ICU

1. By
AdelAlfons
By
AdelAlfons
Dellinger et al.Surviving Sepsis Campaign:International Guidelines for
Management of Severe Sepsis and Septic Shock:2012.Crit Care Med.
2013;41(2):580‐637
AdelAlfons
Senior anesthesia resident SCU hospital
AdelAlfons
Senior anesthesia resident SCU hospital

2.  Sepsis = infection + systemic manifestations
of infection.
 Severe sepsis = sepsis + sepsis‐induced organ Severe sepsis = sepsis + sepsis‐induced organ
dysfunction or tissue hypoperfusion.
 Septic shock = persistent sepsis‐induced
hypotension despite adequate fluid resuscitation.

3. Sepsis induced
hypotension = SBP
< 90 mmHg or MAP
< 70mmHg or SBP
decrease > 40 mmHg
Lactate above
the upper
limit of
normal
Platelet <
INR >
1.5
decrease > 40 mmHg
or less than 2 standard
deviation below
normal for age in the
absence of other cause
for hypotension.
UoP < 0.5 mL/Kg/hr for
more than 2 hours despite
adequate fluid
resuscitation
Acute lung injury
with PaO2/FiO2
< 250 in the
absence of PNA as
infection source
Acute lung injury
with PaO2/FiO2
< 200 in the
presence of PNA as
infection source
Cr > 2
mL/d
L
TBili >
2mg/dL
Platelet <
100K

4. • a.Temperature: Fever > 38.3C or hypothermia <36C
• b. HR: > 90/min, or more than 2 standard deviation above
normal for age
• c.Tachypnea
• d.Altered mental status
• e. Significant edema or positive fluid balance > 20 mL/Kg
over 24 hrs
1-Vital signs
over 24 hrs
• f. Hyperglycemia > 140 mg/dL in the absence of diabetes
mellitus
• a.WBC: > 12K or < 4K
• b. NormalWBC count with > 10% immature
forms
• c. CRP > 2 standard deviation above normal value
• d. Pro‐calcitonin > 2 standard deviation above
normal value
2.
Inflammatory
markers:

5. • SBP < 90mmHg, MAP < 70mmHg or SBP decrease >
40mmHg in adults or less than 2 standard deviation
below normal for age
3.
Hemodynamic
• a.Arterial hypoxemia (PaO2/FiO2 < 300)
• b.Acute Oliguria (UoP < 0.5 mL/Kg/hr for at least 2
hours despite adequate fluid resuscitation)
• c. Cr increase > 0.5 mg/dL or 44.2 μmol/L
• d. Coagulopathy: INR > 1.5 or aPTT > 60 sec
4. Organ
dysfunction • d. Coagulopathy: INR > 1.5 or aPTT > 60 sec
• e. Ileus (no bowel sounds)
• f.Thrombocytopenia: PLT < 100K
• g. Hyperbilirubinemia:TBili > 4 mg/dL
dysfunction
• a. Lactate > 1 mmol/L
• b. Decrease cap refill or mottling
5.Tissue
perfusion

6. 3 hours of diagnosis
• Draw Lactate
• 2 sets of Blood cultures
(best done within 45
minutes)
6 hours of diagnosis
• Vasopressor to keep MAP ≥ 65mmHg if goals
not met by fluid challenge, Norepinephrine is
first choice
• If persistent hypotension despite fluid resuscitation or
initial lactate ≥ 4 mmol/L:
‐ ‐
‐
• Broad spectrum
antimicrobials (best done
within 1 hour)
• At least 30 mL/Kg
crystalloid fluid challenge
• CVP: goal 8‐12 mmHg; 12‐15 mmHg for
patients with mechanically‐ventilation or ↑
intraabdominal pressure (due to cardiac filling
impediment)
• ScvO2: goal ≥ 70% (or, SvO2 ≥ 65%)
• Re‐measure lactate: goal is normalizing lactate
• (Other targets: UoP ≥ 0.5 mL/Kg/hr, normalizing
lactate as a marker for improved tissue hypoperfusion)

7. It’s a matter of time !!!It’s a matter of time !!!
VasodilationVasodilation
End organ
damage
End organ
damage

8. 1.Most common bugs in septic shock are Gram Positive > Gram
Negative > mixed flora >> candida /toxic‐shock …
2 sets of blood cultures drawn prior to antimicrobial therapy
and give antimicrobials within 1 hour of diagnosis .and give antimicrobials within 1 hour of diagnosis .
3. If the blood culture drawn from the vascular access device turns
positive ≥ 2 hours before the peripheral blood culture, data
supports that the vascular access device is the source of the infection.
Central access peripheral access

9. 4. Initial empiric broad spectrum antimicrobial therapy
(selected to cover all suspected organism) within 1 hour
after recognition of septic shock and severe sepsis without septic
shock .
5. Mortality rises every hour without antimicrobials .
6. Combine empirial therapy with:
For Strep pneumo,
extended‐spectrum beta‐lactams and aminoglycoside or fluoroquinolone
use beta‐lactam and macrolide

10. 7.Antimicrobial regiment should be reassessed daily for
de‐escalation. Empiric combination therapy should not be
administered for > 3‐5 days.
8. Use pro‐calcitonin level or other markers to consider
discontinuation of empiric antibiotic for those who was
initially diagnosed septic, but have no subsequent evidence
‐
of infection.
9. Duration of therapy typically 7‐10 days.
10. No antimicrobial therapy if patient’s severe inflammatory
state is not due to infectious causes.

11.  Initial fluid resuscitation with crystalloid, minimum of 30
mL/Kg in adults and 20 mL/Kg in children.
 Consider addition of albumin in patients requiring
substantial amounts of crystalloids to maintain
adequate MAP.adequate MAP.
 Recommendations against hetastarch.
(increase risk of renal injury , no diff. in mortality)
 Continue fluid challenge technique as long as hemodynamic
improvement: based on dynamic variables (change in pulse
pressure, stroke volume) or static variables (arterial pressure,
HR)

12. • is the first choice vasopressor to keep MAP ≥ 65 mmHg.Norepinepherine
• is the second additional agent, or
substitute for NE, if needed to maintain
MAP.
Epinephrine
• can be added to norepinephrine to either
raise MAP to target, or to decrease NE dose.
But, do not use it as the initial vasopressor.
Vasopressin
(0.03
U/min)

13. • is not recommended in septic shock except:
• 1.When NE is associated with serious arrhythmias,
• 2. CO is high, BP persistently low,
• 3.As salvage therapy
Phenylephrine
• is not recommended, with good evidence, except in
highly selective cases.
• It causes more tachycardia and is more arrythmogenic
‐ ‐
Dopamine • It causes more tachycardia and is more arrythmogenic
than NE. It may affect the hypothalamic‐pituitary‐axis and
have immunosuppressive effects.
Dopamine
• can be added to vasopressor in the presence of myocardial
dysfunction (suggested by increased cardiac filling pressure and
low cardiac output) or ongoing signs of hypoperfusion
(cardiac index and ScvO2) despite achieving adequate
intravascular volume and goal MAP
Dobutamine 20
mcg/Kg/min

14. SteroidsSteroids
 Avoid IV hydrocortisone in adult septic shock if IVF
and vasopressor can restore hymodynamic stability.
 Steroid show significant shock reversal and mortality
reduction in patients with relative adrenal
insufficiency based onACTH stimulation test.

15. Blood ProductsBlood Products
 1. Hgb target 7‐9 g/dL
 2. Recommended against using FFP to correct
coagulopathy in the absence of bleeding or plannedcoagulopathy in the absence of bleeding or planned
invasive procedure.
 3.Platelet transfusion: prophylactically when ≤ 10K
without bleeding, ≤ 20K with high risk of bleed,
≥50K if active bleed or planned surgery.

16. InsulinInsulin
 Start insulin drip protocol when 2 consecutive BG >
180mg/dL. Glucose goal ≤ 180 mg/dL, not ≤ 110
mg/dL. BGmg/dL. BG
 monitoring every 1‐2 hour until stable then q4hrs after.

17. IV Sodium BicarbonateIV Sodium Bicarbonate
 Recommended against using Bicarb to improve
hemodynamics, reducing vasopressor requirement in
patient with hypoperfusion‐induced lactic acidosispatient with hypoperfusion‐induced lactic acidosis
pH ≥ 7.15.

18. Stress Ulcer ProphylaxisStress Ulcer Prophylaxis
 GI prophylaxis recommended to prevent UGIB from stress
ulcers, only for those with bleeding risks. PPI > H2 blocker.
 No PPI if no bleeding risks.

19. NutritionNutrition
 Enteral feeding recommended over complete fasting or solo IV
glucose within first 48hours after diagnosis.
 Avoid mandatory full caloric feeding within first week. Start
with low dose feeding of 500 calories per day and
advance as tolerated.
 First 7 days, use IV glucose plus enteral nutrition rather than
TPN alone or parenteral nutrition with enteral feeding.

20. Thank youThank youThank youThank you