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Sepsis

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Information about Sepsis
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Published on February 25, 2014

Author: markpbrady

Source: authorstream.com

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PowerPoint Presentation: sep·sis   n . pl. sep·ses (-sz ) A profound inflammatory response to an underlying infection Pathophysiology of Sepsis: Pathophysiology of Sepsis Leads to profound vasodilation Inflammatory Response Cellular Injury Infection Creates a Procoagulant state Can result in Multi-organ Dysfunction syndrome (MODS) SIRS: SIRS Systemic Inflammatory Response Syndrome Temp > 38 C°(100.4 F °) or < 36 C° ( 96.8 F °) HR > 90 RR > 20 or PaCO2 < 32 WBC > 12 or < 4 or Bands > 10 % PowerPoint Presentation: Sepsis = At least 2 SIRS criteria + Presumed / Known Source Severe Sepsis = Sepsis + Organ Hypoperfusion Septic Shock = Sepsis + Shock refractory to fluid resuscitation Definitions PowerPoint Presentation: Signs & Symptoms Fever Tachycardia Tachypnea AMS AKI SOB N&V Septic emboli Hypotension Fatigue Coagulopathy Ileus PowerPoint Presentation: N Engl J Med 1997;336:912-8 Common Sites of Infection in Severe Sepsis PowerPoint Presentation: Mortality rate increases progressively with severity of illness 7% with SIRS alone 16% with sepsis 20% with severe sepsis 46% with septic shock Mortality Diagnosis of Sepsis: Diagnosis of Sepsis Known or suspected infection with at least 2 of the following SIRS criteria Temp > 38 C°(100.4 F ° ) or < 36 C°(96.8 F ° ) HR > 90 RR > 20 or PaCO2 < 32 WBC > 12 or < 4 or Bands > 10% Early Recognition: Early Recognition History and Physical Vital Signs Lactate Central Venous Oxygenation (scv0 2) ** 5. Procalcitonin ** Treatment of Sepsis: Treatment of Sepsis 1. Early Recognition Don’t forget the basics 2. Treatment of Sepsis: Treatment of Sepsis 3 . Antibiotics 4 . Fluids Fluids Fluids (30 ml/kg) 5 . Source Removal Source Control: Source Control Don’ t be satisfied with a diagnosis of sepsis and no source . PowerPoint Presentation: Antibiotics Within 1 hr Every delay of 1 hr decreases survival by 8% Early Goal Directed Therapy:  Early Goal Directed Therapy Urine output ≥ 0.5 ml/kg/hr MAP ≥ 65 mm Hg Identify Source and treat, Broad Spectrum Antibiotics within 1 hr PowerPoint Presentation: Fluid Responsiveness Intravascular volume estimation IVC <2 cm in diameter and inspiratory collapse greater than 50% approximates CVP <10 cmH20 PowerPoint Presentation: Fluid Responsiveness PowerPoint Presentation: Corticosteroids Do not give unless you are unable achieve a SBP of at least 90 mm HG with IV fluids and vasopressors. PowerPoint Presentation: Mechanical Ventilation in ARDS Use low tidal volumes 6 ml / kg + PEEP PowerPoint Presentation: Transfusion Strategy Transfusion goal: Hgb 7-9 gm/dl PowerPoint Presentation: Glucose Control Glucose goal is ≤ 180 mg/dl PowerPoint Presentation: http:// www.sccm.org /Documents/SSC- Guidelines.pdf 2012 Changes PowerPoint Presentation: Xigris (Activated Protein C) Protocolized Care:  Protocolized Care EGDT ( early goal directed therapy) (targets BP, CVP, U O , Scvo2 ) with the use of fluids, pressors, transfusion, dobutamine (1C) New Protocol: New Protocol We suggest targeting resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (grade 2C) Vasopressors: Vasopressors We recommend norepinephrine (Levophed) as the first-choice vasopressor (grade 1B). We suggest epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure (grade 2B). Steroids: Steroids 2012: We suggest not using intravenous hydrocortisone as a treatment of adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability . If this is not achievable, we suggest intravenous hydrocortisone alone at a dose of 200 mg per day (grade 2C) ARDS: ARDS T arget a tidal volume of 6 mL/kg predicted body weight in patients with sepsis-induced ARDS (grade 1A vs. 12 mL/kg). We suggest strategies based on higher rather than lower levels of PEEP for patients with sepsis-induced moderate to severe ARDS (grade 2C). Controversies and changes: – sweet is good!: Controversies and changes: – sweet is good! Target an upper blood glucose ≤180 mg/dL rather than an upper target blood glucose ≤ 110 mg/dL (grade 1A). Platelets: Platelets In patients with severe sepsis, we suggest that platelets be administered prophylactically when counts are ≤ 10,000/ mm3 (10 × 109/L) in the absence of apparent bleeding, as well when counts are ≤ 20,000/mm3 (20 × 109/L) if the patient has a significant risk of bleeding. Higher platelet counts (≥ 50,000/mm3 [50 × 109/L]) are advised for active bleeding, surgery, or invasive procedures (grade 2D). Team Work:  Team W ork Sepsis management requires a multidisciplinary team (physicians, nurses, pharmacy, respiratory, dieticians, and administration) and multispecialty collaboration (medicine, surgery, and emergency medicine) to maximize the chance for success. PowerPoint Presentation: Sepsis Summary Resuscitation Sepsis Identification Targeted Therapy Source ID Source Control Fluids, Fluids, Fluids Vasopressors Scv0 2 Sepsis Summary: Sepsis Summary Identify Sepsis as early as possible Identify source and give broad s pectrum antibiotics within 1 hr Identify severity: Vitals , mental status, UOP , LACTATE , LACTATE , LACTATE Volume and physiologic resuscitation ASAP with EGDT .

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