Aims Early recognition Early goal directed therapy Source control                       Modified by Ihan Tarawa   01/02...
Less than one half of the patients who have signs and symptoms of sepsis have                         positive blood cultu...
Modified by Ihan Tarawa   01/02/13   4
 50 year old male smoker Right hemicolectomy for colon cancer Day 5 post-op Temperature 37.2°C WCC 15.2 Respiratory ...
 What is going on?                      Modified by Ihan Tarawa   01/02/13   6
 Confused Oliguric BP 80/40             Modified by Ihan Tarawa   01/02/13   7
Modified by Ihan Tarawa   01/02/13   8
 Although the 1991 Consensus Conference laid  the framework to define sepsis, it had  important limitations. The “2 out ...
 The criteria for sepsis were revised to include  infection and the presence of any of the  diagnostic criteria. These c...
Modified by Ihan Tarawa   01/02/13   11
 There was no single parameter or set of  clinical or laboratory parameters that are  adequately sensitive or specific to...
Challenge Early recognition remains a challenge. Tissue hypoperfusion can occur in the  absence of hypotension and could...
Spectrum of sepsiscontinuum               Modified by Ihan Tarawa   01/02/13   14
SIRS       Ihab B Abdalrahman   11/16/2011   15
Sever sepsis, SIRS plus organdysfunction                Ihab B Abdalrahman   11/16/2011   16
Ihab B Abdalrahman   11/16/2011   17
 Sepsis is described as an autodestructive  process.                         Ihab B Abdalrahman   11/16/2011   18
It permits extension of the normalpathophysiologic response to infectionto involve otherwise normal tissuesand results in ...
Severe sepsis & septic shock Severe sepsis                Septic shock   Sepsis                          Sepsis   plu...
 What do you want to do for this patient? What are your goals?                       Modified by Ihan Tarawa   01/02/13 ...
Management principles Early aggressive resuscitation Early treatment   Rapid identification of source of sepsis   Earl...
Initial history              & examination                                 Further history                                ...
Need to work rapidly toachieve goals: to administer antibiotics within 1 hour. In this time the patient has to be  resus...
Modified by Ihan Tarawa   01/02/13   25
Resuscitate Fluid resuscitate   Fluid challenges     300-500 ml colloid     500-1000 ml crystalloid   Titrate against...
Resuscitate Vasopressors   Indications:     Hypotension not responsive to fluid     Life threatening hypotension   Ag...
 CVP 10 BP 110/50, MAP 65 Urine output 50 ml/h Central venous saturation 65%                      Modified by Ihan Tar...
Resuscitation Goals Initial target:   MAP ≥65 mmHg   CVP 8-12 mmHg (12-15 if ventilated)      Rise of 3-5 mmHg after f...
Likely sources of sepsis Chest Intra-abdominal Urinary tract infection                        Modified by Ihan Tarawa  ...
Source of sepsis Breathless, bilateral crackles Abdomen soft Urine dipstick:   WBC 0   Protein +                     ...
Modified by Ihan Tarawa   01/02/13   32
Investigations Other radiology depending on history and  examination                      Modified by Ihan Tarawa   01/02...
Investigations Microbiology   Blood cultures     2 sets     Strict asepsis     20 ml blood sample   Urine specimen  ...
Treatment Assess every patient for a source of infection  that is amenable to source control measure                     ...
Treatment Source control   Percutaneous or open drainage   Excision   Debridement   Removal of potentially infected d...
Treatment Antibiotics   Early   Initially cover all likely organisms     Local flora and sensitivity patterns   After...
Likely organisms Source Environment     Community     Healthcare facility     Intensive Care     Local factors Pati...
Antibiotics Healthcare associated peritonitis   More resistant flora   Similar organisms to those seen in other    noso...
Antibiotics Re-assess   Clinical response   Microbiological results     Aim to use narrower spectrum                  ...
Antibiotics Penetration   Aminoglycosides and glycopeptides have    relatively poor tissue penetration   Most agents ha...
Antibiotics Dual therapy   Pseudomonas aeruginosa                        Modified by Ihan Tarawa   01/02/13   42
Activated protein C Withdrawn             Modified by Ihan Tarawa   01/02/13   43
Other Support Modalities Steroids Glucose control Early RRT in those AKI
Other Support Modalities Early feeding   enteral feeding lowers risk of infection and    improves survival compared with...
Summary Early recognition Early resuscitation Early identification of source Early appropriate antibiotics Early sour...
Sepsis
Sepsis
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Sepsis

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Sepsis

  1. 1. Aims Early recognition Early goal directed therapy Source control Modified by Ihan Tarawa 01/02/13 2
  2. 2. Less than one half of the patients who have signs and symptoms of sepsis have positive blood culture results. Fishing in the dark Ihab B Abdalrahman 11/16/2011 3
  3. 3. Modified by Ihan Tarawa 01/02/13 4
  4. 4.  50 year old male smoker Right hemicolectomy for colon cancer Day 5 post-op Temperature 37.2°C WCC 15.2 Respiratory rate 30/min HR 110/min Modified by Ihan Tarawa 01/02/13 5
  5. 5.  What is going on? Modified by Ihan Tarawa 01/02/13 6
  6. 6.  Confused Oliguric BP 80/40 Modified by Ihan Tarawa 01/02/13 7
  7. 7. Modified by Ihan Tarawa 01/02/13 8
  8. 8.  Although the 1991 Consensus Conference laid the framework to define sepsis, it had important limitations. The “2 out of 4” criteria for SIRS and the thresholds were somewhat arbitrary and not specific to sepsis alone. The criteria did not include biochemical markers, such as CRP, procalcitonin, IL-6, all of which are elevated in sepsis. Modified by Ihan Tarawa 01/02/13 9
  9. 9.  The criteria for sepsis were revised to include infection and the presence of any of the diagnostic criteria. These criteria were based on an expansion of the clinical and laboratory parameters. Modified by Ihan Tarawa 01/02/13 10
  10. 10. Modified by Ihan Tarawa 01/02/13 11
  11. 11.  There was no single parameter or set of clinical or laboratory parameters that are adequately sensitive or specific to diagnose sepsis. Modified by Ihan Tarawa 01/02/13 12
  12. 12. Challenge Early recognition remains a challenge. Tissue hypoperfusion can occur in the absence of hypotension and could be present for hours before organ dysfunction manifests. Modified by Ihan Tarawa 01/02/13 13
  13. 13. Spectrum of sepsiscontinuum Modified by Ihan Tarawa 01/02/13 14
  14. 14. SIRS Ihab B Abdalrahman 11/16/2011 15
  15. 15. Sever sepsis, SIRS plus organdysfunction Ihab B Abdalrahman 11/16/2011 16
  16. 16. Ihab B Abdalrahman 11/16/2011 17
  17. 17.  Sepsis is described as an autodestructive process. Ihab B Abdalrahman 11/16/2011 18
  18. 18. It permits extension of the normalpathophysiologic response to infectionto involve otherwise normal tissuesand results in MODS. Ihab B Abdalrahman 11/16/2011 19
  19. 19. Severe sepsis & septic shock Severe sepsis  Septic shock  Sepsis  Sepsis  plus organ dysfunction,  hypotension despite hypotension or adequate fluid hypoperfusion resuscitation  plus evidence of abnormal perfusion Modified by Ihan Tarawa 01/02/13 20
  20. 20.  What do you want to do for this patient? What are your goals? Modified by Ihan Tarawa 01/02/13 21
  21. 21. Management principles Early aggressive resuscitation Early treatment  Rapid identification of source of sepsis  Early source control  Early, appropriate antibiotics Modified by Ihan Tarawa 01/02/13 22
  22. 22. Initial history & examination Further history & examination 1 hour InvestigationsResuscitate Microbiological specimens Antibiotics Modified by Ihan Tarawa 01/02/13 23
  23. 23. Need to work rapidly toachieve goals: to administer antibiotics within 1 hour. In this time the patient has to be resuscitated, diagnosis made and microbiological specimens taken Modified by Ihan Tarawa 01/02/13 24
  24. 24. Modified by Ihan Tarawa 01/02/13 25
  25. 25. Resuscitate Fluid resuscitate  Fluid challenges  300-500 ml colloid  500-1000 ml crystalloid  Titrate against response (BP & tissue perfusion) and adverse effects  Ignore fluid balance in first 24h Modified by Ihan Tarawa 01/02/13 26
  26. 26. Resuscitate Vasopressors  Indications:  Hypotension not responsive to fluid  Life threatening hypotension  Agents:  Norepinephrine  Dopamine Dobutamine  Tissue hypoperfusion despite adequate fluid resuscitation and blood pressure Modified by Ihan Tarawa 01/02/13 27
  27. 27.  CVP 10 BP 110/50, MAP 65 Urine output 50 ml/h Central venous saturation 65% Modified by Ihan Tarawa 01/02/13 28
  28. 28. Resuscitation Goals Initial target:  MAP ≥65 mmHg  CVP 8-12 mmHg (12-15 if ventilated)  Rise of 3-5 mmHg after fluid challenge  Urine output ≥0.5 ml/kg If central venous saturation <70%  transfusion of packed cells to achieve a haematocrit ≥0.3  dobutamine Modified by Ihan Tarawa 01/02/13 29
  29. 29. Likely sources of sepsis Chest Intra-abdominal Urinary tract infection Modified by Ihan Tarawa 01/02/13 30
  30. 30. Source of sepsis Breathless, bilateral crackles Abdomen soft Urine dipstick:  WBC 0  Protein + Modified by Ihan Tarawa 01/02/13 31
  31. 31. Modified by Ihan Tarawa 01/02/13 32
  32. 32. Investigations Other radiology depending on history and examination Modified by Ihan Tarawa 01/02/13 33
  33. 33. Investigations Microbiology  Blood cultures  2 sets  Strict asepsis  20 ml blood sample  Urine specimen  Other cultures depending on clinical features Modified by Ihan Tarawa 01/02/13 34
  34. 34. Treatment Assess every patient for a source of infection that is amenable to source control measure Modified by Ihan Tarawa 01/02/13 35
  35. 35. Treatment Source control  Percutaneous or open drainage  Excision  Debridement  Removal of potentially infected devices Modified by Ihan Tarawa 01/02/13 36
  36. 36. Treatment Antibiotics  Early  Initially cover all likely organisms  Local flora and sensitivity patterns  After appropriate microbiological specimens have been taken Modified by Ihan Tarawa 01/02/13 37
  37. 37. Likely organisms Source Environment  Community  Healthcare facility  Intensive Care  Local factors Patient factors  Co-existing illness  Previous antibiotics  Immunosuppression Modified by Ihan Tarawa 01/02/13 38
  38. 38. Antibiotics Healthcare associated peritonitis  More resistant flora  Similar organisms to those seen in other nosocomial infections Modified by Ihan Tarawa 01/02/13 39
  39. 39. Antibiotics Re-assess  Clinical response  Microbiological results  Aim to use narrower spectrum Modified by Ihan Tarawa 01/02/13 40
  40. 40. Antibiotics Penetration  Aminoglycosides and glycopeptides have relatively poor tissue penetration  Most agents have poor CNS penetration unless meninges inflammed Adverse effects Modified by Ihan Tarawa 01/02/13 41
  41. 41. Antibiotics Dual therapy  Pseudomonas aeruginosa Modified by Ihan Tarawa 01/02/13 42
  42. 42. Activated protein C Withdrawn Modified by Ihan Tarawa 01/02/13 43
  43. 43. Other Support Modalities Steroids Glucose control Early RRT in those AKI
  44. 44. Other Support Modalities Early feeding  enteral feeding lowers risk of infection and improves survival compared with delayed feeding in the critically ill.  Other studies demonstrate the superiority of enteral over parenteral feeding in critically ill patients, with respect to costs and complications, including risk of infection
  45. 45. Summary Early recognition Early resuscitation Early identification of source Early appropriate antibiotics Early source control Modified by Ihan Tarawa 01/02/13 46

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