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Dr. Najm-us-saqib Department of Anaesthesia and intensive care Combined Military Hospital Rawalpindi The sepsis resuscitat...
Sepsis:   <ul><li>SEPSIS </li></ul><ul><li>Suspected or proven infection  </li></ul><ul><li>Presence of at least 2 signs  ...
<ul><li>Infection  </li></ul><ul><ul><ul><li>Acute organ dysfunction   </li></ul></ul></ul>Infection / Trauma SIRS Sepsis ...
Septic shock <ul><li>SBP  <   90 mm Hg  </li></ul><ul><li>Reduction of 40 mm Hg or more from baseline  </li></ul><ul><li>O...
Common symptoms <ul><li>Respiratory system dysfunction </li></ul><ul><li>Shock  </li></ul><ul><li>Renal system dysfunction...
<ul><li>The Institute for Healthcare Improvement (IHI) </li></ul><ul><li>Surviving sepsis campaign </li></ul>
Sepsis treatment bundles <ul><li>Resuscitation </li></ul><ul><li>Management </li></ul>
<ul><li>Apply all elements in the bundle. </li></ul>
Resuscitation bundle  during the first 6 hours <ul><li>Measure serum lactate level. </li></ul><ul><li>Blood cultures befor...
<ul><li>Hypotension  </li></ul><ul><li>lactate > 4 mmol/L </li></ul><ul><ul><li>Crystalloid 20 mL/kg (or colloid )  </li><...
Hypotension despite fluid resuscitation <ul><li>Septic shock  </li></ul><ul><li>Lactate level > 4 mmol/L  </li></ul><ul><u...
The sepsis management bundle,  during the first 24 hours   <ul><li>Low-dose steroids  </li></ul><ul><li>Activated drotreco...
Management <ul><li>Goals during the first 6 hrs of resuscitation </li></ul><ul><ul><li>CVP 8-12 mm Hg </li></ul></ul><ul><...
<ul><li>HCT of ≥ 30%  </li></ul><ul><li>Dobutamine infusion  </li></ul><ul><li>Grade 2C evidence </li></ul><ul><li>Survivi...
Diagnosis <ul><li>Appropriate cultures before antibiotic administration </li></ul><ul><li>Two blood cultures </li></ul><ul...
Imaging studies  <ul><li>Source of  </li></ul><ul><li>Infection </li></ul><ul><li>Sampling </li></ul><ul><li>In unstable p...
Antibiotic Therapy <ul><li>IV antibiotic therapy  </li></ul><ul><li>first hour </li></ul><ul><li>Grade 1B evidence </li></...
<ul><li>  Cultures should not delay antimicrobial therapy  </li></ul><ul><li>Grade 1D evidence </li></ul><ul><li>Surviving...
<ul><li>Initial empirical therapy </li></ul><ul><li>Grade 1B evidence </li></ul><ul><li>Surviving Sepsis Campaign: Interna...
<ul><li>Antimicrobial regimen should be reassessed daily  </li></ul><ul><li>Grade 1C evidence </li></ul><ul><li>Surviving ...
<ul><li>Combination therapy is recommended for 3 -5 days </li></ul><ul><ul><li>Pseudomonas infections </li></ul></ul><ul><...
<ul><li>De-escalation to the single therapy as soon as the sensitivity is known </li></ul><ul><li>Grade 2D evidence </li><...
<ul><li>Duration of antibiotic therapy should be 7-10 days  </li></ul><ul><li>Longer courses: </li></ul><ul><ul><li>Slow c...
In Noninfectious cause <ul><li>Antimicrobial therapy is stopped so that patient may not be </li></ul><ul><li>Infected with...
Source Control <ul><li>Specific anatomical diagnosis of infection should be made within the first 6 hrs  </li></ul><ul><li...
<ul><li>Patients should be evaluated for  </li></ul><ul><ul><li>Drainage  </li></ul></ul><ul><ul><li>Debridement </li></ul...
<ul><li>The least physiologic insult should be given  </li></ul><ul><ul><ul><li>Percutaneous  </li></ul></ul></ul><ul><ul>...
<ul><li>Intravascular access devices should be changed. </li></ul><ul><li>Grade 1C evidence </li></ul><ul><li>Surviving Se...
Fluid Therapy <ul><li>Fluid resuscitation  </li></ul><ul><ul><li>Natural/artificial colloids  </li></ul></ul><ul><ul><li>C...
Central venous pressure <ul><li>Target CVP of ≥ 8 mm Hg  </li></ul><ul><li>(12 mm Hg in mechanically ventilated patients) ...
Fluid challenge <ul><li>In Hypovolemia  </li></ul><ul><ul><li>≥ 1000 mL of crystalloids  </li></ul></ul><ul><ul><li>300-50...
fluid resuscitation end point <ul><li>Continue fluid resuscitation as long as the Hemodynamic improvement continues  </li>...
Reduce  Rate of fluid administration   <ul><li>When cardiac filling pressures increase  </li></ul><ul><li>Without  </li></...
Vasopressors <ul><li>MAP should be maintained ≥ 65 mm Hg  </li></ul><ul><li>Grade 1C evidence </li></ul><ul><li>Surviving ...
First choice vasopressor agent <ul><li>Norepinephrine or dopamine  </li></ul><ul><li>(Administered through a central cathe...
<ul><li>Epinephrine </li></ul><ul><li>Phenylephrine </li></ul><ul><li>Vasopressin  </li></ul><ul><li>Should not be adminis...
<ul><li>Vasopressin 0.03 units/min may be added to norepinephrine </li></ul><ul><li>Alternative agent in septic shock  </l...
Low dose dopamine <ul><li>Low-dose dopamine should not be used for renal protection  </li></ul><ul><li>Grade 2A evidence <...
Arterial line <ul><li>If resources are available arterial line should be placed as soon as practical </li></ul><ul><li>Gra...
Inotropic Therapy <ul><li>Dobutamine  </li></ul><ul><li>Myocardial dysfunction </li></ul><ul><li>Grade 1C evidence </li></...
<ul><li>cardiac index  </li></ul><ul><li>predetermined supranormal levels  </li></ul><ul><li>Grade 1B evidence </li></ul><...
Corticosteroids <ul><li>Intravenous hydrocortisone  </li></ul><ul><ul><ul><li>  </li></ul></ul></ul><ul><ul><ul><li>adult ...
Steroids <ul><li>ACTH stimulation test </li></ul><ul><li>Grade 2B evidence </li></ul><ul><li>Surviving Sepsis Campaign: In...
Steroids <ul><li>Hydrocortisone  </li></ul><ul><li>Dexamethasone  </li></ul><ul><li>Grade 2B evidence </li></ul><ul><li>Su...
Steroids <ul><li>Oral fludrocortisone (50 µg) </li></ul><ul><li>+ </li></ul><ul><li>Steroid (no significant mineralocortic...
Steroids <ul><li>Wean from steroid therapy when  </li></ul><ul><li>Vasopressors are no longer required  </li></ul><ul><li>...
<ul><li>Doses  </li></ul><ul><li>> 300 mg of hydrocortisone   </li></ul><ul><li>× </li></ul><ul><li>Grade 1D evidence </li...
<ul><li>Corticosteroids should not be administered in the absence of shock. </li></ul><ul><li>Grade 1D evidence </li></ul>...
Recombinant Human Activated Protein C (rhAPC) <ul><li>Adult patients with severe sepsis should  receive rhAPC   </li></ul>...
<ul><li>should not receive rhAPC   </li></ul><ul><ul><li>Low risk of death  </li></ul></ul><ul><ul><li>APACHE II < 20  </l...
Blood Product Administration <ul><li>Once tissue hypoperfusion has resolved and in the absence of </li></ul><ul><ul><li>My...
<ul><li>Erythropoietin should not be used as a specific treatment of anemia  </li></ul><ul><li>Grade 1B evidence </li></ul...
Fresh frozen plasma <ul><li>Should not be given in the Absence of  </li></ul><ul><ul><li>Bleeding  </li></ul></ul><ul><ul>...
<ul><li>Antithrombin </li></ul><ul><li>Grade 1B evidence </li></ul><ul><li>Surviving Sepsis Campaign: International Guidel...
Platelet transfusion <ul><li>Transfusion required </li></ul><ul><li>< 5000/mm3  </li></ul><ul><li>May be considered when c...
Mechanical Ventilation  Sepsis-Induced ALI/ARDS <ul><li>Target a tidal volume of 6 mL/kg  </li></ul><ul><li>Grade 1B evide...
<ul><ul><li>Plateau pressure ≤ 30 cm H2O  </li></ul></ul><ul><ul><li>Permissive hypercapnia </li></ul></ul><ul><ul><li>PEE...
<ul><li>Prone positioning </li></ul><ul><ul><li>High Fio2  </li></ul></ul><ul><ul><li>Increased Plateau pressure  </li></u...
<ul><li>Head of the bed elevated  </li></ul><ul><li>Grade 1B evidence </li></ul><ul><li>Surviving Sepsis Campaign: Interna...
<ul><li>Head of bed be elevated approx  </li></ul><ul><li>30-45°  </li></ul><ul><li>Grade 2C evidence </li></ul><ul><li>Su...
Non invasive ventilation <ul><li>Mild-moderate hypoxemia </li></ul><ul><li>With stable Hemodynamics  </li></ul><ul><li>Who...
<ul><li>Spontaneous breathing trial   </li></ul><ul><ul><ul><li>Pressure support  </li></ul></ul></ul><ul><ul><ul><li>CPAP...
<ul><ul><ul><li>Discontinue mechanical ventilation </li></ul></ul></ul><ul><ul><ul><li>Arousable </li></ul></ul></ul><ul><...
<ul><li>Pulmonary artery catheter  </li></ul><ul><li>for patients with ALI/ARDS  </li></ul><ul><li>Grade 1A evidence </li>...
<ul><li>Conservative fluid strategy  </li></ul><ul><ul><li>Acute lung injury  </li></ul></ul><ul><ul><li>(Tissue hypoperfu...
Sedation, Analgesia <ul><li>Sedation protocols </li></ul><ul><li>Sedation goal  </li></ul><ul><li>Grade 1B evidence </li><...
<ul><li>Intermittent bolus sedation  </li></ul><ul><li>Continuous infusion sedation  </li></ul><ul><li>(to predetermined e...
Neuromuscular Blockade in Sepsis <ul><li>NMBAs can  be given as </li></ul><ul><ul><li>Intermittent bolus  </li></ul></ul><...
Glucose Control <ul><li>Intravenous insulin therapy to reduce blood glucose levels  </li></ul><ul><li>Grade 1B evidence </...
<ul><li>Validated protocol for insulin dose adjustments  </li></ul><ul><li>Targeting glucose levels to the < 150 mg/dL  </...
<ul><li>Give glucose calorie source to patient </li></ul><ul><li>Monitor every 1-2 hrs until stable  </li></ul><ul><li>The...
Renal Replacement <ul><li>Continuous renal replacement therapy </li></ul><ul><li>Intermittent hemodialysis  </li></ul><ul>...
Bicarbonate Therapy <ul><li>Do not use sodium bicarbonate  </li></ul><ul><li>When pH ≥ 7.15  </li></ul><ul><li>Grade 1B ev...
Deep Vein Thrombosis Prophylaxis <ul><ul><li>Low-dose UFH  2-3 times per day </li></ul></ul><ul><ul><li>LMWH </li></ul></u...
<ul><li>H igh-risk  </li></ul><ul><ul><ul><li>Pharmacologic  </li></ul></ul></ul><ul><ul><ul><li>LMWH  </li></ul></ul></ul...
Stress Ulcer Prophylaxis <ul><li>H2 blocker  </li></ul><ul><li>Grade 1A evidence </li></ul><ul><li>Surviving Sepsis Campai...
Selective Digest Tract Decontamination (SDD) <ul><li>Approved by the entire committee  </li></ul><ul><li>Grade 1D evidence...
<ul><li>Although this document is static, the optimum treatment of severe sepsis and septic shock is a dynamic and evolvin...
<ul><li>Thank you </li></ul>
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The Sepsis Resuscitation And Management Bundles

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The Sepsis Resuscitation And Management Bundles

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

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