The Sepsis Resuscitation And Management Bundles
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The Sepsis Resuscitation And Management Bundles

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The Sepsis Resuscitation And Management Bundles The Sepsis Resuscitation And Management Bundles Presentation Transcript

  • Dr. Najm-us-saqib Department of Anaesthesia and intensive care Combined Military Hospital Rawalpindi The sepsis resuscitation and management bundles
  • Sepsis:
    • SEPSIS
    • Suspected or proven infection
    • Presence of at least 2 signs
      • Temperature  38oC or  36oC
      • HR  90 beats/min
      • Respirations  20/min
      • WBC count  12,000/mm3 or  4,000/mm3 or >10% immature bands
    Sepsis SIRS Infection / Trauma Severe Sepsis
    • Infection
        • Acute organ dysfunction
    Infection / Trauma SIRS Sepsis Severe Sepsis Sepsis:
  • Septic shock
    • SBP < 90 mm Hg
    • Reduction of 40 mm Hg or more from baseline
    • Oliguria
    • Lactic acidosis
  • Common symptoms
    • Respiratory system dysfunction
    • Shock
    • Renal system dysfunction
    • The Institute for Healthcare Improvement (IHI)
    • Surviving sepsis campaign
  • Sepsis treatment bundles
    • Resuscitation
    • Management
    • Apply all elements in the bundle.
  • Resuscitation bundle during the first 6 hours
    • Measure serum lactate level.
    • Blood cultures before antibiotic administration.
    • Broad-spectrum antibiotics Within
    • 3 hours for emergency
    • 1 hour for ICU admission
    • Hypotension
    • lactate > 4 mmol/L
      • Crystalloid 20 mL/kg (or colloid )
      • Use Vasopressors
      • Maintain MAP ≥ of 65 mm Hg
  • Hypotension despite fluid resuscitation
    • Septic shock
    • Lactate level > 4 mmol/L
      • CVP ≥ 8 mm Hg
      • Central venous oxygen saturation ≥ 70%
      • Mixed venous oxygen saturation ≥ 65%
  • The sepsis management bundle, during the first 24 hours
    • Low-dose steroids
    • Activated drotrecogin alfa
    • Maintain glucose
    • ≥ the lower limit of normal
    • but < 150 mg/dL
    • In Plp < 30 cm H2O
  • Management
    • Goals during the first 6 hrs of resuscitation
      • CVP 8-12 mm Hg
      • MAP ≥ 65 mm Hg
      • Urine output ≥ 0.5 mL • kg-1 • hr -1
      • Central venous oxygen saturation ≥ 70%
      • Mixed venous ≥ 65%
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • HCT of ≥ 30%
    • Dobutamine infusion
    • Grade 2C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Diagnosis
    • Appropriate cultures before antibiotic administration
    • Two blood cultures
      • Percutaneous
      • Vascular access device,
    • Cultures of other sites
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Imaging studies
    • Source of
    • Infection
    • Sampling
    • In unstable patients
    • Bedside ultrasound
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Antibiotic Therapy
    • IV antibiotic therapy
    • first hour
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Cultures should not delay antimicrobial therapy
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Initial empirical therapy
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Antimicrobial regimen should be reassessed daily
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Combination therapy is recommended for 3 -5 days
      • Pseudomonas infections
      • Neutropenic patients
    • De-escalation to the single therapy as soon as the sensitivity is known
    • Grade 2D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Duration of antibiotic therapy should be 7-10 days
    • Longer courses:
      • Slow clinical response
      • Undrainable foci of infection
      • Immunologic deficiencies
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • In Noninfectious cause
    • Antimicrobial therapy is stopped so that patient may not be
    • Infected with resistant pathogen
    • Drug-related adverse effect
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Source Control
    • Specific anatomical diagnosis of infection should be made within the first 6 hrs
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Patients should be evaluated for
      • Drainage
      • Debridement
      • Removal of a potentially infected device
      • The definitive control of ongoing microbial contamination
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • The least physiologic insult should be given
        • Percutaneous
        • Surgical drainage
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Intravascular access devices should be changed.
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Fluid Therapy
    • Fluid resuscitation
      • Natural/artificial colloids
      • Crystalloids
    • There is no evidence-based support for one type of fluid over another
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Central venous pressure
    • Target CVP of ≥ 8 mm Hg
    • (12 mm Hg in mechanically ventilated patients)
    • Further fluid therapy is often required
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Fluid challenge
    • In Hypovolemia
      • ≥ 1000 mL of crystalloids
      • 300-500 mL of colloids over 30 mins
    • More rapid and greater amounts of fluid may be needed in patients with septic shock.
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • fluid resuscitation end point
    • Continue fluid resuscitation as long as the Hemodynamic improvement continues
      • Arterial pressure
      • Heart rate
      • Urine output
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Reduce Rate of fluid administration
    • When cardiac filling pressures increase
    • Without
    • Hemodynamic improvement
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Vasopressors
    • MAP should be maintained ≥ 65 mm Hg
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • First choice vasopressor agent
    • Norepinephrine or dopamine
    • (Administered through a central catheter as soon as one is available)
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Epinephrine
    • Phenylephrine
    • Vasopressin
    • Should not be administered as the initial vasopressor in septic shock
    • Grade 2C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Vasopressin 0.03 units/min may be added to norepinephrine
    • Alternative agent in septic shock
    • Epinephrine
    • Grade 2B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Low dose dopamine
    • Low-dose dopamine should not be used for renal protection
    • Grade 2A evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Arterial line
    • If resources are available arterial line should be placed as soon as practical
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Inotropic Therapy
    • Dobutamine
    • Myocardial dysfunction
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • cardiac index
    • predetermined supranormal levels
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Corticosteroids
    • Intravenous hydrocortisone
        • adult
        • poorly responsive
    • Grade 2D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Steroids
    • ACTH stimulation test
    • Grade 2B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Steroids
    • Hydrocortisone
    • Dexamethasone
    • Grade 2B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Steroids
    • Oral fludrocortisone (50 µg)
    • +
    • Steroid (no significant mineralocorticoid activity)
    • Grade 2C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Steroids
    • Wean from steroid therapy when
    • Vasopressors are no longer required
    • Grade 2D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Doses
    • > 300 mg of hydrocortisone
    • ×
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Corticosteroids should not be administered in the absence of shock.
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Recombinant Human Activated Protein C (rhAPC)
    • Adult patients with severe sepsis should receive rhAPC
    • High risk of death
    • APACHE II score ≥ 25
    • Multiple organ failure
    • Grade 2B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • should not receive rhAPC
      • Low risk of death
      • APACHE II < 20
      • One organ failure
    • Grade 1A evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Blood Product Administration
    • Once tissue hypoperfusion has resolved and in the absence of
      • Myocardial ischemia
      • Severe hypoxemia
      • Acute hemorrhage
      • Cyanotic heart disease
      • Lactic acidosis
      • RBC transfusion
    • Hb < 7.0 g/dL
    • Target Hb 7.0-9.0 g/dL in adults
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Erythropoietin should not be used as a specific treatment of anemia
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Fresh frozen plasma
    • Should not be given in the Absence of
      • Bleeding
      • Planned invasive procedures
    • Grade 2D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Antithrombin
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Platelet transfusion
    • Transfusion required
    • < 5000/mm3
    • May be considered when counts are
      • 5000-30,000/mm3
      • significant risk of bleeding
    • ≥  50,000/mm3 is required
        • surgery
        • invasive procedures
    • Grade 2D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Mechanical Ventilation Sepsis-Induced ALI/ARDS
    • Target a tidal volume of 6 mL/kg
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
      • Plateau pressure ≤ 30 cm H2O
      • Permissive hypercapnia
      • PEEP
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Prone positioning
      • High Fio2
      • Increased Plateau pressure
    • Not at high risk
    • In experienced facilities
    • Grade 2Cevidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Head of the bed elevated
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Head of bed be elevated approx
    • 30-45°
    • Grade 2C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Non invasive ventilation
    • Mild-moderate hypoxemia
    • With stable Hemodynamics
    • Who are able to protect the airway
    • Clear secretions
    • Anticipated to recover rapidly
    • Grade 2B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Spontaneous breathing trial
        • Pressure support
        • CPAP (~5 cm H2O)
        • T-piece
        • Discontinue mechanical ventilation
        • Arousable
        • Hemodynamically stable
        • No new serious conditions
        • Low pressures
        • Low Fio2 requirements
    • Grade 1A evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Pulmonary artery catheter
    • for patients with ALI/ARDS
    • Grade 1A evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Conservative fluid strategy
      • Acute lung injury
      • (Tissue hypoperfusion)
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Sedation, Analgesia
    • Sedation protocols
    • Sedation goal
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Intermittent bolus sedation
    • Continuous infusion sedation
    • (to predetermined end points)
    • Daily interruption/lightening of continuous infusion sedation
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Neuromuscular Blockade in Sepsis
    • NMBAs can be given as
      • Intermittent bolus
      • Continuous infusion
    • Avoid NMBAs if possible
    • Monitoring with train-of-four
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Glucose Control
    • Intravenous insulin therapy to reduce blood glucose levels
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Validated protocol for insulin dose adjustments
    • Targeting glucose levels to the < 150 mg/dL
    • Grade 2C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Give glucose calorie source to patient
    • Monitor every 1-2 hrs until stable
    • Then every 4 hrly
    • Grade 1C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Renal Replacement
    • Continuous renal replacement therapy
    • Intermittent hemodialysis
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Continuous therapies
    • Hemodynamically unstable septic patients
    • Grade 2D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Bicarbonate Therapy
    • Do not use sodium bicarbonate
    • When pH ≥ 7.15
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Deep Vein Thrombosis Prophylaxis
      • Low-dose UFH 2-3 times per day
      • LMWH
      • Mechanical device
          • Graduated compression stockings
          • Intermittent compression devices
    • Grade 1A evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • H igh-risk
        • Pharmacologic
        • LMWH
        • Mechanical therapy
    • Grade 2C evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Stress Ulcer Prophylaxis
    • H2 blocker
    • Grade 1A evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Proton pump inhibitor
    • Grade 1B evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
  • Selective Digest Tract Decontamination (SDD)
    • Approved by the entire committee
    • Grade 1D evidence
    • Surviving Sepsis Campaign: International Guidelines
    • for Management of Severe Sepsis and Septic Shock: 2008
    • Although this document is static, the optimum treatment of severe sepsis and septic shock is a dynamic and evolving process.
    • New interventions will be proven and, as stated in the current recommendations, these interventions may need modification in the future.
    • Thank you