severe sepsis ??? septic shock - dms.moph.go.th sepsis และ septic... · severe sepsis...
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severe sepsis
septic shock
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severe sepsis septic shock
Septic shock
r on n non o
onon invasive devices on n
n o o
Septic shock n o
n n r o
o noon
Septic shock o
Systemic Inflammatory Response Syndrome ( SIRS)
on n n
inflammatory stimuli n n burns
SIRS on o n no 2 :
1. 38.0 C 36.0 C
2. 90 /
3. 20 / PaCO2 32 .
4. 12,000 /.. 4,000 /..
band form 10%
o oo on onnn oon
Sepsis
n SIRS n
-
Severe sepsis
sepsis n ( organ dysfunction )
( hypoperfusion ) ( hypotension )
lactic acidosis o o o
Septic shock
sepsis on oo o o
n n n ( hypoperfusion ) lactic acidosis
o o on o o
hypoperfusion
o inflammatory foci non endotoxin ,
exotoxin , peptidoglycans o ohost defense system monocyte ,
neutrophil endothelial cell o mediator n tumor necrosis factor (TNF), IL-1
o nTNF, IL-1 o o cytokine TNF, IL-1,
IL-2 ocomplement pathway, coagulation system,platlet activating factors
inflammatory response n
Systemic inflammation n
no n o n
microcirculation vasoconstriction, vasodilatation vascular leakage myocardial
depression
septic shock
o n n ooxygen r
rno o mixed venous oxygen saturation(SvO2)
oxygen extraction ratio on
-
red blood cells red blood cells deformability
acidosis , mediators white cell
arteriovenous shunting o
hemolysis white blood cell microcirculation
ro endotoxin cell endothelium enzyme
permeability
disseminated intravascular coagulation ocoagulation cascade
microthombosis deposition fibrin
microcirculation multiorgan failure endothelium
microvascular permeability no
o arteriolar
vasoconstriction vasodilation o o
Severe sepsis Septic shock
Shock SIRS n n
3 :
1. n
2. Intensive life support
3. o n o Septic shock
1) o n
4 o nbody fliud
exudate n n on Septic shock hemoculture
2
-
o n Septic schock
o on n n o nn
( grams stain, AFB ) o onon o
o n
on febrile neutropenia o n o
n
n SIRS
1. drain infected fluid collection
2. debridement infected solid tissue
3. medical device ( )
( central venous catheter) o
4. n n
2) Intensive life support
2.1 o ( Fluid therapy)
2.2 vasopressure inotrope
2.3 hemodynamic monitoring
2.4 renal support
2.5 pulmonary support
2.1 o ( Fluid therapy )
o ocrystalloid normal
saline solution lactateds ringer solution (LRS) 500-1,000 ml 15 60
o n on n
intravascular volume
-
nn non o n on
venous pressure o nnon
central venous catheter (CVP) CVP Pulmonary artery catheter
PCWP fluid challenge
fluid challenge
Guided by CVP PCWP Infusion
( cmH20 ) ( mmHg )
Start < 8 < 10 200 ml/ 10 min
< 12 < 14 100 ml /10 min
12 14 50 ml/ 10 min
During infusion 5 7 Stop
After 10 min 2 3 Continue
2 5 3 7 Wait 10 min
5 7 Stop
After waiting 10 min Still 2 Still 3 Stop
2 3 Repeat
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2.2 vasopressure inotrope
2.2.1Vasopressure therapy
n on o non n
o o ohemodynamic profile
Dopamine: 1-5 ././ () inotropic
20 ././
: dopamine renal blood flow
noorenal perfusion
Norepinephrine: nsplanchnic blood flow
tachycardia dopamine
2.2.2 Inotropic therapy
Dobutaminne : oon cardiac output o n o
o n o o n nvasopressure
-
Inotrope Vasopressure septic shock
Drug Dose
(g/kg/min
or g/min*)
Cardiac
Stimulation
(1)
Vasoconstriction Vasodilatation
(2)
Dopaminergic
Dopamine 1-10
10-20
++
+++
+
+++
++
+
+++
0
Norepinephrine 2-10* +++ ++++ 0 0
Epinephrine 1-8* ++++ ++++ 0 0
Dobutamine 1-10 ++++ + 0 0
2.3 Hemodynamic monitoring
resuscitrate septic shock ooon 6
Early goal-directed therapy ohemodynamic monitoring n:
2.3.1 Central venous pressure 8-12 mmHg on o n12-15
mmHg on n n
2.3.2 Mean arterial pressure ( MAP) 65 mmHg
2.3.3 Urine output > 0.5 ml/kg/hr
2.3.4 Central venous mixed venous oxygen saturation (ScvO2 SvO2) n
70% (ScvO2) 65% (SvO2)
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2.4 renal support
n n n hypercatabolic state septic
shock o o optimized volume status
on on renal replacement therapy
2.5 pulmonary support
n Acute lung injury Acute respiratory distress syndrome
Septic shock o low tidal volume 6 ml/kg of predicted body weight Plateau
pressure 30 cmH20 oon hypercapnea Plateau pressure
( Permissive hypercapnea ) , PEEP ( Positive end expiratory pressure) o
n oxygen Fi02
Ventilator management
Assist control mode - volume ventilation
Reduced tidal volume to 6 mL/kg predicted body weight
Keep Ppla < 30 cm H20
Maintain Sao2/Spo2 88-95%
Anticipated PEEP setting at varius Fi02 requirements
Fi02 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0
PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 20-24
Predicted Body Weight Calculation
Male : 50 + 2.3(height (inches) 60) or 50 + 0.91(height(cm) 152.4)
Female : 45.5 + 2.3(height (inches) 60) or 45.5 + 0.91(height(cm) 152.4)
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n o n o nnsemirecumbent o 45
o ventilator-associated pneumonia
n on on o
( spontaneous breathing trial pressure support n PEEP 5 cmH20 T-piece)
oonn:
1.
2. ( vasopressur )
3. serious
4. ventilation end-expiratory pressure
5. Fi02 omask nasal cannula
-
Use of spontaneous breathing trail in weaning ARDS patients
Original illness resolving : no new illness
Off vasopressure and sedative , Cough durning suctioning
PaO2/FiO2 >200 mm Hg , PEEP < 5 cm H2O
Minute ventilation < 15 L/min , F/Tv ratio < 105 durning 2-min spontaneous breathing trial
Spontaneous breathing trial ( 30-120 min)
( include: T-piece , continuous positive airway pressure 5 cm H2O ,or low-level
( 5-10cm H2O ) pressure support ventilation )
Respiratory rate > 35/min , Oxygen saturation < 90
Pluse > 140 /min or change > 20 % , SBP > 180 mm Hg or < 90 mm Hg
Agitation, diaphoresis , or anxiety
F/Tv ratio > 105
No Yes
Cough adequate to clear secretions
Able to protect airway
Yes No
Extubate Return to maintenance MV
-
3) o
3.1 Steroid
oon refractory septic shock ( adequate intravascular volume
vasopressure o n) adrenal insufficiency septic
shock hydrocortisone 200-300 mg/day 3-4 7 (
hydrocortisone 300 mg/day ) ACTH stimulation test n
serum cortisol hydrocortisone
Severe sepsis Septic shock adrenal insufficiency orn:
- baseline cortisol n10 g/dl
- cortisol o n9 g/dl cosyntropin
- free cortisol on n2 g/dl
adrenal insufficiency cortisol 44 g/dl
Cortisol n16.8 g/dl cosyntropin
3.2 Glucose control
oo n150 mg/dl insulin n n
n on nn o o ,
insulin anti-inflammation endothelium
mitochondria
3.3 Blood product administration
red blood cell transfusion oxygen delivery on hematocrit
< 30% , erythropoietin severe sepsis
3.4 Bicarbonate therapy
bicarbonate therapy on severe metabolic acidosis septic shock
arterial PH < 7.15
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3.5 Recombinant human activated ptotein C ( rhAPC )
on severe sepsis rhAPC
oo o o
Septic shock
oo 6
1. ( presumptive diagnosis) 1
2. Antibiotic 4 o nsepsis
3. Resuscitrate o n
4. o MAP < 65 mmHg n o o
5. CVP
6. PRC Central venous oxygen saturation < 70% o
CVP > 8 mm Hg
7. non o nn o Steroids
o24
1. o n150 mg/dl
2. o on Acute lung injury ARDS tidal volume 6 ml/Kg
plateau pressure 30 cmH2O
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Clinical practice guideline for Severe sepsis and Septic shock
o n ( Early Recognition )
Criteria SIRS 2 on
Temp > 38.0 C < 36.0 C
Heart Rate > 90 bpm No
Resp. Rate > 20 bpm PaCO2 < 32 mmHg
WBC > 12,000 < 4,000 Bandform Neutrophil 10%
Yes
n No
H/C 2 specimen , Plasma glucose, Bun/Cr , Elyte, LFT, CBC
Imaging Specimen n n n
Sepsis with hypotension or sign of hypoperfusion
-SBP < 90 mm Hg - Change in mental status
-MAP < 65 mm Hg - Decreased urine output No
-Decreased SBP > 40 mm Hg - Increased lactate
Yes
- o o0.9% NSS 500-1000 ml in 30-60 min
( )
-
BP : MAP > 65, SBP > 90 mmHg Yes
-
BP : MAP > 65, SBP > 90 mmHg SBP = Systolic Blood Pressure
No MAP = Mean Arterial Pressure
[ MAP = ( SBP+DBP)/3 + DBP ]
Notify r : Fluid challenge test ICU Early Goal Directed Therapy
( 6 . )
EARLY GOAL DIRECTED THERAPY ( 0 - 6 )
A : Invasive hemodynamic monitoring CVP monitoring
B : Broad Spectrum Antibiotic n
Fluid challenge test Crystalloid (0.9%NSS
CVP 30 min < 8 cmH2O or Lactate Ringer ) 20-30 ml/kg
free flow Pressure bag n
8-12 cm H2O oo 500 ml. 30
CVP 8-12 cmH2O
MAP < 65 mmHg ( SBP < 90 mmHg) Yes Vasopressors
Norepinephrine Dopamine
MAP 65-90, SBP 90-140
No Yes
echo LV function
Adequate perfusion Dobutamine
-
Adequate perfusion Yes MAP 65-90, SBP 90-140
Yes No No
n Refractory septic shock
o- Vasopressure 2 (
Resuscitation Norepinephrine )
- Epinephrine Second Venous line
- Steroid ( Hydrocortisone )
- Fluid challenge ( oon)
- Hct < 30 % PRC
- Acidosis / Low SvO2 Dobutamine
-
Empyrical treatment sepsis ( Antibiogram )
1) o on oon
n1 on n
n nDRSP
n2 on
nDRSP
n3 on o n
ICU
n 3.1
n DRSP
n 3.2
DRSP
Oral macrolide Oral doxycycline
Oral lactam ( high dose amoxicillin,
amoxicillic/clavulanate,cefuroxime,cefpodoxime)
oral macrolide doxycycline
Oral antipneumococcal fluoroquinolone
Intravenous advance macrolide
Intravenous antipneumococcal fluoroquinolone
Intravenous -lactam ( ceftriaxone, cefotaxime,
-lactam, -lactamase inhibitor, high dose
ampicillin) macrolide doxycycline
Intravenous antipneumococcal fluoroquinolone
-
n4 on ICU
n 4.1 n n
P.aeruginosa
n 4.2 n P.aeruginosa
Intravenous -lactam Intravenous advance
macrolide
Intravenous antipneumococcal fluoroquinolone
Antipseudomonal lactam
aminoglycoside anti-pseudomonal quinolone
Note: Antipneumococcal fluoroquinolone levofloxacin , gatifloxacin, and moxifloxacin
: Andvanced generation macrolide clarithromycin and azithromycin
n
1. Drug resistant Streptococcus pneumonia ( DRSP)
1.1 Age > 65 years
1.2 Beta-lactam therapy within 3 months
1.3 Alcoholism , exposure to child in day care
1.4 Multiple medical comorbidities
-
2. Enteric gram negatives
2.1 Underlying cardiopulmonary disease
2.2 Recent antibiotic therapy
2.3 Nursing home residence
2.4 Multiple medical comorbidities
3. Pseudomonas aeruginosa
3.1 Structural lung disease eg. Bronchiectasis
3.2 Broad-spectrum antibiotics for > 7 days within the past month
3.3 Corticosteroids therapy ( > 10 mg prednisolone )
3.4 Severe malnutrition
2) o on o n o
Early onset HAP/VAP , no specific risk factor
Enteric gram negative ( nonpseudomonal )
Enterobactor spp.
Escherichia spp.
Klebsiella spp.
Cephalosporin
Second generation or
Nonpseudomonal third generation or
Beta-lactam/beta-lactamase inhibitor or
-
Proteus spp.
Serratia marcescens
Haemophillus influenza
Methicillin sensitive Staph. Aureus
Late onset HAP/VAP
As early onset plus
Pseudomonas aeruginosa
Acinetobactor baumannii
Methicillin resistant Staph. aureus
Fiuoroquinolones if allergic to penicillin
Aminoglycoside or antipseudomonal quinolone plus
One of the followings:
Antipseudomonal penicillin
Ceftazidime
Cefoperazone/beta-lactamase inhibitor
Carbapenem groups
Vancomycin
3) o soft tissue
( Abcess, Cellulitis and Erysipelas )
MSSA SSTI MRSA SSTI
Oxacillin 1-2 gm IV q 6 hr
Cefazolin 1 gm IV q 8 hr
Clindamycin 600 mg IV q 8 hr
Vancomycin 30 mg/kg/day IV q 12 hr
Clindamycin 600 mg IV q 8 hr
MSSA: methicilin-susceptible S.aureus, MRSA : methicilin-resistant S.aureus, SSTI : skin and soft-tissue infection
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4) necrotizing of the skin, fascia, and muscle
First-line antimicrobial agent, by infection type Adult dose
Mixed-infection
Ampicillin-sulbactam or
Piperacillin-tazobactam plus
Clindamycin plus
Ciprofloxacin
Imipenem/cilastin
Meropenem
Cefotaxime plus
Metronidazole or
Clindamycin
Streptococcus infection
Pennicillin plus
Clindamycin
S.aureus infection
Oxacillin
Cefazolin
Vancomycin ( for resistant )
1.5-3.0 gm q 6-8 h IV
3.37 gm q 6-8 h IV
600 mg q 8 h IV
400 mg q 12 h IV
1 gm q 6-8 h IV
1 gm q 8 h IV
2 gm q 6 h IV
500 mg q 8 h IV
600 mg q 8 h IV
2-4 MU q 4-6 h IV
600 mg q 8 h IV
1-2 gm q 4 h IV
1 gm q 8 h IV
30 mg/kg/day q 12 h IV
-
Clindamycin
Clostridium infection
Clindamycin
Penicillin
600 mg q 8 h IV
600 mg q 8 h IV
2-4 MU q 4-6 h IV
5) o no o
(Community-Acquired Complicated Intra-Abdominal Infections )
Single agent
-lactam/-lactamase
inhibitor
Combination regimens
Cephalosporin based
Fluoloquinolone based
Ampicillin/sulbactam
Cefazolin or cefuroxime plus
metronidazole
Ciprofloxacin, levofloxacin
or moxifloxacin each in
combination with
metronidazole
Piperacillin/tazobactam
Third/fourth- generation cephalosporin
(ceftriaxone,ceftazidime,cefotaxime,cefepime)
plus metronidazole
Ciprofloxacin in combination with
metronidazole
-
6) o
oE.coli, Klebsiella spp.,Proteus spp.,S. aureus
First-line antimicrobial agent Adult dose
Gentamicin
Cefotaxime
Ceftriaxone
Amikacin
Neltilmycin
Imipenem
7 mg/kg day 5 mg/kg/day IV
1 gm IV q 6 hr
2 gm o o1 gm IV q 12 hr
1 gm 15 mg/kg/day IV
300 mg ( 6 mg/kg/day) 4 mg/kg/day IV
1 gm o o 500 mg IV q 6 hr
7) o
oKlebsiella spp., Enterobacte spp., Pseudomonas aeruginosa, Acinetobactor spp.
o n
Antimicrobial agent Adult dose
Beta-lactam group
- Ceftazidime/Cefepime
- Cefoperazone/sulbactam
- Imipenem
- Meropenem
2 gm IV q 8 hr
1.5 2 gm o o1.5 1 gm IV q 8-12 hr
1gm 0.5 gm IV q 6-8 hr
2gm 1 gm IV q 8 hr
-
- Piperacillin+tazobactam
- Colistin
Amikacin
Neltilmycin
Levofloxacin
Ciprofloxacin
4.5gm IV q 8 hr
3 on o o1.0-1.5 IV q 8 hr
1 gm 15 mg/kg/day IV
6 mg/kg/day 4 mg/kg/day IV
750 mg IV OD
400 mg IV q 12 hr
8) Primary bacteremia/sepsis n rickettsia leptospira
Antimicrobial agent
- Ceftriaxone 2gm IV o 1 gm IV q 12 hr Doxycycline 200 mg oral
100 mg q 12 hr
- Ceftriaxone 2gm IV o 1 gm IV q 12 hr azithromycin(
doxycycline) 2 gm o o500 mg IV q 12 hr 3-5
Severe sepsis Septic shock nn o o
n oo n oo o
o 1-6
o o
-
n n o o
n oon o n
o o o
n ono o o
sepsis oo ono
ro
1. R.Phillip Dellinger,Jean M.Carlet et al; Surviving Sepsis Campaign guidelines for management of
severe sepsis and septic shock. Crit Care Med 2004 ;32: 859-872.
2. River E , Nyugen B, Havstad S et al; Early goal directed therapy in the treatment of severe
sepsis and septic shock. N Eng J Med 2001;345:1368-77.
3. ; Septic shock :an Update 2007. Best Practices in Critical Care
2006;227-246.
4. MacArthur RD, Miller M,Albertson T et al; Adequacy of early empiric antibiotic treatment and
survival in severe sepsis:experience from the MONARCS trial. Clin Infect Dis 2004;38:284-8.
5. Annanae D, Maxime V, Ibrahim F,Alvarez JC,Abe E. Diagnosis of adrenal insufficiency in
severe sepsis in severe sepsis and septic shock . Amer J Respir Crit Care Med 2006;174:1319-26.
6. .. ; Septic shock :More Than Just Antibiotic. Update on Infectious Diseases:An
Evidence-Based Approach to Patient Care 2008;56-103.
7. Lionel A. Mandell et al; Guidelines on the management of Community-Acquired Pneumonia in
Adults. Clin Infect Dis 2007;44:22-72.
8. Michael S. Niederman et al; Guidelines for the Management of Adults with Hospital-
Acquired,Ventilator-associated, and Health-care associated Pneumonia.Am J Respire Care
Med2005;171:388-416.
9. Dennis L.Stevens et al; Guidelines for Skin and Soft-tissue infections. Clin Infect Dis
2005;41:1373-1408.
10. Joseph S.Solomkin; Guideline for the Selection of Anti-infective Agents for Complicated Intra-
abdominal Infections. Clin Infect Dis 2003;37:997-1005.
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