mm Hg
lactate level
b) MAP 65 mm Hg
c) Urine output 0.5 mLkghr
(grade 2C).
d) Superior vena cava oxygenation
saturation (Scvo2) or mixed venous
oxygen saturation (Svo 2) 70% or
65%
15.9% absolute
reduction in 28-day
mortality rate
SCREENING FOR SEPSIS AND
PERFORMANCE IMPROVEMENT
4b. Combination
Avoid antimicrobial resistance
therapy not be
administered >
3-5 days (grade
2B).
slow clinical
response
undrainable
foci of
infection
5. Duration of
therapy: 7-10
days.
immunologic
deficiencies,
bacteremia
including
with S. aureus
neutropenia
(grade 2C).
some fungal
and viral
infections,
confirmed
influenza among
persons with
severe influenza
Antiviral initiated as
early as possible
5. fluid challenge
1. crystalloids as the
initial fluid (grade
Fluid technique be applied
continued as long as
1B). Therapy there is
hemodynamic
improvement
Scandinavian multicenter
CRYSTMAS no study increased
difference in mortality with mortality rates with 6%
HES vs. 0.9% normal saline HES 130/0.42 compared to
(31% vs. 25.3%, p = 0.37) Ringers acetate (51% vs.
43% p = 0.03)
Dopamine:
1st choice
alternation of
norepinephrin
vasopressor
Vasopressor
Low dose
vasopressin and Additional
phenylephrine agent
not epinephrin
recommended
Vasopressin
(0,03 U/m) can
be added
Dopamine
Norepinephrine
a) myocardial dysfunction:
elevated cardiac filling
pressures and low cardiac
Dobutamine infusion up to output
20 g/kg/min be
administered or added to
vasopressor (if in use) in b) ongoing signs of
the presence of: hypoperfusion, despite
achieving adequate
intravascular volume and
MAP (grade 1C).
CORTICOSTEROID
1.Not using intravenous hydrocortisone as a treatment if hemodynamic is stable
after the resuscitation.
If not hydrocortisone IV single 200 mg per day (grade 2C).
2. Not using the ACTH stimulation test to identify who should receive
hydrocortisone (grade 2B).
In one study, the observation of a potential interaction between steroid use and
ACTH test was not statistically significant.
Recruitment
Measure plateau
maneuvers in
Mechanical
severe refractory
pressures (30
cmH2O)
hypoxemia
Ventilation of
Sepsis-Induced
ARDS
Apply PEEP to
Base strategy on
avoid alveolar
higher PEEP
collapse
Prone positioning in
patients with PaO2/FiO2
100 mmHg in
experienced facilities
Maintain ventilated
Spontaneous breathing
trials regularly Mechanical patient with head
elevated 30-45
Ventilation of
Sepsis-Induced
ARDS
Noninvasive mask
A weaning protocol ventilation in some
needs to be in place patients where benefits >
risks
no new potentially
serious conditions
Mechanical
Ventilation of
Sepsis-Induced
Not using 2-
ARDS Conservative fluid
agonists unless strategy if no sign of
indicated hypoperfusion
SEDATION, ANALGESIA, AND
NEUROMUSCULAR BLOCKADE
If prophylaxis used:
PPI > H2 inhibitor
Setting
Goals
of Care
Incorporate Address goals of
goals of care care as early as
feasible, but no
into treatment later than 72
and end-of-life hours of ICU
care planning admission
THE 2015 UPDATE
Rationale: 3 trials do not demonstrate superiority of required use of a
central venous catheter (CVC) to monitor central venous pressure
(CVP) and central venous oxygen saturation (ScvO2) in all patients with
septic shock who have received timely antibiotics and fluid resuscitation
compared with controls or in all patients with lactate >4 mmol/L
BUNDLES
Within 3 hours of time of
presentation
Within 6 hours of time of
presentation
How to deliver continuous fluid therapy in septic shock after this issue has been
resolved?
Resuscitation guidelines only, no such guideline in SSC-
Leo
Combined ABs 5-7 days only, avoid resistance. 7-10 days also for combi therapy?
What do we fear with continuous sedation?
Can still be given to prevent ARDS...
Sedative agents only used for <48 hrs due to its metabolites
Excessive use also interferes with hemodynamics other than arousability and longer days