SIRS / SEPSIS  SUMMARY  RECOMMENDATIONS
Systemic Inflammatory Response Syndrome SIRS   <ul><li>TWO OR MORE  of the following conditions: </li></ul><ul><li>KP Temp...
Patients Who Present With   SIRS WHAT DO I DO <ul><li>Recognize the diagnosis of SIRS </li></ul><ul><li>Determine the  SEV...
Early Treatment for SIRS/SEPSIS <ul><li>Open sepsis order set </li></ul><ul><li>SEPSIS ICU IP SCAL NATL </li></ul><ul><li>...
Early Treatment for SIRS/SEPSIS <ul><li>Address the Source of Infection </li></ul><ul><li>Start Antibiotics within 1 Hr  /...
Fluid Goals/Endpoints <ul><li>INITIAL  rapid infusion (30min) of  1-1.5  liter NS  </li></ul><ul><li>Start  with ~ 20-30  ...
Empiric Antibiotics for  Suspected SIRS / Sepsis <ul><li>Suspect  Pyelonephritis </li></ul><ul><li>START GENTAMICIN PLUS O...
Sepsis LACTATE < 36 mg/dl  AND EVIDENCE OF ONLY 1 OR NONE signs of ORGAN DYSFUNCTION <ul><li>SEPSIS = SIRS with DOCUMENTED...
Severe Sepsis SEPSIS PLUS TWO OR MORE ABNORMAL VALUES REPRESENTING SEVERE ORGAN DYSFUNCTION  <ul><li>ADMIT TO ICU FOR GOAL...
Septic Shock    Severe Sepsis with Sx/Sx of 2 or more Organ Dysfunction  WITH   NO RESPONSE TO FLUID BOLUS ADMIT TO ICU FO...
FLUIDS FAIL TO IMPROVE BP/Perfusion <ul><li>Intravenous fluid boluses should be repeated until  </li></ul><ul><li>MAP is >...
PULMONARY EDEMA    ARDS & ALI Diagnosis <ul><li>Acute onset </li></ul><ul><li>Bilateral infiltrates (radiographically simi...
“ PULMONARY EDEMA”    ARDS & ALI Diagnosis  ALI  & ARDS The same except for PaO2 ratio <ul><li>ARDS  </li></ul><ul><li>SpO...
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Summary sirs-sepsis

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Summary sirs-sepsis

  1. 1. SIRS / SEPSIS SUMMARY RECOMMENDATIONS
  2. 2. Systemic Inflammatory Response Syndrome SIRS <ul><li>TWO OR MORE of the following conditions: </li></ul><ul><li>KP Temp >100.5 (38.1c) or < 96.8 (36.0c) </li></ul><ul><li>Lit Temp >101.3 (38.5c) or < 95.0 (35.0c) </li></ul><ul><li>Heart rate of >90 beats/min </li></ul><ul><li>Respiratory rate of >20 breaths/min </li></ul><ul><li>or PaCO2 of <32 mm Hg </li></ul><ul><li>and WBC count of </li></ul><ul><li>>12,000 </li></ul><ul><li><4000 OR </li></ul><ul><li>>10 percent immature (band) forms </li></ul>
  3. 3. Patients Who Present With SIRS WHAT DO I DO <ul><li>Recognize the diagnosis of SIRS </li></ul><ul><li>Determine the SEVERITY & SOURCE of Infection via labs & cultures ; including Lactic Acid </li></ul><ul><li>Start empiric / appropriate antibiotics </li></ul><ul><li>Correct Fluid Deficit </li></ul>
  4. 4. Early Treatment for SIRS/SEPSIS <ul><li>Open sepsis order set </li></ul><ul><li>SEPSIS ICU IP SCAL NATL </li></ul><ul><li>AND ORDER LABS / BLOOD CULTURES / ANTIBIOTICS / FLUID BOLUS AS DIRECTED IN NEXT SLIDE </li></ul>
  5. 5. Early Treatment for SIRS/SEPSIS <ul><li>Address the Source of Infection </li></ul><ul><li>Start Antibiotics within 1 Hr / Maintain SaO2 > 96% </li></ul><ul><li>IV NS 1-1.5 liter bolus within 1 hour ( 20-30 ml/Kg) </li></ul><ul><li>CBC with Diff / Lactate STAT / Blood Cultures </li></ul><ul><li>INR/PTT/Fibrinogen / LDH / LFT’s & Total bilirubin / BUN / Cr / Lytes / Glucose / Calcium </li></ul><ul><li>CXR & Suspected Source Cultures </li></ul><ul><li>If lactate >/= to 18 but < 36 repeat Q 6 hours until < 18. Consider continuation of fluid bolus 500 ml NS Q 30 min until lactate < 18 or BP responds with goals MAP > 60 or SBP > 90 with a maximum of 40-60 ml NS / Kg or complication by pulmonary edema onset. Should goals not be met or pulmonary edema ensues an Arterial line and Central line in addition to ICU transfer recommended. </li></ul><ul><li>Transfer to ICU for goal directed therapy if no response to fluid boluses or severe sepsis is present </li></ul><ul><li>Goal directed therapy requires an Arterial line & Central line within 2 hours of admission to guide further Tx Goals </li></ul>
  6. 6. Fluid Goals/Endpoints <ul><li>INITIAL rapid infusion (30min) of 1-1.5 liter NS </li></ul><ul><li>Start with ~ 20-30 ml/Kg </li></ul><ul><li>Continue with fluid Bolus NS 500 ml q 30 minutes until goals reached </li></ul><ul><li>Stop @ 40 - 60 ml/Kg or if perfusion goals not met or with Pulmonary Edema onset as a complication AND Transfer to ICU TO FACILITATE GOAL DIRECTED THERAPY VIA ARTERIAL LINE & CENTRAL LINE </li></ul><ul><li>Low threshold for RBC transfusion ( Hct goal of 30%) </li></ul><ul><li>IF MAP < 60-65 & CVP < 8 and/or lactate > 18 Continue fluid Boluses 500 mL-1000mL (Q 30 Min) </li></ul><ul><li>Evaluate before/after each fluid bolus/Achieve goal < 6 Hrs </li></ul><ul><li>Volume Status (CVP) goal 8-12 </li></ul><ul><li>Blood Pressure (MAP) goal >65 or SBP >90 </li></ul><ul><li>Tissue Perfusion (LA) goal < 18 mg/dl </li></ul>
  7. 7. Empiric Antibiotics for Suspected SIRS / Sepsis <ul><li>Suspect Pyelonephritis </li></ul><ul><li>START GENTAMICIN PLUS ONE OF EITHER : </li></ul><ul><li>Fortaz® 1g IV q8 OR </li></ul><ul><li>Zosyn® 3.375 g IV q 6 </li></ul><ul><li>Suspect community acquired Pneumonia Ceftriaxone 2g IV q24hrs and </li></ul><ul><li>Zithromax 500mg IV Q 12 hrs </li></ul><ul><li>Suspect GI SOURCE </li></ul><ul><li>Vancomycin 1 g IV q 12hrs </li></ul><ul><li>Zosyn 3.375 g IV q 6hrs </li></ul>
  8. 8. Sepsis LACTATE < 36 mg/dl AND EVIDENCE OF ONLY 1 OR NONE signs of ORGAN DYSFUNCTION <ul><li>SEPSIS = SIRS with DOCUMENTED infection </li></ul><ul><li>- Culture or Gram stain of blood, sputum, urine, amniotic fluid etc, positive for bacteria </li></ul><ul><li>-OR focus of Infection identified by visual inspection, eg, purulent amniotic fluid or cervical discharge, infected incision </li></ul><ul><li>If lactate >/= to 18 but < 36 repeat Lactate Q 6 hours until < 18. Consider continuation of fluid bolus 500 ml NS Q 30 min after initial fluid bolus of 20-30 ml NS /Kg until lactate < 18 or BP responds with goals MAP > 60 or SBP > 90 with a maximum of 40-60 ml NS / Kg or complication by pulmonary edema onset. An evaluation for pulmonary edema should be performed (lung ausculation/SaO2) prior to each fluid bolus. Should goals not be met or pulmonary edema ensues an Arterial line and Central line in addition to ICU transfer is recommended. </li></ul>
  9. 9. Severe Sepsis SEPSIS PLUS TWO OR MORE ABNORMAL VALUES REPRESENTING SEVERE ORGAN DYSFUNCTION <ul><li>ADMIT TO ICU FOR GOAL DIRECTED THERAPY </li></ul><ul><li>Serum Lactate >/= 36 mg/dl </li></ul><ul><li>Urine output <0.5 mL/kg after fluid bolus OR Cr >2.0 OR Cr incremental increase =/> than 0.5 above baseline </li></ul><ul><li>INR>1.5 or PTT > 60 sec or Total bilirubin >4.0 </li></ul><ul><li>Platelet count of <100,000 cells/mL </li></ul><ul><li>ARDS or Acute Lung Injury ( PaO2/FiO2 < 300 ) </li></ul><ul><li>Mottled skin or capillary refill >or= to 3 seconds </li></ul><ul><li>Abrupt change in mental status </li></ul><ul><li>Cardiac dysfunction by echocardiography </li></ul>
  10. 10. Septic Shock Severe Sepsis with Sx/Sx of 2 or more Organ Dysfunction WITH NO RESPONSE TO FLUID BOLUS ADMIT TO ICU FOR GOAL DIRECTED THERAPY <ul><li>MAP of <60-65 mm Hg or SBP<90 </li></ul><ul><li>AFTER aggressive fluid resuscitation </li></ul><ul><li>~ 40-60 mL/kg NS </li></ul><ul><li>Sepsis causes systemic vasodilatation preventing the bodies normal response to peripherally vasoconstrict & shunt blood to the vital organs </li></ul>
  11. 11. FLUIDS FAIL TO IMPROVE BP/Perfusion <ul><li>Intravenous fluid boluses should be repeated until </li></ul><ul><li>MAP is > 65 or SBP > 90 and Lactate is < 18 </li></ul><ul><li>If fluid therapy ( 40-60 ml/Kg) does not correct BP/perfusion or pulmonary edema ensues a vasoconstrictor Norepinephrine (Levophed) or Dopamine is indicated. </li></ul><ul><li>Start with low dose DOPAMINE 5-20 MCG/Kg/Min to maintain MAP > 65 mm Hg </li></ul><ul><li>OR </li></ul><ul><li>(Levophed) <0.25 mcg/kg/min </li></ul><ul><li>Refractory Septic Shock is present when </li></ul><ul><li>> 0.25mcg/Kg/min is required to maintain MAP > 65 </li></ul>
  12. 12. PULMONARY EDEMA ARDS & ALI Diagnosis <ul><li>Acute onset </li></ul><ul><li>Bilateral infiltrates (radiographically similar to pulmonary edema) </li></ul><ul><li>No evidence of cardiogenic pulmonary edema </li></ul><ul><li>If necessary determine PCWP ≤18 mmHg </li></ul><ul><li>Determine ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2) </li></ul>
  13. 13. “ PULMONARY EDEMA” ARDS & ALI Diagnosis ALI & ARDS The same except for PaO2 ratio <ul><li>ARDS </li></ul><ul><li>SpO2/FiO2 of < 235 or </li></ul><ul><li>PaO2/FiO2 is < 200 mmHg </li></ul><ul><li>vs </li></ul><ul><li>ALI </li></ul><ul><li>SpO2/FiO2 of > 315 or </li></ul><ul><li>PaO2/FiO2 >200 mmHg </li></ul>

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