Stop Sepsis

邱振峰 醫師

What is Sepsis ?

Sepsis 是什麼 ? 如何處理 Sepsis ?

該做什麼 ? ( 項目 ? 優先順序 ?)

監測什麼 ?

有没有漏掉什麼 ? 救回可救回的病人

回答下列問題 ?

Sepsis 是什麼 ? 那些病人有 sepsis ? 何時啓動 Sepsis bundle ? 輸液什麼時候給 ? 給多少 ? 給多快 ? 什麼

停 ( 減 ) ? 抗生素什麼時候給 ? 用那類 ? 合併那類 ? 升壓劑什麼時候給 ? 用那類 ?

SIRS (Systemic Inflammatory Response Syndrome)

Temp < 36 ° C or > 38.3 ° C HR > 90 RR > 20 or PCO2 < 32 WBC < 4K or > 12K or bands > 10%      以上符合兩項 ( 含 ) 以上

Sepsis 敗血症的定義

     SIRS +Infection

Septic Shock 敗血性休克  Hypotension that does NOT respond to fluid (500 cc bolus)

Severe Sepsis 嚴重敗血症 Sepsis + Organ Dysfunction Elevated Creatinine (>2) Elevated INR (DIC) Altered Mental Status (GCS <12) Elevated Lactate (>4 mmol/L)Hypotension that responds to fluid

敗血症 EGDT 流程啟動時機 SIRS：符合兩項以上 疑似感染或有陽性培養 經靜脈罐注後 SBP ＜ 90mmHg 或MAP < 65mmHg或 lactate   36 mg/dl≧ 或一種以上器官急性機能失調

STOP Bundle Strategies 執行目標 2小時內啟用血流動力監測 (CVP/ScvO2) 1小時內投予廣效抗生素 EGDT流程啟動６小時內達成下列目標：CVP   8 mmHg, MAP  65 mmHg, ≧ ≧ScvO2 70%≧

監測乳酸是否下降；如使用升壓劑，考慮使用 steroid

Fluid Therapy of Severe Sepsis

1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).

2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B).

3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C).

4. Initial fluid challenge : > 30 mL/kg of crystalloids (a portion of this may be albumin equivalent). (grade 1C).

5. Fluid challenge technique is continued as long as there is hemodynamic improvement ( dynamic, eg, change in pulse pressure, stroke volume variation, or static, eg, arterial pressure, heart rate) .

Fluid Therapy of Severe Sepsis

Vasopressors

1. Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65 mm Hg (grade 1C).

2. Norepinephrine as the first choice vasopressor (grade 1B).

3. Epinephrine (added to and potentially substituted for norepinephrine) when an addition-al agent is needed to maintain adequate blood pressure (grade 2B).

Vasopressors

4. Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage.

5. Low dose vasopressin is not recommended as the single initial vasopressor for treatment of sepsis-induced hypotension and vaso-pressin doses higher than 0.03-0.04 units/minute should be reserved for salvage therapy (failure to achieve adequate MAP with other vasopressor agents)

6. Dopamine, only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (grade 2C).

7. Low-dose dopamine should not be used for renal protection (grade 1A).

Vasopressors

Thank for your attention !