Surviving Sepsis Campaign

1
Surviving Sepsis Campaign
2

• SIRS
• systemic inflammatory response syndrome
• CARS
• counter anti-inflammatory response syndrome
• MARS
• Mixed inflammatory-antiinflammatory response
  syndrome

3
Mechanism of severe sepsis

• Direct indirect endotoxin damage
• Pro-inflammatory cytokine
• Diffuse endovascular injury
• Pro-coagulation
• Anti-inflammatory response
• Immunosuppression (immunoparalysis)
• Extremely low conc. of proinflammatory cytokines
  (further inhibition of inflammation ? ?)
• A complex profile (proinflammation vs
  anti-inflammation)

4
Treatment of severe sepsis

• Early goal-directed resuscitation
• (SvO2 gt 70, lact ?)
• Early and appropriate antibiotics
• Tight control of blood sugar (lt110 mg/dL)
• Corticosteroid for refractory septic shock

5

• Hand washing
• Aseptic technique during CVP insertion
• Avoidance of excessive sedation
• Selective decontamination of GI tract
• Treatment of underlying diseases

6
Initial Resuscitation

• Goal
• MABP gt 65 mmHg
• SvO2 gt 70
• U/O gt 0.5 mL/kg/hr
• By
• CVP 8 12 mmHg
• Hct gt 30
• Dobutamine infusion ( 20mcg/kg/min)

As soon as possible
7
Fluid Therapy

• Crystalloid 500 1000 mL
• Colloid 300500 mL
• The same effect
• Repeat if
• BP, U/O not responsive
• CVP lt 8 mmHg

8
Antibiotics

• Begin IV antibiotics immediately
• Step-down policy (broad spectrum initially)
• 48-72 hr later ? reassess narrow down
  antibiotics spectrum
• Stop antibiotics if not a infectious cause

Source control find treat
9
inotropes

• If hypotension not response to fluid challenge
• ? Dopamine or norepinephrine infusion
• Pitressin infusion (0.01 0.04 U/min)
• MABP gt 65 mmHg
• Dobutamine infusion for low cardiac output

Low dose dopamine for renal protection (X)
10
Steroids

• Indication septic shock
• Hydrocortisone 50 mg q6h x 7 days
• (or 200 300 mg/day infusion)
• Fludrocortisone 50 mcg PO qd
• ACTH test
• 250 mcg ? cortisol increase less than 9 mcg/dL
• Taper steroid if septic shock resolves

But if no septic shock, do not use steroid
11
rhAPC(recombinant human activated protein C)

• Indication
• APACHE ? 25
• Septic shock
• Sepsis with organ failure
• Risk bleeding tendency
• Dose 24 mcg/kg/hr x 4 days

12
Anti-coagulation

• AT III (anti-thrombin III)
• TFPI (tissue factor pathway inhibitor)
• aPC (activated protein C)
• APACHE gt 25
• Coagulation disorder
• Cost effective?
• Low dose heparin ?

13
Blood Transfusion

• RBC transfusion if Hb lt 7 g/dL
• except heart, lung, brain problems
• No FFP even PT, PTT abnormal
• unless bleeding or planned procedure
• Platelet
• lt 5000/mm3 ? transfuse
• 500030,000/mm3 bleeding risk ? transfuse
• keep gt 50,000/mm3 for surgery or invasive
  procedure

14
Lung protection ventilator strategy

• Plateau pressure lt 30 cmH2O
• PEEP to prevent lung collapse
• FiO2
• Sedation
• Intermittent IV bolus
• Continuous infusion with daily interruption
• Avoid neuromuscular blocker if possible

15

• Sugar 80 110 mg/dL
• Bicarbonate if pH lt 7.15
• H2 blocker
• Palliative critical care