Bundle of sepsis


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Bundle of sepsis

  1. 1. Associate Prof. DrHuda NasserMD, FARCSIFaculty of Medicine –Aleppo University
  2. 2. Agenda Clinical syndromes related to sepsis Septic shock, pathogenesis, manifestations Goals of treatment of septic shock Initial resuscitation with fluid Stabilize hemodynamics with pressors Antibiotics Interruption of inflammatory mediators Early goal directed therapy
  3. 3. BacteremiaTransient Infection in the blood
  4. 4. Systemic Inflammatory Response Syndrome (( SIRS  Trigger: infectious or non-infectious (e.g., pancreatitis, crush injuries, and certain drug ingestions such as salicylates)  Cause: release of inflammatory mediators  Can be self limited or can progress to severe sepsis and septic shock
  5. 5. Systemic Inflammatory Response Syndrome
  6. 6. SepsisSIRS + Blood Infection
  7. 7. Severe Sepsis SIRS + Blood Infection Plus Organ Failure
  8. 8. Septic Shock SIRS or Sepsis PlusHypotension (SBP< 90) or Lactate ≥ 4 mmol/L
  9. 9. Refractory Hypotension Systolic blood pressure < 90 mm Hg after a crystalloid-fluid challenge. Dose of fluid Challenge: 20 to 30 ml per kilogram of body weight over 60 minutes Example: (70 kg) fluid challenge= 1.5-2.0 L
  10. 10. Septic Shock Is caused by the systemic release of mediators that usually are triggered by circulating bacteria or their products Or caused by systemic mediators triggered by noninfectious causes Refractory Hypotension MUST be present
  11. 11. Clinical Manifestation of Shock
  12. 12. Septic Shock: Goals of Treatment
  13. 13. Septic Shock-Initial Resuscitation Appropriate large-volume fluid administration to compensate for the decrease in vascular tone and dilated ventricular capacity. First Goal: CVP = 8-12 cm H2Oa) Crystalloid fluid Administrationb) Central venous pressure monitorc) During first 6 hours
  14. 14. Fluid Therapy We recommend fluid resuscitation with either natural/artificial colloids or crystalloids. There is no evidence-based support for one type of fluid over another (grade 1B).A comparison of albumin and saline for fluid resuscitation in the intensive care unit.N Engl J Med 2004; 350:2247-2256.
  15. 15. Stabilize Hemodynamics Second goal is: 65 ≤ MAP ≤ 90a) Norepinephrine or Dopamine IV dripb) Arterial line monitorc) During first 6 hours Third goal is: ScvO2 ≥ 70 %a) Blood transfusion to keep Hct ≥ 30 %b) Use Inotropic agent to improve cardiac indexc) Central venous monitor of O2 saturationd) During first 6 hours
  16. 16. Blood ProductAdministration Give red blood cells when hemoglobin decrease to < 7 g/dl to target a hemoglobin of 7.0-9.0 g/dl in adults Do not use erythropoietin to treat sepsis related anemia
  17. 17. Norepinephrine Dose 0.2-1.5 mcg/kg/min Large dose: 3.3 mcg/kg/min have been used because of the alpha-receptor down-regulation in sepsis.
  18. 18. Norepinephrine versus Dopamine  Two recent trials have shown that a significantly greater proportion of patients treated with norepinephrine were resuscitated successfully, as opposed to the patients treated with dopamine.  Norepinephrine should be used early and should not be withheld as a last resort in patients with severe sepsis who are in shock. Critical Care Medicine 2000;28,2758-2765 Chest 1993;103,1826-1831
  19. 19. DopamineDopamine is capable of stimulating:1. Cardiac ß1-receptors2. Peripheral α-receptors3. Dopaminergic receptors in renal, splanchnic, and other vascular beds.
  20. 20. Bicarbonate Therapy Do not use bicarbonate for the purpose of improving hemodynamics or reducing vasopressor requirements when treating hypoperfusion-induced lactic acidemia with PH ≥ 7.15
  21. 21. Control of Underlying Infection Replacement of Central and Arterial lines: 1) Infected lines or old lines ( ≥ 7 days ) 2) Avoid Femoral Vein if possible 3) Full sterile technique ( mask, gown, gloves ) 4) Antibiotics Treatment of Pneumonia: 1) Good Oral Hygiene 2) Aspiration Precaution: ↑ HOB 45 ˚ 3) Antibiotics Treatment of Intra-abdominal infections: 1) Cholecystitis, diverticulitis, gut ischemia, abscess, pancreatitis, appendicitis, UTI ( change catheter ) 2) Mini-invasive surgery vs. surgery 3) Antibiotics
  22. 22. (Blood Cultures ( BCs Obtain ≥ 2 BCs ≥ 1 BC should be percutaneous One BC from each vascular access device in place > 48 Should be obtained very early Obtain Lactate level with blood culture
  23. 23. Empiric Antibiotics: Broad Spectrum  Must be broad-spectrum agents and must cover gram-positive, gram-negative, and anaerobic bacteria.
  24. 24. Empiric Antibiotics: First Hour Should be started within the first hour of recognition of septic shock and severe sepsis Appropriate cultures should be obtained before initiating antibiotic therapy Blood cultures should not significantly delay antibiotic therapy
  25. 25. Empiric Antibiotics: Selection Host defenses, potential sources of infection, and most likely organisms Antibiotic experienced patient: use aminoglycoside rather than a quinolone or cephalosporin for gram-negative coverage Antibiotic resistance patterns of both the hospital itself and its referral base (i.e., nursing homes)
  26. 26. Empiric Antibiotics: Duration  Should not be administered for > 3-5 days  De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known
  27. 27. Anti-Fungal If candidemia is a likely cause Risk factors for Candidemia: TPN, Propofol, DM, HIV, Chemotherapy Empirical antifungal therapy (e.g., fluconazole, amphotericin B, or echinocandin)
  28. 28. Specific Antibiotics: Duration Typically 7-10 days Longer courses in patients:1. Slow clinical response2. Undrainable foci of infection3. Immunologic deficiencies4. Neutropenia
  29. 29. Interrupt InflammatoryMediators Activated Protein C: 1) Reduced mortality rate in sever sepsis and septic shock 2) Very expensive therapy Corticosteroid therapy: 1) Persistent Hypotension 2) Non responder to ACTH stimulation test Glucose control: 1. Keep glucose < 150 mg/dl 2. Use Intravenous insulin protocol
  30. 30. Activated Protein C
  31. 31. Drotrecogin alfa DoseContinuous infusion of 24 mcg/kg/hour for 96 hours
  32. 32. Contraindications to Use of Recombinant Human Activated Protein C ( (rhAPC Active internal bleeding Recent (within 3 months) hemorrhagic stroke Recent (within 2 months) intracranial or intraspinal surgery, or severe head trauma Trauma with an increased risk of life-threatening bleeding Presence of an epidural catheter Intracranial neoplasm or mass lesion or evidence of cerebral herniation Known hypersensitivity to rhAPC or any component of the product The committee recommends that platelet count be maintained at ≥30,000 during infusion of rhAPC.Physicians Desk Reference, 61st Edition. Montvale, NJ, Thompson PDR, 2007, Page 1829
  33. 33. EARLY GOAL-DIRECTED THERAPY ( ( EGDTEarly detection and treatment: Decreases mortality rate
  34. 34. Septic Shock
  35. 35. Fluid Dose: First Golden 6 Hours A 500-ml bolus of crystalloid ( NS ) was given every 30 minutes to achieve a central venous pressure of 8 to 12 mm Hg Central venous catheter capable of measuring central venous oxygen saturation (Edwards Lifesciences, Irvine, Calif.)
  36. 36. Sepsis BundleIs defined as a group of interventionsrelated to a disease process that, whenexecuted together, result in betteroutcomes than when implementedindividually
  37. 37. Sepsis BundleReduces mortality and ICU stayif implemented within 6 hours
  38. 38. Thank you