Severe Sepsis

11

Transcript of Severe Sepsis

Page 1: Severe Sepsis
Page 2: Severe Sepsis

21,000 cases per year

27% of ITU admissions

46% of bed days

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Potentially 4-5 cases per month from MAU

More in CDU About 60-70

severe sepsis cases per year

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Several interventions are implemented together and result in a better outcome then when implemented individually

Every intervention in the bundle is based on irrefutable evidence and all elements in the bundle must be executed in the same place and time to ensure that clinical improvement occurs

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New infection and any two: Fever > 38.3 C Hypothermia < 36 C Chills and rigors Tachycardia > 90 bpm Tachypnoea > 20 bpm Systolic BP < 90 mmHg Headache or stiff neck WBC > 12,000 or < 4,000 Raised CRP

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Acutely altered mental status Systolic BP < 90 mmHg SpO2 < 90% on room air Rising creatinine or > 176

μmol/L or urine output < 0.5 ml/kg/hr for > 2 hours

Rising bilirubin or > 34 μmol/L INR > 1.5 or PTT > 60 sec Platelets < 100,000 Lactate > 2 mmol/L

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To be accomplished as soon as possible and scored over the next 6 hours:

Measure serum lactate Take blood cultures before administering antibiotics Give broad spectrum antibiotics (<1 hour for ITU

admissions, <3 hours for MAU admissions) If hypotensive and/or lactate > 4 mmol/L: IV

crystalloid at 20ml/kg and if MAP does not increase to >64 mmHg start vasopressors

If hypotension persists and/or lactate > 4 mmol/L: IV fluids to achieve CVP > 7 mmHg and ScvO2 > 70%

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Blood cultures IV broad spectrum antibiotics within 1 hour of diagnosis Involve consultant and ITU Start IV fluids Catherterise bladder Insert a central line and monitor CVP Monitor response with lactate and BP Monitor central venous oxygen saturation Monitor glucose control Monitor urine output (>= 0.5 ml/kg/hr) Prophylactic LMWH and H2 antagonists ITU for vasopressors, inotropes and low dose steroids Address source of infection ALL TO BE COMPLETED WITHIN 2 HOURS OF ARRIVAL

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To be accomplished as soon as possible and scored over the next 24 hours:

Low dose steroids Drotecogin alfa Maintain glucose control For ventilated patients maintain

inspiratory plateau pressures < 30 mmH2O

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Lactate measurement is integral to the Sepsis Bundle

Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance

Lactate is a better prognostic measure than cytokines

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16% reduction in mortality: In-hospital mortality was

30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009)