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severe sepsis
septic shock
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
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)
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)
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
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
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
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
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severe sepsis and septic shock. Crit Care Med 2004 ;32: 859-872.
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