copy (2) of sepsis present เซกา revised

Khittisak Hankla, MD,FRCSTSeka Hospital

7th Oct 2014

Severe sepsis and Septic shock

SSC-Guidelines 2012.pdf

Content

What is Sepsis/Severe Sepsis and Septic shock?

Treatment Guideline

KPI

Pitfall/ Gap analysis

Pathophysiogyof

Severe sepsis and septic shock

The Sepsis Continuum


Clinical response arising from nonspecific insult, with ≥2 of the following: T >38oC or <36oC HR >90 beats/min RR >20/min or PaCO2< 32 WBC >12,000/mm3

<4,000/mm3 or >10% bands


SIRSwith apresumedor confirmed infectiousprocess

Clinical response arising from nonspecific insult, with ≥2 of the following: T >38oC or <36oC HR >90 beats/min RR >20/min WBC >12,000/mm3 or

<4,000/mm3 or >10% bands


SIRSwith apresumedor confirmed infectiousprocess

Clinical response arising from nonspecific insult, with ≥2 of the following: T >38oC or <36oC HR >90 beats/min RR >20/min WBC >12,000/mm3 or

<4,000/mm3 or >10% bands

Refractoryhypotension

Severe Sepsis

Treat sepsis

Resuscitation

1: The goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following (grade 1C): within 6 hrs after diagnosis

1: CVP 8–12 mm Hg ( JVP 8-10cm H2O) 2: MAP ≥ 65 mm Hg3: Urine output ≥ 0.5 ml/kg/hr4: Scvo2 or Svo2 ≥70% or ≥ 65%, respectively

Initial resuscitationInitial Resuscitation

2: Suggest targeting resuscitation to normalize lactate inpatients with elevated lactate levels as a marker of tissuehypoperfusion (grade 2C).

1: The goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following (grade 1C): within 6 hrs after diagnosis

1: CVP 8–12 mm Hg ( JVP 8-10cm H2O)

2: MAP ≥ 65 mm Hg3: Urine output ≥ 0.5 ml/kg/hr4: Scvo2 or Svo2 ≥70% or ≥

65%, respectively

http://epomedicine.com/wp-content/uploads/2013/11/JVP-measurement_mini.jpg

http://epomedicine.com/wp-content/uploads/2013/11/JVP.png

ResuscitationInfection Issue

2:Antimicrobial Therapy

Infection Issue

1: Diagnosis

3: Identification source and Control

2:Antimicrobial Therapy

Infection Issue

1: Diagnosis

Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s)

At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted


Infection Issue

Diagnosis Antimicrobial TherapyThe administration of effective intravenous antimicrobialswithin the first hour of recognition of septic shock (grad1B)and severe sepsis without septic shock (grade 1C)should be the goal of therapy.

Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known

Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have

- a slow clinical response- Undrainable foci of infection- Bacteremia with S. aureus; some fungal and viral

infections - Immunologic deficiencies, including neutropenia

Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause

Infection Issue

Diagnosis Antimicrobial Therapy

Infection Issue


DiagnosisAntimicrobial Therapy


Hemodynamic support

Hemodynamic support And Adjunctive therapy

Adequate volume

Acceptable BPAdequate

tissue perfusion

Fluid Therapy of Severe Sepsis


Adequate volume


tissue perfusion

Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock

Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock

Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids

Fluid Therapy of Severe Sepsis


Adequate volume


tissue perfusion

การใหสารน้ํา

เลือก crystalloids เปนอันดับแรก ในการ resuscitationเร่ิม challenge โดยให crystalloid อยางนอย 30 มล/กก.


Adequate volume


tissue perfusion

• Vasopressor and inotropic therapy

• Corticosteroid


Adequate volume


tissue perfusion

Vasopressor


Adequate volume


tissue perfusion

Vasopressor and inotropic therapyA trial of Dobutamine infusion up to 20 micrograms/kg/min ( max) be administered or added to vasopressor (if in use) in the presence of

(A) Myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, (grade 1C). or

(B) Ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP (grade 1C).


Adequate volume


tissue perfusion

• Vasopressor and inotropic therapy

•Corticosteroid


Adequate volume


tissue perfusion

Corticosteroid

1:Not using IV hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stabilityIn case this is not achievable, we suggest IV Hydrocortisone at a dose of 200 mg per day (grade 2C).2. Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone (grade 2B).3. In treated patients hydrocortisone tapered when vasopressors are no longer required (grade 2D)4. Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grade 1D).5. When hydrocortisone is given, use continuous flow (grade 2D).


Adequate volume


tissue perfusion

Corticosteroid

Hemodynamic not achieved goal :MAP < 65 mmHg despiteAdequate volumeAdequate or near adequate Vasopressor : IV Hydrocortisone 50 mg IV q 6 hr or 100 mg IV q 8 hr and tailor off within 7 days


Adequate volume


tissue perfusion 1 : CVP 8–12 mm

Hg2: MAP ≥ 65 mm Hg3: Urine output ≥ 0.5 ml/kg/hr4: Scvo2 or Svo2 ≥70% or ≥ 65%, respective

?

No Yes

Achieve goal ท่ีเวลา......


Adequate volume


tissue perfusion 1 : CVP 8–12 mm

Hg2: MAP ≥ 65 mm Hg3: Urine output ≥ 0.5 ml/kg/hr4: Scvo2 or Svo2 ≥70% or ≥ 65%, respective

?

No


Adequate volume


tissue perfusion

1: Urine output < 0.5 ml/kg/hr2: Scvo2 or Svo2 <70% or < 65%, respective3: serum lactate > 4 mmol/l or capillary lactate > 5 mmol/l

Check 1 If MAP > 90 mmHg ::::: Vasopressor ; Keep MAP 60-90 mmHg2 If Hct < 30 % ; PRC3 If Hct ≥ 30 % ; Dobutamine 2.5 µg/kg/min titrate ครั้งละ 2.5 µg/kg/min Until

SVC O2 sat ≥ 70Max= 20 µg/kg/min

3 Checks


Adequate volume


tissue perfusion 1: CVP 8–12 mm Hg

2: MAP ≥ 65 mm Hg3: Urine output ≥ 0.5 ml/kg/hr4: Scvo2 or Svo2 ≥70% or ≥ 65%, respective1st choice :Crystalloid

Colloid :alternative e.g Albumin


Adequate volume


tissue perfusion

Vasopressor and InotropictherapyCorticosteroid

1: CVP 8–12 mm Hg2: MAP ≥ 65 mm Hg3: Urine output ≥ 0.5 ml/kg/hr4: Scvo2 or Svo2 ≥70% or ≥ 65%, respective1st choice :Crystalloid

Colloid :alternative e.g Albumin


Adequate volume


tissue perfusion

Vasopressor and InotropictherapyCorticosteroid

1: CVP 8–12 mm Hg2: MAP ≥ 65 mm Hg3: Urine output ≥ 0.5 ml/kg/hr4: Scvo2 or Svo2 ≥70% or ≥ 65%, respective1st choice :Crystalloid

Colloid :alternative e.g Albumin Adjust MAPPRCDobutamine administration


Hemodynamic support

Supportive therapy

Supportive Therapy: Metabolic and organs support


Blood Product Administration ImmunoglobulinsSeleniumHistory of Recommendations Regarding Use of Recombinant Activated Protein C (rhAPC) Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)Sedation, Analgesia, and Neuromuscular Blockade in SepsisGlucose Control Renal Replacement Therapy Bicarbonate Therapy Stress ulcer prophylaxisDeep Vein Thrombosis Prophylaxis Nutrition

Issue


Blood Product Administration Issue


Blood Product Administration• PRC transfusion occur only whenHb decreases to <7.0 g/dL to target a Hb of 7.0 –9.0 g/dL in adults (grade 1B).

•Platelets prophylactically when - Platelet counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding. - < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding. - ≥50,000/mm3 [50 x 109/L] are advised for active bleeding, surgery, or invasive

procedures (grade 2D).

Issue


Issue

This protocolized approach should target an upper blood glucose ≤180 mg/dL rather than an upper target blood glucose ≤ 110 mg/dL (grade 1A).

Glucose Control


IssueStress Ulcer Prophylaxis

Coagulopathy :- Platelet <50,000 per/mm3,- INR >1.5, or PTT >2 times the control value

Mechanical ventilation for >48 hoursHistory of GI ulceration or bleeding within the past yearTraumatic brain injury, traumatic spinal cord injury, or burn injury≥ 2 of the following:

SepsisICU stay >1 weekOccult GI bleeding for ≥6 daysGlucocorticoid therapy (more than 250 mg hydrocortisone or the equivalent)


IssueStress Ulcer Prophylaxis

Nutrition

Take home message

Take home message

BP drop Load NSS อยางนอย 30 ml/kg กอนพิจารณา vasopressorLevophed is preferedตอง H/C x 2 spp. กอน start Antibiotic

-H/C เลือดใชอยางนอย 10 ml ตอขวด -แนะนําเจาะเลือด peripheral x 2 site ตางตําแหนงกันSevere sepsis or septic shock

antibiotic within 1 hr after diagnosis

ตัวชี้วัด เปาหมาย 2555 2556 2557 2558

ผูปวยไดรับยาปฏิชีวนะภายใน 1

ชั่งโมงหลงั วินิจฉัยSepsis≥ 80%

Septic Culture กอนใหยา

ปฏิชีวนะ≥ 80%

อัตราเสียชีวิตจาก Sepsis < 30%

อัตราการเกิดภาวะแทรกซอน < 50 %

Respiratory Failure

Acute Kidney Injury

Septic shock

อัตราการปฏิบัตติาม CPG ≥ 80%

เคร่ืองชี้วัด เปาหมาย 2555 2556 2557

อัตราท่ีผูปวยไดยาปฏิชีวนะภายใน 1 ชั่วโมงหลัง

วินิจฉัย Severe sepsis or septic shock≥80 %

อัตราผูปวยมีAdequate tissue perfusionภายใน 6 ชั่วโมง

≥80 %

อัตราการเสียชีวิตดวยภาวะ Sepsis ≤ 30%อัตราการเกิดภาวะแทรกซอน ≤ 50%

Septic shock

Respiratory failure

Acute kidney injury

ระยะวันนอนโรงพยาบาล

อัตราการปฏิบัติตาม CPG

Question ?

Thank you

copy (2) of sepsis present เซกา revised

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