1. The document discusses definitions of sepsis, severe sepsis, septic shock from 1992, 2001, and 2016. It describes the criteria for systemic inflammatory response syndrome, sepsis, and septic shock.
2. Guidelines for management of sepsis from the Surviving Sepsis Campaign are summarized, including early goal directed therapy, resuscitation bundles, and antimicrobial therapy recommendations.
3. Key aspects of the updated 2018 Surviving Sepsis Campaign guidelines are highlighted, such as initial fluid resuscitation, hemodynamic support, antimicrobial administration, and duration of therapy.
Latest definition of sepsis, application of qSOFA, latest evidence on treatment of septic shock,role of fluids, role of steroids, isobalance salt solution
Latest definition of sepsis, application of qSOFA, latest evidence on treatment of septic shock,role of fluids, role of steroids, isobalance salt solution
Septic shock, updated presentation, including latest guidelines from Intensive care societies and how to approach to the diagnosis with few notes about Early Goal Directed Therapy and role of steroids
The recent definition, concept and terminologies of septic shock, surviving sepsis campaign, management techniques, SOFA score. Also includes antibiotics and supportive modalities.
This lecture details the science of sepsis care in 2015 with compliments to the multiple online sources used, some of which are other lectures on SlideShare.
Septic shock, updated presentation, including latest guidelines from Intensive care societies and how to approach to the diagnosis with few notes about Early Goal Directed Therapy and role of steroids
The recent definition, concept and terminologies of septic shock, surviving sepsis campaign, management techniques, SOFA score. Also includes antibiotics and supportive modalities.
This lecture details the science of sepsis care in 2015 with compliments to the multiple online sources used, some of which are other lectures on SlideShare.
The lecture describes the definition of sepsis, infection, basteremia and how it leads to spetic shock and a general managent guidelines - for King Edward Medical Unviversity, Lahore
From Stress to Success How Oakland's Corporate Wellness Programs are Cultivat...Kitchen on Fire
Discover how Oakland's innovative corporate wellness initiatives are transforming workplace culture, nurturing the well-being of employees, and fostering a thriving environment. From comprehensive mental health support to flexible work arrangements and holistic wellness workshops, these programs are empowering individuals to navigate stress effectively, leading to increased productivity, satisfaction, and overall success.
La transidentité, un sujet qui fractionne les FrançaisIpsos France
Ipsos, l’une des principales sociétés mondiales d’études de marché dévoile les résultats de son étude Ipsos Global Advisor “Pride 2024”. De ses débuts aux Etats-Unis et désormais dans de très nombreux pays, le mois de juin est traditionnellement consacré aux « Marches des Fiertés » et à des événements festifs autour du concept de Pride. A cette occasion, Ipsos a réalisé une enquête dans vingt-six pays dressant plusieurs constats. Les clivages des opinions entre générations s’accentuent tandis que le soutien à des mesures sociétales et d’inclusion en faveur des LGBT+ notamment transgenres continue de s’effriter.
Johnny Depp Long Hair: A Signature Look Through the Yearsgreendigital
Johnny Depp, synonymous with eclectic roles and unparalleled acting prowess. has also been a significant figure in fashion and style. Johnny Depp long hair is a distinctive trademark among the various elements that define his unique persona. This article delves into the evolution, impact. and cultural significance of Johnny Depp long hair. exploring how it has contributed to his iconic status.
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Introduction
Johnny Depp is an actor known for his chameleon-like ability to transform into a wide range of characters. from the eccentric Captain Jack Sparrow in "Pirates of the Caribbean" to the introspective Edward Scissorhands. His long hair is one constant throughout his evolving roles and public appearances. Johnny Depp long hair is not a style choice but a significant aspect of his identity. contributing to his allure and mystique. This article explores the journey and significance of Johnny Depp long hair. highlighting how it has become integral to his brand.
The Early Years: A Budding Star with Signature Locks
1980s: The Rise of a Young Heartthrob
Johnny Depp's journey in Hollywood began in the 1980s. with his breakout role in the television series "21 Jump Street." During this time, his hair was short, but it was already clear that Depp had a penchant for unique and edgy styles. By the decade's end, Depp started experimenting with longer hair. setting the stage for a lifelong signature.
1990s: From Heartthrob to Icon
The 1990s were transformative for Johnny Depp his career and personal style. Films like "Edward Scissorhands" (1990) and "Benny & Joon" (1993) saw Depp sporting various hair lengths and styles. But, his long, unkempt hair in "What's Eating Gilbert Grape" (1993) began to draw significant attention. This period marked the beginning of Johnny Depp long hair. which became a defining feature of his image.
The Iconic Roles: Hair as a Character Element
Edward Scissorhands (1990)
In "Edward Scissorhands," Johnny Depp's character had a wild and mane that complemented his ethereal and misunderstood persona. This role showcased how long hair Johnny Depp could enhance a character's depth and mystery.
Captain Jack Sparrow: The Pirate with Flowing Locks
One of Johnny Depp's iconic roles is Captain Jack Sparrow from the "Pirates of the Caribbean" series. Sparrow's long, dreadlocked hair symbolised his rebellious and unpredictable nature. The character's look, complete with beads and trinkets woven into his hair. was a collaboration between Depp and the film's costume designers. This style became iconic and influenced fashion trends and Halloween costumes worldwide.
Other Memorable Characters
Depp's long hair has also been featured in other roles, such as Ichabod Crane in "Sleepy Hollow" (1999). and Roux in "Chocolat" (2000). In these films, his hair added a layer of authenticity and depth to his characters. proving that Johnny Depp with long hair is more than a style—it's a storytelling tool.
Off-Screen Influenc
Is your favorite ring slipping and sliding on your finger? You're not alone. Must Read this Guide on What To Do If Your Ring Is Too Big as shared by the experts of Andrews Jewelers.
What Makes Candle Making The Ultimate Bachelorette CelebrationWick & Pour
The above-discussed factors are the reason behind an increasing number of millennials opting for candle making events to celebrate their bachelorette. If you are in search of any theme for your bachelorette then do opt for a candle making session to make your celebration memorable for everyone involved.
2. 1992 Definitions for Sepsis and Organ Failure and
Guidelines for the Use of Innovative Therapies in
Sepsis
3. Systemic Inflammatory Response
Syndrome
• Temperature > 38℃ or < 36℃
• Heart rate >90 /minute
• Respiratory rate >20 /minute or PaCO2 <32 mm Hg
• White blood cell count >12,000, <4,000, or >10%
immature (band) forms.
4. 1992 Definitions for Sepsis and Organ Failure and
Guidelines for the Use of Innovative Therapies in
Sepsis
• Severe Sepsis : sepsis + organ dysfunction or hypoperfusion
(lactic acidosis, oliguria, alteration of mental status), hypotension
• Septic Shock : severe sepsis despite adequate fluid resuscitation
5. 2001 SCCM/ESICM/ACCP/ATS/SIS International
Sepsis Definitions Conference
Infection
a
Documented or suspected and some of the following
b
:
General parameters
Fever (core temperature >38.3°C)
Hypothermia (core temperature <36°C
Heart rate >90 bpmor >2 SD above the normal value for age
Tachypnea: >30 bpm
Altered mental status
Significant edema or positive fluid balance (>20 ml/kg over 24 h)
Hyperglycemia (plasma glucose >110 mg/dl or 7.7 mM/l) in the absence of diabetes
Inflammatory parameters
Leukocytosis (white blood cell count >12,000/µl)
Leukopenia (white blood cell count <4,000/µl)
Normal white blood cell count with >10% immature forms
Plasma C reactive protein>2 SD above the normal value
Plasma procalcitonin >2 SD above the normal value
Hemodynamic parameters
Arterial hypotension
b
(systolic blood pressure <90 mmHg, mean arterial pressure <70, or a systolic blood pressure decrease >40 mmHg
in adults or <2 SD below normal for age)
Mixed venous oxygen saturation >70%
b
Cardiac index >3.5 l min
−1
m
−2c,d
6. 2001 SCCM/ESICM/ACCP/ATS/SIS International
Sepsis Definitions Conference
Organ dysfunction parameters
Arterial hypoxemia (PaO2/FIO2 <300)
Acute oliguria (urine output <0.5 ml kg
−1
h
−1
or 45 mM/l for at least 2 h)
Creatinine increase ≥0.5 mg/dl
Coagulation abnormalities (international normalized ratio >1.5 or activated partial thromboplastin time >60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count <100,000/µl)
Hyperbilirubinemia (plasma total bilirubin >4 mg/dl or 70 mmol/l)
Tissue perfusion parameters
Hyperlactatemia (>3 mmol/l)
Decreased capillary refill or mottling
1.aDefined as a pathological process induced by a micro-organism
2.bValues above 70% are normal in children (normally 75–80%) and should therefore not be used as a sign of sepsis in newborns or children
3.cValues of 3.5–5.5 are normal in children and should therefore not be used as a sign of sepsis in newborns or children
4.dDiagnostic criteria for sepsis in the pediatric population is signs and symptoms of inflammation plus infection with hyper- or hypothermia
(rectal temperature >38.5°C or <35°C), tachycardia (may be absent in hypothermic patients) and at least one of the following indications of
altered organ function: altered mental status, hypoxemia, elevated serum lactate level, and bounding pulses
7. The PIRO system
Domain Present Future Rationale
Predisposition Premorbid illness with reduced pr
obability of short tem survival. Cu
ltural or religious beliefs, age, gen
der
Genetic polymorphisms in components o
f inflammatory response (e.g., Toll-like re
ceptor, tumor necrosis factor, interleukin
1, CD14); enhanced understanding of sp
ecific interactions between pathogens an
d host diseases
At the present, premorbid factors impact on the p
otential attributable morbidity and mortality of an
acute insult; deleterious consequences of insult de
pend heavily on genetic predisposition (future)
Insult
(infection)
Culture and sensitivity of infecting
pathogens; detection of disease a
menable to source control
Assay of microbial products (lipopolysacc
haride, mannan, bacterial DNA); gene tra
nscript profiles
Specific therapies directed against inciting insult r
equire demonstration and characterization of that
insult
Response SIRS, other signs of sepsis, shock,
C-reactive protein
Nonspecific markers of activated inflamm
ation (e.g., procalcitonin or interleukin 6)
or impaired host responsiveness (e.g., HL
A-DR); specific detection of target of ther
apy (e.g., protein C, tumor necrosis factor
, platelet-activating factor)
Both mortality risk and potential to respond to th
erapy vary with nonspecific measures of disease s
everity (e.g., shock); specific mediator-targeted the
rapy is predicated on presence and activity of me
diator
Organ
dysfunction
Organ dysfunction as number of f
ailing organs or composite score (
e.g.,multiple-organ dysfunction sy
ndrome, logistic organ dysfunctio
n system, Sequential Organ Failur
e Assessment, Pediatric Multiple
Organ Dysfunction, Pediatric Logis
tic Organ Dysfunction)
Dynamic measures of cellular response t
o insult – apoptosis, cytopathic hypoxia,
cell stress
Response to preemptive therapy (e.g., targeting m
icro-organism or early mediator) not possible if d
amage already present; therapies targeting the inj
urious cellular process require that it be present
8. The Third International Consensus Definitions
for Sepsis and Septic Shock (Sepsis-3) : 2016
2001 sepsis-2 2016 sepsis-3
Sepsis
Severe Sepsis Sepsis
Septic Shock Septic Shock
• SIRS: unhelpful
• SOFA score: helpful
9. Organ dysfunction
• Sequential Organ Failure Assessment score(SOFA)
SOFA score Mortality risk
0 - 6 <10%
7 - 9 15 - 20%
10 - 12 40 - 50%
13 - 14 50 - 60%
15 >80%
16 - 24 >90%
Vincent JL, et al. Intensive Care Med
1996;22:707-10
10. The Third International Consensus Definitions
for Sepsis and Septic Shock (Sepsis-3)
Sepsis
• Life threatening organ dysfunction caused by a dysregulated host
response to infection
• SOFA score variation >+2
Septic shock
• persisting hypotension requiring vasopressors to maintain MAP ≥65
mm Hg and serum lactate level >2 mmol/L (18 mg/dL) despite
adequate volume resuscitation.
11. Surviving Sepsis Campaign guidelines for
management of severe sepsis and septic shock
Early Goal Directed Therapy(EGDT)
• Central venous pressure (CVP) 8–12 mmHg
• Mean arterial pressure (MAP) ≥65 mmHg
• Urine output ≥0.5 ml/kg h−1
• Central venous (superior vena cava) or mixed venous oxygen
saturation ≥70%.
12. SSC bundle (2012 SSC)
Dellinger RP, et al. Crit Care Med 2013;41:580-637
13. SSC bundle (2016 SSC)
Rhodes A, et al. Crit Care Med 2017;45:486-552
17. Initial resuscitation
• Sepsis and septic shock are medical emergencies,
and we recommend that treatment and resuscitation begin
immediately.
• We recommend that, in the resuscitation from sepsis-induced
hypoperfusion, at least 30 mL/kg of IV crystalloid fluid be given
within the first 3h.
• We recommend that, following initial fluid resuscitation, additional
fluids be guided by frequent reassessment of hemodynamic
status.
18. Initial resuscitation
• We recommend further hemodynamic assessment (such as assessing
cardiac function) to determine the type of shock if the clinical
examination does not lead to a clear diagnosis.
• We suggest that dynamic over static variables be used to predict
fluid responsiveness, where available.
• We recommend an initial target mean arterial pressure (MAP) of 65
mmHg in patients with septic shock requiring vasopressors.
19. Initial resuscitation
• We suggest guiding resuscitation to normalize lactate in
patients with elevated lactate levels as a marker of tissue
hypoperfusion.
Intensive Care Medicine 41, 1862-1863(2015)
20. Diagnosis
• We recommend that appropriate routine microbiologic cultures
(including blood) be obtained before starting antimicrobial therapy
in patients with suspected sepsis or septic shock if doing so results in
no substantial delay in the start of antimicrobials.
Antimicrobial therapy
• We recommend that administration of IV antimicrobials be initiated
as soon as possible after recognition and within 1 h for both sepsis
and septic shock.
21. Crit Care Med 34, 1589-96 (June 2015) Crit Care Med 42,1749-55 (Aug 2014)
22. Antimicrobial therapy
• We recommend empiric broad-spectrum therapy with one or
more antimicrobials for patients presenting with sepsis or septic
shock to cover all likely pathogens (including bacterial and
potentially fungal or viral coverage).
• We recommend that empiric antimicrobial therapy be narrowed
once pathogen identification and sensitivities are established
and/or adequate clinical improvement is noted.
• We recommend against sustained systemic antimicrobial
prophylaxis in patients with severe inflammatory states of
noninfectious origin (e.g., severe pancreatitis, burn injury)
23. Antimicrobial therapy
• We suggest empiric combination therapy (using at least two
antibiotics of different antimicrobial classes) aimed at the
most likely bacterial pathogen(s) for the initial management
of septic shock.
• We suggest that combination therapy not be routinely
used for ongoing treatment of most other serious infections,
including bacteremia and sepsis without shock
• We recommend against combination therapy for the
routine treatment of neutropenic sepsis/bacteremia.
24. Antimicrobial therapy
• If combination therapy is initially used for septic shock, we
recommend de-escalation with discontinuation of
combination therapy within the first few days in response
to clinical improvement and/ or evidence of infection
resolution. This applies to both targeted (for culture-positive
infections) and empiric (for culture-negative infections)
combination therapy.
25. Antimicrobial therapy
• We suggest that an antimicrobial treatment duration of 7–10
days is adequate for most serious infections associated with
sepsis and septic shock.
• We suggest that longer courses are appropriate in patients who
have a slow clinical response, undrainable foci of infection,
bacteremia with S. aureus, some fungal and viral infections, or
immunologic deficiencies, including neutropenia.
• We recommend daily assessment for de-escalation of
antimicrobial therapy in patients with sepsis and septic shock.
26. Antimicrobial therapy
• We suggest that measurement of procalcitonin levels can
be used to support shortening the duration of
antimicrobial therapy in sepsis patients.
27. Source control
• We recommend that a specific anatomic diagnosis of
infection requiring emergent source control be identified or
excluded as rapidly as possible in patients with sepsis or
septic shock, and that any required source control
intervention be implemented as soon as medically and
logistically practical after the diagnosis is made.
• We recommend prompt removal of intravascular access
devices that are a possible source of sepsis or septic shock
after other vascular access has been established
28. Fluid therapy
• We recommend that a fluid challenge technique be applied
where fluid administration is continued as long as
hemodynamic factors continue to improve.
• We recommend crystalloids as the fluid of choice for initial
resuscitation and subsequent intravascular volume
replacement in patients with sepsis and septic shock.
• We suggest using either balanced crystalloids or
saline for fluid resuscitation of patients with sepsis or septic
shock.
29.
30.
31. Fluid therapy
• We suggest using albumin in addition to crystalloids for initial
resuscitation and subsequent intravascular volume replacement in
patients with sepsis and septic shock when patients require
substantial amounts of crystalloids.
• We recommend against using hydroxyethyl starches (HESs) for
intravascular volume replacement in patients with sepsis or septic
shock.
• We suggest using crystalloids over gelatins when resuscitating
patients with sepsis or septic shock.
32. Vasoactive medications
• We recommend norepinephrine as the first choice vasopressor.
• We suggest adding either vasopressin (up to 0.03 U/min) or
epinephrine to norepinephrine with the intent of raising MAP to
target, or adding vasopressin (up to 0.03 U/min) to decrease
norepinephrine dosage.
• We suggest using dopamine as an alternative vasopressor agent
to norepinephrine only in highly selected patients (e.g., patients
with low risk of tachyarrhythmias and absolute or relative
bradycardia).
33. Vasoactive medications
• We recommend against using low-dose dopamine for renal
protection.
• We suggest using dobutamine in patients who show
evidence of persistent hypoperfusion despite adequate fluid
loading and the use of vasopressor agents.
• We suggest that all patients requiring vasopressors have an
arterial catheter placed as soon as practical if resources are
available.
34. Corticosteroid
• We suggest against using IV hydrocortisone to treat septic
shock patients if adequate fluid resuscitation and
vasopressor therapy are able to restore hemodynamic
stability.
• If this is not achievable, we suggest IV hydrocortisone at a
dose of 200 mg per day.
37. Blood product
• We recommend that RBC transfusion occur only when
hemoglobin concentration decreases to <7.0 g/dL in
adults in the absence of extenuating circumstances, such as
myocardial ischemia, severe hypoxemia, or acute hemorrhage.
• We recommend against the use of erythropoietin for
treatment of anemia associated with sepsis.
38. Blood product
• We suggest against the use of fresh frozen plasma to correct
clotting abnormalities in the absence of bleeding or planned invasive
procedures.
• We suggest prophylactic platelet transfusion when counts are
<10,000/mm3 in the absence of apparent bleeding and when counts
are <20,000/mm3 if the patient has a significant risk of bleeding.
Higher platelet counts [≥50,000/mm3 (50 × 109/L)] are advised for
active bleeding, surgery, or invasive procedures.
39. Glucose control
• We recommend a protocolized approach to blood glucose
management in ICU patients with sepsis, commencing insulin dosing
when two consecutive blood glucose levels are >180 mg/dL. This
approach should target an upper blood glucose level ≤180 mg/dL
rather than an upper target blood glucose level ≤110 mg/dL.
• We recommend that blood glucose values be monitored every 1–2 h
until glucose values and insulin infusion rates are stable, then every
4h thereafter in patients receiving insulin infusions.
• We suggest the use of arterial blood rather than capillary blood for
point-of-care testing using glucose meters if patients have arterial
catheters.
40. Renal replacement therapy
• We suggest that either continuous RRT (CRRT) or
intermittent RRT be used in patients with sepsis and acute
kidney injury.
• We suggest using CRRT to facilitate management of fluid
balance in hemodynamically unstable septic patients
• We suggest against the use of RRT in patients with sepsis
and acute kidney injury for increase in creatinine or oliguria
without other definitive indications for dialysis.
41. Bicarbonate therapy
• We suggest against the use of sodium bicarbonate therapy
to improve hemodynamics or to reduce vasopressor
requirements in patients with hypoperfusion-induced lactic
acidemia with pH ≥ 7.15.
42. Nutrition
• We recommend against the administration of early parenteral
nutrition alone or parenteral nutrition in combination with enteral
feedings (but rather initiate early enteral nutrition) in critically ill
patients with sepsis or septic shock who can be fed enterally.
• We recommend against the administration of parenteral nutrition
alone or in combination with enteral feeds (but rather to initiate IV
glucose and advance enteral feeds as tolerated) over the first 7 days
in critically ill patients with sepsis or septic shock for whom early
enteral feeding is not feasible.
43. Nutrition
• We suggest the early initiation of enteral feeding rather
than a complete fast or only IV glucose in critically ill
patients with sepsis or septic shock who can be fed enterally.
• We suggest either early trophic/hypocaloric or early full
enteral feeding in critically ill patients with sepsis or septic
shock; if trophic/hypocaloric feeding is the initial strategy,
then feeds should be advanced according to patient
tolerance.
44. Nutrition
• We suggest against routinely monitoring gastric residual
volumes (GRVs) in critically ill patients with sepsis or septic shock.
However, we suggest measurement of gastric residuals in
patients with feeding intolerance or who are considered to be
at high risk of aspiration.
• We suggest the use of prokinetic agents in critically ill patients
with sepsis or septic shock and feeding intolerance.
• We suggest placement of post-pyloric feeding tubes in critically
ill patients with sepsis or septic shock with feeding intolerance or
who are considered to be at high risk of aspiration.
45. Reference
• Bone RC, Balk PA et al (1992), Definitions for sepsis and organ failure and guidelines
for the use of innovative therapies in sepsis. Chest, 101(6):1644-55.
• Mitchell M Levy, Mitchell P Fink et al (2003), 2001 SCCM/ESICM/ACCP/ATS/SIS
International Sepsis Definitions Conference, Intensive Care Med, 29(4):530-8.
• Andrew Rhodes, Laura E. Evans (2017), Surviving Sepsis Campaign: International
Guidelines for Management
of Sepsis and Septic Shock: 2016 , Intensive Care Med, 43: 304-377
Editor's Notes
(BPS) immediate rescucitation 필요
(strong recommendation, low quality of evidence) 30kg IV crystalloid within 3hr
(BPS)
cvp/ ScvO2 이용한 EGDT 는 large RCT 에서 mortality reduction을 보이지 않아 x
(BPS)
(weak recommendation, low quality of evidence)
dynamic measure 가 fluid status 평가하는데 있어 더 diagnostic accuracy가 높다.
static measure : CVP / dynamic measure : passive leg raise, fluid challenge against stroke volume measurement,
variation in SBP, PP, storke volume in Intrathoracic Pressure induced by MV.
Monnet X, Marik P, Teboul JL (2016) Passive leg raising for predicting fluid responsiveness: a systematic review and meta‑analysis. Intensive Care Med 42(12):1935–1947
3. (strong recommendation, moderate quality of evidence)
MAP는 tissue perfusion의 driving pressure : autoregulation 에 의한 regional perfusion 을 kidney/brain에서 유지하지만
threshold MAP가되면 tissue perfusion은 arterial Pressure에 linear 하게 dependent 하다.
NE titration MAP 65->85은 cardiac index는 올리지만, urinary flow/ lactate level, Oxygen delivery/consumption, skin capillary flow를 변화시키지는 못한다.
(Bourgoin A, (2005) Increasing mean arterial pressure in patients with septic shock: effects on oxygen variables and renal function. Crit Care Med)
1 multicenter trial에서 MAP 65->85 (low target , high target) 일때 mortality 도 올리지 못한다는 연구.
high target 일때 arrhythmia 의 high risk, but HTN 병력 있는 환자인 경우 RRT risk를 낮춤.
75세 이상에서 low target 일때 mortality 가 낮은 pilot study 있었음.
따라서 low target 이 high target 에 비해 더 권장되지만, target 은 환자 상태에 따라 개별화 될수 있음.
(weak recommendation, low quality of evidence)
lact level은 tissue hypoxia 를 의미하지만, beta adrenergic stimulation 이나 liver failure 일때도 올라감.
5 RCT lact guided resuscitation with septic shock (lactate clearance strategy) ->
lactate monitoring 을 안햇을 떼보다 moratlity 가 낮아지나 ICU LOS 는 변화 없었음.
ScvO2 normalization strategy 에 비해서도 mortatlity 가 낮아진다.
(BPS)
culture 를 항생제 투약전 pathogen isolation 이 용이하며, 결국 de escalation 을 가능하게 함.
De-escalation을 했을 때 survival 향상과 관련 있고, Culture 얻는 동안 AntiBx 사용지연이없는 것으로 간주 될 수있는 시간으로 45 분을 제안??
(strong recommendation, moderate quality of evidence; grade applies to both conditions).
1시간 늦어질수록 motratlity 증가 & AKI, ALI, organ injury 등 모두 증가
Kumar A, Roberts D, Wood KE et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determi‑nant of survival in human septic shock. Crit Care Med.
Kumar A, Roberts D, Wood KE et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determi‑nant of survival in human septic shock. Crit Care Med.
Cumulative antiBx initiatio이 survival fraction/hypoteion과 관계
-- Ferrer R, Martin‑Loeches I, Phillips G et al (2014) Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from thefirst hour: results from a guideline‑based performance improvement program. Crit Care Med
Anti투여시간에 따른 mortality 신뢰구간.
(strong recommendation, moderate quality of evidence).
G (-) G (+), mixed,
Neutropenic pt 는 resistant G(-) bacilli / Candida
nosocomial acquisition : MRSA, VRE coverage 필요
health care associated infection cover 할수 있어야.. Carbapenem , pip/tazo 등.. cepha 써도 되나 multidrug regimen
immunocompromised like Neutropenia/ TPL/ hemdialysis catheter : candidiasis cover
2. (BPS). 1/3 정도는 culture에서 균이 동정되지 않음
1. (BPS). Noninfectious origin SIRS에서 antiBx 쓰지 말라. 이전에는 necrotizing pancreatitis 에서 prophylaxis 쓰라고 했으나 최근 가이드라인은 피하는것을 선호
burn의경우에도 최근 meta연구에서 prolonged prophylaxis는 그 benefit에 의문.
brief prophylaxis for specific invasive procedure 는 적절할수도 있다.
(weak recommendation, low quality of evidence)
(weak recommendation, low quality of evidence).
(strong recommendation, moderate quality of evidence).
combination therapy 가 septic shock 환자에서 mortality 줄이지만
메타분석에서는 low risk infection 인 경우에 combination T하는경우 오히려 mortality가 높일수있다.
low risk infectio일경우 carbapenem 단독에 비해 carbapenem + FQ 는 환자 outcome을 좋게하지 못한다.
(BPS).
Early de-escalation 은 observation study에서 superior outcome but superinfection/ longer ICU 를 갖는다는 연구도 있음.
De-escalatio의 trigerring 명확한 criteria가 부족함.
Clinical progress/ inection resoluation by biomarkers (procalcitonin), fixed duration 등이 있겠으나 data부족.
(weak recommendation, low quality of evidence).
prolonged antiBx은 항생제 resistence 뿐 아니라 개인에게서는 Clostridium difficile colitis 유발, mortality risk를 높임.
7-10일이 source control 부재시 대부분의 심각한 감염에서 적당.
VAP나 HAP에서 7일 용법으로 권고하며 source control 이 된다면 짧은 코스로 치료하는 것이 결과에 큰 차이가 없다는 것이 최근 연구.
APN, uncomplicated cellulitis, SBP등 7일 이내 항생제 사용이 longer duration 보다 더 effective
(weak recommendation, low quality of evidence).
임상반응이 느리거나 source control어렵거나 Saureus bacteremia (특히 MRSA) 나 candidemia 와 같은 경우는 긴 치료를 요할수있다.
Neutropenic infetion의 경우 적어도 neutropenia가 지속되는 기간동안 Therpay를 요하며,
S. aureus 는 적어도 14일, complicated bacteremia의 경우 endovascular infection으로 6주 항생제 치료를 요한다.
Uncomplicated bacteremia 1) endocarditis 의 배제가 필요 2) prostheses 가 없어야되고 3) culture 가 2-4일뒤 negative 여야 하며 4)72시간이내 발열이없어야되고 5) metastatic infectio이 없어야 함.
(BPS).
(weak recommendation, low quality of evidence).
Beta-D glucan은 aspergillus
Procalcitonin 과 관련한 알고리즘들이 있으나 advantage에 대해서는 명확하지 않다.
Early de –escalation 과 관계하여 survival을 좋게 한다는 연구가 있음.
메타 분석 중에는 infectious dz.와 non infectious dz를 구분할수 있게 해줌.
CD I 를 줄인다는 증거는 없음.
Biomarker 들은 중요하지만 단지 marker만으로 antiBx의 변경이나 중단과 같은 결정을 내릴순 없음.
(BPS) . Abscess drainage, infected necrotic tissu에 대하여 debridement, surgical intervention, 혹은 infected device 제거 등의 source contro이 필요.
initial resuscitation 후 빠르게 필요. 진단 후 Observation study 에서는 6-12시간 이내로 진행하는 것 추천.
(BPS).
(BPS)
ICU stay 시 postivie fluid balance 는 해가 될수 있어
(strong recommendation, moderate quality of evidence)
crystalloid 에 비해 colloid 가 이점이 없어 initial resuscitation 에는 강력 crystalloid 권장
(weak recommendation, low quality of evidence).
indirect low-quality evidence 의 메타 분석에서 balanced soln이 NS 에 비해 outcome을 향상 시킨다고 되어 있으나
명확히 비교한 study 는 아직 없는것을도 되어 있고 NS 로 resuscitation 시 hyperchloremia 를 주의해야함.
Balanced soln 에서 AKI 및 RRT 감소 시키며 2019년 NEJM
Am J Respir Crit Care Med 2019.12 발표에서는 balanced crystalloid 를 투여한 ICU 입원한 sepsis 환자에서 30일 mortality를 향상 시킴
회색면적은 95% 신뢰구간.
위 . 같은 Cl 농도에서 NS 가 mortality 가 높고, 같은 농도의 bicarb에서도 NS 의 mortality 가 높다.
아래. ICU 재실기간에 따른 승압제 용량/ lactate level . Balanced soln 에서 둘다 낮다.
(weak recommendation, low quality of evidence)
SAFE study : albumin 투여가 saline 주는것과 마찬가지의 효과/안전성.
2012년 SSC 가이드라인 이후 6개의 메타 분석 이 발표. 대체적으로 albumin 의 사용이 crystalloid사용에 비해 mortality benefit이 있다는 결과
그러나 The ALBIOS trial 에서는 sepsis/septic shock에서 crystalloid 단독에 비해 albumin + crystalloid 가 mortality 에 이득이 없다/
But Subgroup analysis 에 서 septic shock에서는 90일 mortality 에 이득이 있다.
(strong recommendation, high quality of evidence)
(weak recommendation, low quality of evidence).
HES는 mortality 및 RRT risk 를 높이고 ,
gelatin 은 synthetic colloid 로서 albumin/crystalloid보다 mortality 나 RRT risk를 높이지 않는다고 되어 있으나 critically ill pt focus된 연구가 아직 부족.
(strong recommendation, moderate quality of evidence).
NE : vaso constrictive, little change in HR, less increase stroke Volume.
Dopamine : stroke volume/HR 향상-> CO 증가 (systolic fx compromised되어 있을시 유용)
NE 가 dopa에 비해 lower mortality, lower risk arrhythmia
(weak recommendation, moderate quality of evidence)
Epinephrine infusion: splanchnic circulation 감소/hyperlactemia 발생한다고 알려져 있으나 meta 분석에서는 mortaltiy에 NE 와 큰 차이 없다함.
epi는 aerobic lactate 생성( skeletal m의 beta2 adrenergic Rc 자극) 하기 때문에 lactate clearance 를 resuscitation 의 가이드로서 사용하면 안됨.
(weak recommendation, moderate quality of evidence)
Vasopressin level 은 septic shock 초기에는 높다가 24-48시간 뒤부터 정상치 정도로 낮아져서 relative vasopression deficiency 를 보이며
Low dose Vaso 는 승압제 반응없는 refractory low BP에 효과가 있다.
NE 와 NE + vaso 0.03U/min 는 outcome 차이가 없다.
High dose vaso는 cardiac/digital/sphlacnic ischemia 조장
Sepsis 의 Large study 에서 vaso와 다른 승압제 비교하는 연구는 부족하지만, 대부분은 NE 의 sparing effect 로 효과가 있으나 mortality 는 차이가 없다.
NE 를 1st choice 로 , vaso는 첫번째로 쓰이지 않으며 euvolemic하거나 0.03보다 higher dose 는 주의 요함.
(weak recommendation, low quality of evidence)
Phenylephrine 은 pure alpha agonist ; splanchnic vasoconstriction, clinical outcome 은 uncertain
(strong recommendation, high quality of evidence).
low dose dopamine 은 need for RRT/ U/O/ renal recovery 뿐 아니라 survival/ICU stay/ hospital stay/ arrhthmia 에서 차이가 없다.
(weak recommendation, low quality of evidence)
Low CO ( LV filling P은 적절한경우, 즉 적절한 fluid resuscitation 이 이루어진 경우) 이 의심되고 MAP 가 유지되면서 hypoperfusion 지속되는 경우
Dobutamine 이 1st choice 로 사용될수 있음. -> lactate level 감소 , ScvO2 향상. 하지만 dobutamine 과 placebo 비교한 RCT 없음.
NE+dobutamine 과 epi 는 mortality 에 차이가 없다는 연구도.. EGDT clinical trial 에서 first choice 승압제로 쓰였으나 motrality에 대한 adverse effect는 확인x
Alternative inotorpics :
PEDi (cAMP 증가 -> inotropic effect independent beta Rc, ex : milirone)
levosimendan ( cardiac monocyte Ca responsivenss, ATP dependent K channel open, inotropic+vasodilatory )
: RCT higher risk of tachyarrhythmia, placebo와 mortality 차이는 없음.
(weak recommendation, very low quality of evidence).
(weak recommendation, low quality of evidence).
프랑스 RCT 에서 vasopressor unresponsive septic shock 에서 relative AI (ACTH maximal cortisol 이 9미만) 에서 shock reversal 에 효과
작은 두 RCT 에서 도 이를 뒷받침. 반대로 유럽 multicenter RCT 에서는 mortality benefit 에 대해서는 증명 x
Controversial : low dose hydrocortisone
Prolonged Low dose hydrocortisone 가 28day mortality/ICU stay 줄인다는 연구가 있는 반면
Placebo 에 비해 mortality 차이가 없다고 하기때문에 convincing evidence 가 명확하지 않으므로
Fluid +vasopressor에 v/s stable 한 경우 steroid 는 weak recommendation against
ACTH test 를 통하여 cortisol level 확인하는 것은 absolute AI 를 확인하는데 유용하지만,
상대적 AI 가 있는 septic shock환자에서는 random cortisol lv은 의미x
Etomidate 가 HPA axis 억제, etomidate 사용 -> 28 mortality 높임.
Fixed steroid Duration 혹은 tapering vs abrupt cessation 에 관한 비교 연구가 없다.
3 일 – 7일 hydrocortisone 사용에 outcome 차이가 없다는 연구도 있음.. -> suggest tapering steroids when vasopressors are no longer needed.
(strong recommendation, high quality of evidence).
TRISS trial 에서는 7 vs 9 를 수혈 threshol로 연구. 90일 mortality/ischemic event 등등에서 비슷한 결과.
ProCESS trial 에서는 hct<30% (Hb 10mg/dL) when ScvO2<70% vs only when Hb <7.5 -> no difference in mortality (60d, 90d)
두 군간 차이가 없다면 Lower Hb threshol는 선호
(strong recommendation, moderate quality of evidence). EPO 는 critically ill pt 에서 RBC T/F 을 약간 감소, but mortality는 변화 없으며
Sepsis/septic shock 에서 다른 condition에 비해 더 이득있다고 기대하지 않음.EPO는 thrombogenic event 발생률을 높임.
(weak recommendation, very low quality of evidence).
no RCT about prophylactic FFP T/F in sepsis.
최근 recomendation 은 coagulation Factor 부족일시 혹은 active bleeding or procedure 전 FFP 수혈하도록 되어 있으나
FFP 수혈이 PT 교정이 잘되지 않으며, Bleeding 이 없는Severe coagulation abnormality 교정이 이득이 있다는 연구 없음.
(weak recommendation, very low quality of evidence).
no RCT about prophylactic platelet T/F in sepsis.
최근 recommendation 은 therapy induced thrombocytopenia (leukemia , cell transplant) 시에 예방적으로 수혈.
(strong recommendation, high quality of evidence)
intensive 한 glucose control 은 mortality change 없으며 hypoGlc 발생 관계.
NICE-SUGAR trial 에 따르면 180 기준으로 insulin 치료 시작/중단여러 organization ( AA of clinical endocrinologits() 에서 140-180을 target 으로 하지만, 110-140 targent 차이가 있다는 evidence 가 없어
upper targent 은 180, hypoglycemia 만 아니면 lower target은 없다.
(BPS)
(weak recommendation, low quality of evidence)
capillary blood measurements may not accurately estimate arterial blood or plasma glucose values
Hct 이 낮아 false elevation (frequent false elvation)
(weak recommendation, moderate quality of evidence).
CRRT / intermittent RRT 는 hospital mortality 에 최근 RCT에서 큰 차이가 없다고 알려져 있음. (Lancet 2006)
Typical dose 20-25ml/kg/h ( dose 는 mortality 에 큰 차이 없음)
Early vs late RRT 개시 : early CRRT 가 mortality에 benefit/harm (c-line infection) 모두 있고, result가 확실성이 낮은것으로 판단되어
명확한 dialysis indication 이 아닌 AKI에서 RRT 는 사용하지 않는 것으로 제안.
(weak recommendation, moderate quality of evidence).
Sepsis 에서 hypoperfusion induced lactic acidemia 에서 bivon 사용에 대한 support 할 근거가 없음.
RCT 들에서 lactic acidosis 가 saline/ bivon 비교에서 hemodynamic variables, vasopressor requirement 에 차이가 없었음.
pH < 7.15 미만에서는 Evidence certainty 는 높지 않고, septc shock 뿐 아니라 그외 환자 포함 연구에서
Na, fluid overload, lac. PaCO2 증가와 관계하는 것으로 알려져 있다.
모든 PH에서 Bivon 투여는 혈역학적 안정성 및 clinical outcome 에 대해서는 알려진바 없다.
2012년 가이드라인과 변화 없음.
(strong recommendation, moderate quality of evidence).
Parenteral delivery 는 infection risk 를 높이는 complication 있음.
Early parenteral vs parenteral + enteral : systematic review ( septic shock환자 군이 아니라 surgical , TBI, … )
early parenteral 이 mortality 줄이지 못하고 infection risk 높고, ICU LOS 길고
Large RCT 에서 early parenteral group이 저혈당/ 구토는 적으나 mortality 는 차이 없었음.
(strong recommendation, moderate quality of evidence)
Early parenteral nutrition support 는 Mortality benefit 없고, infection risk 높이고 cost 많이 들고 clinical benefit 은 없고
7일동안 early parenteral nutrition개시에 대한 support 할 evidence 없음. Future research 필요
(weak recommendation, low quality of evidence)
장관영양을 일찍 시작하는 것이 physiologic advantage (염증반응완화, 대사 반응 조절 등) 을 위해 이득.
Early full feeding (48h 이내 시작 및 72 시간 이내 feeding goal 도달 ) vs delayed feeding ( 적어도 48 시간뒤 feeding ) ;
mortality 나 infection 조절은 큰 차이 없음. Trauma환자에서 death, pneumonia 줄임.
possible physiologic evidence gut permeability 를 줄이고, inflammation risk 를 줄여 weak recommendation으로..
(weak recommendation, moderate quality of evidence)
Early trophic/ hypocaloric feeding ( 48시간 이내 eneteralfeeding 시작 및 70% target calorie 에 48시간 이내 도달) 이 delayed enteral feeding 비교에서
최근 systematic review 에서도 mortality,infection , ICU LOS, ventilator free day 는 큰 차이가 없는 것으로 알려졌다.
Trophic/hypocaloric feeding 시 enteral feeding restriction (6day 까지 20% of caloric goal) 하여도 6개월/1년뒤 muscle mass, 6min walk test 특별히 차이 없음.
(weak recommendation, low quality of evidence).
(weak recommendation, low quality of evidence).
(weak recommendation, low quality of evidence).