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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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