1) Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a major healthcare problem with high mortality rates, especially septic shock which has mortality rates of 50-60%.
2) The new Sepsis-3 definition defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection represented by an increase of two or more points in the SOFA score.
3) Early goal-directed therapy (EGDT) is a protocol-based approach for initial resuscitation of sepsis patients. It aims to achieve specific goals for central venous pressure, mean arterial pressure, ScvO2, and other parameters within 6 hours and
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.The definition of sepsis was updated in 2016 following publication of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This recommended that organ dysfunction should be defined using the Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria or the "quick" (q)SOFA criteria.
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.The definition of sepsis was updated in 2016 following publication of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This recommended that organ dysfunction should be defined using the Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria or the "quick" (q)SOFA criteria.
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
Rhabdomyolysis is potentially life-threatening syndrome due to breakdown of skeletal muscle fibers
with leakage of muscle contents into the circulation, The outcome varies depending on the extent of kidney damage, To avoid this problem Keep yourself always hydrated well supplemented with electrolytes & carbohydrates. Avoid drugs, alcohol, excessive heat & over-exercising,
sepsis and septic shock, sepsis six bundle, fluid resuscitation, lactic acid, antibiotics, urine output, mortality 40%, nurses and health care professionals
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
Rhabdomyolysis is potentially life-threatening syndrome due to breakdown of skeletal muscle fibers
with leakage of muscle contents into the circulation, The outcome varies depending on the extent of kidney damage, To avoid this problem Keep yourself always hydrated well supplemented with electrolytes & carbohydrates. Avoid drugs, alcohol, excessive heat & over-exercising,
sepsis and septic shock, sepsis six bundle, fluid resuscitation, lactic acid, antibiotics, urine output, mortality 40%, nurses and health care professionals
dr Franciscus Ginting - Sepsis PIN PAPDI Surabaya WS-051019.pdfcorinafiqliyin
Penegakan diagnosis sepsis sangat diperlukan dalam kasus sepsis itu sendiri. Sepsis dapat disebabkan oleh beberapa hal. Salah satu komplikasi yang dapat timbul adalah syok sepis
It includes new definition, pathophysiology, management of sepsis, septic shock and neutropenic sepsis and even newer evolving concepts or types of sepsis.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
3. Why we are spending time on sepsis?
0
50000
100000
150000
200000
250000
AIDS Breast
Cancer
AMI SEPSIS
Mortality
0
50
100
150
200
250
300
AIDS Breast
Cancer
1st MI sepsis
Incidence
Cases/100,000
Deaths/Year
4. The third International Consensus 2016
Definition for Sepsis ( Sepsis 3)
SEPSIS IS A
LIFE THREATENING
ORGAN DYSFUNCTION
CAUSED BY A DYSREGULATED HOST
RESPONSE
TO INFECTION
5. Epidemiology
Martin, G. S., Mannino, D. M., Eaton, S., & Moss, M. (2003). The
epidemiology of sepsis in the United States from 1979 through 2000.
New England Journal of Medicine, 348(16), 1546–1554.
Harrison, D. A., Welch, C. A., & Eddleston, J. M. (2006). The
epidemiology of severe sepsis in England, Wales and
Northern Ireland, 1996 to 2004: secondary analysis of a high
quality clinical database, the ICNARC Case Mix Programme
Database. Critical Care, 10(2), R42.
Brun-Buisson, C., Meshaka, P., Pinton, P., Vallet, B., EPISEPSIS
Study Group. (2004). EPISEPSIS: a reappraisal of the epidemiology
and outcome of severe sepsis in French intensive care units.
Intensive Care Medicine, 30(4), 580–588.
[1993 - 2001]...a 17%
reduction in mortality.
[1993-2001]...a
75% increase in... severe
sepsis...
Incidence
of Sepsis
Mortality
of Sepsis
6. Why the burden of sepsis increasing?
Increased geriatric population
Increasing number of immunocompromised host
Increasing drug resistant organism
Increasing metabolic disorder
7. either
Bacteraemia (or viraemia/fungaemia/protozoan)
is the presence of bacteria within the bloodstream
Septic focus (abscess / cavity / tissue mass)
Infection
8. Sepsis is not merely an infection
THE CULPRIT HERE IS OVER REACTION OF OUR
DEFENCE MECHANISM – NOT THE INVADER ALONE.
17. Organ failure in sepsis
Vincent, J.-L., Sakr, Y., Sprung, C. L., Ranieri, V. M., Reinhart, K., Gerlach, H., Moreno, R., et al. (2006). Sepsis in European intensive care units: results of the SOAP study. Critical Care Medicine, 34(2), 344–353.
P/F
Platelets
Bili
BP
GCS
Cr/UOP
19. Sequential Organ Failure Assessment (SOFA)
► Previously known as Sepsis-related Organ Failure Assessment because it was
initially developed in 1994 to describe the degree of organ dysfunction associated with
sepsis in a mixed, medical-surgical ICU patients.
► Nowadays, it has since been validated to describe the degree of organ dysfunction in
various ICU patient groups with organ dysfunctions not due to sepsis.
► The SOFA score involves six organ systems (respiratory, cardiovascular, renal, hepatic,
central nervous, coagulation), and the function of each is scored from 0 (normal
function) to 4 (most abnormal), giving a possible score of 0 to 24.
20. Sequential Organ Failure Assessment (SOFA)
► Mortality rate increases as number of organs with dysfunction increases.
► Unlike other scores, the worst value on each day is recorded.
► A key difference is in the cardiovascular component; instead of the composite
variable, the SOFA score uses a treatment-related variable (dose of vasopressor
agents).
21. Sequential Organ Failure Assessment (SOFA)
► Maximal (highest total) SOFA score: is the sum of highest scores per individual
during the entire ICU stay. A score of >15 predicted mortality of 90%.
► Mean SOFA score (ΔSOFA): is the average of all total SOFA scores in the entire ICU
stay. ΔSOFA for 1st 10 days is significantly higher in non-survivors.
► Delta SOFA score: maximum SOFA – admission SOFA
Crit Care Med 1998;26:1793-1800
23. qSOFA for Non ICU patients with
Infection –
early recognition of severity
24. SEPTIC SHOCK
Septic shock is a subset of sepsis in which
profound circulatory, cellular and
metabolic abnormalities are associated
with a greater risk of mortality than sepsis
alone
25. CLINICAL CRITERIA FOR SEPTIC
SHOCK 2016
DESPITE ADEQUATE FLUID RESUSCITATION
VASOPRESSOR NEEDED TO MAINTAIN MAP >_65mm Of
Hg AND
LACTATE >2 MMOL/LIT
26. Basal lactate production
Muscle Brain RBC WBC Platelets
Renal
medulla
Gut
mucosa
Skin
0.13 mmol/
kg/hr
0.14 mmol/
kg/hr
0.18 mmol/
kg/hr
0.11 mmol/kg/hr
0.11 mmol/
kg/hr
Total = 1290 mmol / 24 hours for 70 kg
28. How is lactate produced?
If pyruvate production > oxidation in CAC then lactate formation increases
PDH
29. Hypoxia blocks oxidative phosphorylation
prevents NADH re-oxidation to NAD
increases the NADH/NAD ratio
increases the lactate/pyruvate ratio
Normal ratio around 10:1
Cardiogenic shock
L/P ratio 40:1
Consistent with hypoxia
Resuscitated septic shock
L/P ratio 14:1
Not consistent with hypoxia
30. When lactate hypoperfusion
Cardiogenic shock
Hemorrhagic shock
Septic shock if
Catecholamine resistant + depressed Cardiac Index
Unresuscitated (see Rivers)
31. Prognostic value
Source doesn’t matter
High lactate still a marker of severe
physiological stress
and risk of death
High lactate often not hypoxia
related but represents metabolic
changes of severe stress
32.
33. Management of SEPSIS
FLUIDS
ANTIBIOTICS
SOURCE IDENTIFICATION AND CONTROL
VASOACTIVE DRUGS TO MAINTAIN MAP
EARLY ORGAN SUPPORT
LUNG PROTECTIVE VENTILATION
AND MANY MORE…
BUT THE MOST IMPORTANT IS A SYSTEMATIC APPROACH
34. System-based Approaches to sepsis
Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Peterson, E., et al. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine, 345(19), 1368–1377.
35. System-based Approaches to sepsis
Early-Goal Directed Therapy
INCLUSION = SEPSIS AND [BP < 90 after fluid OR Lactate > 4]
CVP 8-12 Fluids CVP 8-12
MAP > 65 Vasopressors MAP > 65
Transfusions
Dobutamine
ScvO2 > 70%
49% mortality 33% mortality
Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Peterson, E., et al. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine, 345(19), 1368–1377.
Control Intervention EGDT
36. System-based Approaches to sepsis
Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Peterson, E., et al. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine, 345(19), 1368–1377.
Used to promote:
1. CVP > 8 as an initial target
2. Use of Svo2 monitoring and use of blood/dobutamine
37. A Multidisciplinary Community Hospital Program for Early and Rapid
Resuscitation of Shock in Non-trauma Patients
Sebat, F., Johnson, D., Musthafa, A. A., Watnik, M., Moore, S., Henry, K., & Saari, M. (2005). A multidisciplinary community hospital program for early and rapid resuscitation of shock in
nontrauma patients. Chest, 127(5), 1729–1743.
38. A Multidisciplinary Community Hospital Program for Early and Rapid
Resuscitation of Shock in Non-trauma Patients
Sebat, F., Johnson, D., Musthafa, A. A., Watnik, M., Moore, S., Henry, K., & Saari, M. (2005). A multidisciplinary community hospital program for early and rapid resuscitation of shock in
nontrauma patients. Chest, 127(5), 1729–1743.
39. Early Goal-Directed Therapy in the Treatment of Severe
Sepsis and Septic Shock
Control EGDT
Relative Risk
(95% Confidence
Interval)
P
In-Hospital 46.5 30.5
0.58
(0.38-0.87)
0.009
28-day Mortality 49.2 33.3
0.58
(0.39 – 0.87)
0.01
60-day Mortality 56.9 44.3
0.67
(0.46-0.96)
0.03
Rivers E. N Engl J Med. 2001;345: 1368-1377.
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Copyright 2014 SCCM/ESICM
41. TO BE COMPLETED WITHIN 3
HOURS OF TIME OF
PRESENTATION*:1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
* “Time of presentation” is defined as the time of triage in the emergency
department or, if presenting from another care venue, from the earliest
chart annotation consistent with all elements of severe sepsis or septic
shock ascertained through chart review.
42. TO BE COMPLETED WITHIN 6
HOURS OF TIME OF
PRESENTATION:5. Apply vasopressors (for hypotension that does not
respond to initial fluid resuscitation) to maintain a mean
arterial pressure (MAP) ≥65mmHg
6. In the event of persistent hypotension after initial fluid
administration (MAP < 65 mm Hg) or if initial lactate was
≥4 mmol/L, re-assess volume status and tissue perfusion
and document findings according to Table 1
7. Re-measure lactate if initial lactate elevated
43. DOCUMENT REASSESSMENT OF
VOLUME STATUS AND TISSUE
PERFUSION WITH
EITHER • Repeat focused exam (after initial fluid resuscitation) by
licensed independent practitioner including vital signs, cardiopulmonary,
capillary refill, pulse, and skin findings.
OR TWO OF THE FOLLOWING:
• Measure CVP
• Measure ScvO2
• Bedside cardiovascular ultrasound
• Dynamic assessment of fluid responsiveness with passive leg raise or
fluid challenge
Of note, Central Line no harm no gain. Needed for vasoactive drug
therapy.
Bedside sonologic assessment of Volume status is prioritized.
46. IVF recommendation
Initial fluid challenge ≥ 1000 mL of crystalloids or minimum
of 30 mL/kg of crystalloids in the 1st 4-6 hours
(Strong recommendation; Grade 1C).
Crystalloids is the initial fluid for resuscitation
(Strong recommendation; Grade 1A).
Adding albumin to the initial fluid resuscitation
(Weak recommendation; Grade 2B).
Against hydroxyethyl starches (hetastarches) with MW >200
dalton
(Strong recommendation; Grade 1B).
48. Septic Shock: Timing of Antibiotics
Kumar Crit Care Med 2006
0.0
.20
.40
.60
.80
1.00
% Survival
% Total receiving antibiotics
Percent
Time, hrs
14 ICUs; n = 2,731
Only 50% of patients in Septic Shock
received antibiotics w/in 6 hrs.
49. G. Fluid Therapy of Severe Sepsis
H. Vasopressors
I. Inotropic Therapy
J. Corticosteroids
2. Hemodynamic Support and Adjunctive Therapy
51. Which Inotropes to use?
Norepinephrine as the first choice
( Grade 1B)
Adding or substituting epinephrine when an additional drug is
needed
(Strong recommendation; Grade 1B).
Vasopressin 0.03 units/min may be added
(Weak recommendation; Grade 2A)
Dopamine only in highly selected patients at very low risk of
arrhythmias or low heart rate
(Weak recommendation; Grade 2C).
Dobutamine infusion be started or added with low cardiac output)
or ongoing signs of hypoperfusion, even after adequate
intravascular volume
(Strong recommendation; Grade 1C)
52. Inotropic Therapy
• We recommend that a trial of dobutamine infusion up to 20 μg/kg/min be administered or
added to vasopressor (if in use) in the presence of:
• myocardial dysfunction as suggested by elevated cardiac filling pressures and low
cardiac output, or
• ongoing signs of hypoperfusion, despite achieving adequate intravascular volume
and adequate mean arterial pressure. (Grade 1C)
• We recommend against the use of a strategy to increase cardiac index to predetermined
supranormal levels. (Grade 1B)
Slide 53
Copyright 2014 SCCM/ESICM
53. Diagnosis of Infection
Appropriate cultures before antimicrobial therapy as soon as possible (<45
minutes) (Grade 1C).
At least two sets of blood cultures (both aerobic and anaerobic bottles)
before antimicrobial therapy, with at least one drawn percutaneously and one
drawn through each vascular access device, unless the device was recently
(<48 hours) inserted. Blood cultures can be drawn at the same time if from a
different anatomic site (Grade 1C).
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Copyright 2014 SCCM/ESICM
54. Diagnosis
Cultures of other sites (preferably quantitative where
appropriate), such as urine, cerebrospinal fluid, wounds,
respiratory secretions, or other body fluids that may be the
source of infection, should also be obtained before antimicrobial
therapy if doing so does not cause significant delay in antibiotic
administration (Grade 1C).
We suggest the use of the 1,3 β-D-glucan assay (Grade 2B),
mannan and anti-mannan antibody assays (Grade 2C) when
invasive candidiasis is in the differential diagnosis of infection.
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Copyright 2014 SCCM/ESICM
55. Diagnosis
Imaging studies be performed promptly in attempts to
confirm a potential source of obscure infection. and
aggressive monitoring if the decision is made to transport
for a CT-guided needle aspiration) .
Bedside studies, such as ultrasound, may avoid patient
transport (Ungraded).
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Copyright 2014 SCCM/ESICM
56. Antimicrobial Therapy
The administration of effective intravenous antimicrobials as soon
as possible , but never beyond the first hour of recognition of
SEPSIS
Initial empiric anti-infective therapy include one or more drugs that
have activity against all likely pathogens (bacterial and/or fungal or
viral) and that penetrate in adequate concentrations into the tissues
presumed to be the source of sepsis (Grade 1B).
The antimicrobial regimen should be reassessed daily for potential
de-escalation to prevent the development of resistance, to reduce
toxicity, and to reduce costs (Grade 1B).
Slide 57
Copyright 2014 SCCM/ESICM
57. Antibiotics
• Abx within 1 hr hypotension: 79.9% survival
• Survival decreased 7.6% with each hour of delay
• Mortality increased by 2nd hour post hypotension
• Time to initiation of Antibiotics was the single strongest predictor of
outcome
58. Antimicrobial Therapy …
use of low procalcitonin levels or similar biomarkers to assist the
clinician in the discontinuation of empiric antibiotics in patients who
appeared septic, but have no subsequent evidence of infection
Empiric therapy should attempt to provide antimicrobial activity against
the most likely pathogens based upon each patient’s presenting illness
and local patterns of infection.
We suggest combination empiric therapy for neutropenic patients with
severe sepsis (Grade 2B) and for patients with difficult-to-treat,
multidrug-resistant bacterial pathogens such as Acinetobacter and
Pseudomonas spp.
59. Antimicrobial Therapy …
Duration of therapy typically be 7 to 10 days if clinically indicated;
longer courses may be appropriate in patients
who have a slow clinical response,
Undrainable foci of infection,
Bacteremia with Staphylococcus aureus,
some fungal and viral Infections, or
Immunologic deficiencies, including neutropenia
60. Source Control
When source control in a severely septic patient is required,
the effective intervention associated with the least
physiologic insult should be used (eg, percutaneous rather
than surgical drainage of an abscess) (Ungraded).
If intravascular access devices are a possible source of
severe sepsis or septic shock, they should be removed
promptly after other vascular access has been established
(Ungraded).
61. Corticosteroids
Only when Blood Pessure is not maintained with adquate flid
resuscitation and vasoacive
Intravenous hydrocortisone alone at a dose of 200 mg per
day. Continuous Infusion preferred over bolus doses.
Taper steroid when vasopressors are no longer required
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Copyright 2014 SCCM/ESICM
62. Blood product Administration
Transfuse PRBC only when Hb%v<7.0 g/dL to target a hemoglobin
concentration of 7.0 to 9.0 g/dL in adults (Grade 1B).
Exceptions are myocardial ischemia, severe hypoxemia, acute
hemorrhage, or ischemic coronary artery disease.
NO Erythropoetin in sepsis
No FFP to correct lab abnormality in absence of Bleeding or planned
invasive procedure.
Platelet transfusion –
<10,000 in absence of bleeding
<20000 if bleeding risk high
<50,000 if planned procedure, active bleeding or surgery
63. Glucose Control
• We recommend protocolized approach to blood glucose
management, commencing insulin dosing when two
consecutive blood glucose levels are >180 mg/dL.
• This protocolized approach should target upper blood
glucose <180 mg/dL rather than <110 mg/dL (Grade 1A).
• Treatment should avoid hyperglycemia (>180 mg/dL),
hypoglycemia, and wide swings in glucose levels
Slide 64
Copyright 2014 SCCM/ESICM
64. Glucose control…
Glucometer measured capillary blood be interpreted with
caution, as such measurements may not accurately
estimate arterial blood or plasma glucose values
Capillary point-of-care testing found to be inaccurate with
frequent false glucose elevations over range of glucose
levels, but especially in hypoglycemic and hyperglycemic
glucose ranges and in hypotensive patients or patients
receiving catecholamines..
65. Bicarbonate Therapy
• No to sodium bicarbonate therapy for the purpose of
improving hemodynamics or reducing vasopressor
requirements in patients with hypoperfusion-induced lactic
acidemia with pH ≥7.15 (Grade 2B), in absence of Renal
acidosis.
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66. Nutrition
• We suggest administering oral or enteral feedings, as
tolerated, rather than complete fasting or provision of only
intravenous glucose within the first 48 hours after a
diagnosis of severe sepsis/septic shock (Grade 2C).
• We suggest avoiding mandatory full caloric feeding in the
first week, but rather suggest low-dose feeding (e.g., up to
500 kcal per day), advancing only as tolerated
Slide 67
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Marik and Zaloga. Crit Care Med. 2001;29:2264–2270
Heyland et al. JPEN J Parenter Enteral Nutr. 2003;27:355-373
Doig et al. Intensive Care Med. 2009;35:2018–2027
67. • Enteral nurtrition combined with IV Glucose supplementation
is preferred than Total parenteral Nutrition
• No evidence for the use of Arginine, Glutamine and Omega 3
fatty acid therapy during acute illness with sepsis
Nutrition…
68. Renal Replacement Therapy
• Continuous renal replacement therapies and intermittent
hemodialysis are equivalent in patients with sepsis and
acute renal failure because they achieve similar short-term
survival rates (Grade 2B).
• We suggest the use of continuous therapies to facilitate
management of fluid balance in hemodynamically unstable
septic patients (Grade 2D).
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69. Prophylaxis for VTE
We recommend that patients with severe sepsis receive daily pharmacoprophylaxis
against VTE (Grade 1B).
We recommend that septic patients who have a contraindication to heparin not
receive pharmacoprophylaxis (Grade 1B).
Rather, we suggest they receive mechanical prophylactic treatment, such as
graduated compression stockings or intermittent compression devices, unless
contraindicated (Grade 2C).
When the risk decreases, we suggest starting pharmacoprophylaxis (Grade 2C).
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70. Stress Ulcer Prophylaxis
• We recommend that stress ulcer prophylaxis using H2
blocker or proton pump inhibitor be given to patients with
sepsis/septic shock who have bleeding risk factors (Grade
1B).
• We suggest that patients without risk factors should not
receive prophylaxis (Grade 2B).
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71. Setting Goals of Care
We recommend that goals of care and prognosis be
discussed with patients and families (Grade 1B).
Goals of care be incorporated into treatment and end-of-life
care planning, utilizing palliative care principles where
appropriate
Goals of care be addressed as early as feasible, but no later
than within 72 hours of ICU admission
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73. Take home message…
Identify sepsis early
More and faster fluid
Send cultures early
Antibiotic Fast <1 hr, consider early antifungals, use
biomarkers to deescalate or stop
Earlier Inotropes, Use norepineprine
Chase Lactic acid clearance
Sonologic volume assessment is better than CVP
Wet first, dry later
Higher PEEP