![3-h and 6-h bundles
TO BE COMPLETED WITHIN 3 HOURS:
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid
resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume resuscitation
(septic shock) or initial lactate ≥ 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
7) Re-measure lactate if initial lactate was elevated.](https://image.slidesharecdn.com/whatisnewinsepsis-190205115338/85/What-is-new-in-sepsis-17-320.jpg)
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What is new in sepsis
- 1. What’s New in Sepsis Dr Kamal Bharathi. S Department of Pulmonary Medicine Sri Manakula Vinayagar Medical college and Hospital
- 6. SEPSIS • The clinical criteria for sepsis include suspected or documented infection and an acute increase of two or more Sequential Organ Failure Assessment (SOFA) points as a proxy for organ dysfunction. • This new definition emphasizes the primacy of the non-homeostatic host response to infection, the potential lethality that is considerably in excess of a straightforward infection, and the need for urgent recognition.
- 7. Sepsis vs Septic Shock
- 8. The Sequential Organ Failure Assessment (SOFA) Score • A clinical evaluation of the patient that includes laboratory values is needed to calculate a SOFA score. The SOFA score is most commonly used in the ICU practice setting. The following are the abnormal physiologic SOFA parameters, each of which receives a score of 2 or higher: • PaO2:FiO2, < 300 mmHg • Platelets < 100 × 103/mm3 • Bilirubin ≥ 2 mg/dL • Hypotension requiring vasopressor support • Glasgow Coma Scale score ≤ 12 • Creatinine ≥ 2 mg/dL, or urine output < 500 mL/day.
- 9. SOFA Score
- 10. The Quick Sequential Organ Failure Assessment (qSOFA) Score The following are the abnormal physiologic qSOFA parameters: • systolic blood pressure, ≤ 100 mmHg • respiratory rate, ≥ 22 breaths per minute • any change in mental status Non-ICU patients with a total score of 2 or 3 are considered at elevated risk for an extended ICU stay or death and should be assessed for evidence of organ dysfunction using the SOFA.
- 11. MEWS & NEWS
- 12. Logistic Organ Dysfunction Score
- 13. SIRS versus SOFA and qSOFA in Sepsis • Raith EP, Udy AA, Bailey M, McGloughlin S, MacIsaac C, Bellomo R, Pilcher DV. Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. Jama. 2017 Jan 17;317(3):290-300.
- 14. "Time zero” or “time of presentation” is defined as the time of triage in the emergency department or, if referred from another care location, from the earliest chart annotation consistent with all elements of sepsis (formerly severe sepsis) or septic shock ascertained through chart review."
- 15. Surviving Sepsis Campaign Bundle: 2018 Update HOUR-1 BUNDLE • The most important change in the revision of the SSC bundles is that the 3-h and 6-h bundles have been combined into a single “hour-1 bundle” with the explicit intention of beginning resuscitation and management immediately.
- 16. HOUR-1 BUNDLE • Measure lactate level. Re-measure if initial lactate is >2 mmol/L. • Obtain blood cultures prior to administration of antibiotics. • Administer broad-spectrum antibiotics. • Begin rapid administration of 30m1/kg crystalloid for hypotension or lactate > 4 mmol/L. • Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP 65 mm Hg.
- 17. 3-h and 6-h bundles TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥ 4 mmol/L (36 mg/dL): - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2) 7) Re-measure lactate if initial lactate was elevated.
- 18. Measure Lactate Level • Increases may represent tissue hypoxia, accelerated aerobic glycolysis driven by excess beta-adrenergic stimulation, or other causes associated with worse outcomes. • A significant reduction in mortality with lactate guided resuscitation (24−28). • If initial lactate is elevated (> 2mmol/L), it should be remeasured within 2−4 h to guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion.
- 19. Blood Cultures • Sterilization of cultures can occur within minutes of the first dose of an appropriate antimicrobial, so cultures must be obtained before antibiotic administration to optimize the identification of pathogens and improve outcomes. • Appropriate blood cultures include at least two sets (aerobic and anaerobic). • 1 -percutaneously 1 -drawn through each vascular access device
- 22. Antimicrobial Therapy • Administration of effective IV antimicrobials within the 1st hour of recognition. a) Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens & that penetrate in adequate concentrations into tissues. b) Empiric combination therapy should not be administered for more than 3–5 days c) Antimicrobial regimen should be reassessed daily for potential de-escalation.
- 23. Procalcitonin • Rises with bacterial infections (not viral!!!) • Precursor to calcitonin (responsible for calcium homeostasis) • Normal level is < 10 pg/ml (< 0.5 ng/ml) • 0.5 – 2 ng/ml “grey zone” (repeat level in 6 – 24 hrs) • > 10 ng/ml associated with severe sepsis/shock • Half life of 25 – 30 hours • Discontinue/ taper antibiotics • 2 meta-analysis CAP • 6 days antibiotics (treatment group) vs 10 days (control) We suggest that measurement of procalcitonin levels can be used to support shortening the duration of antimicrobial therapy
- 24. Combination empirical therapy • Beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia. • Beta-lactam and macrolide for bacteremic Streptococcus pneumoniae infections.
- 25. Fluid Therapy • Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock. • Albumin - when patients require substantial amounts of crystalloids. • Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a portion of this may be albumin equivalent). • Continued as long as there is hemodynamic improvement either based on dynamic (eg, change in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart rate) variables.
- 26. Vasopressors • Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65 mm Hg. • Norepinephrine as the first choice vasopressor. • Epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure. • Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage. • Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia)
- 27. Inotropic Therapy • A trial of dobutamine infusion up to 20 micrograms/kg/min be administered or added to vasopressor (if in use) in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP.
- 28. Supportive Therapy of Severe Sepsis
- 29. Mechanical Ventilation of Sepsis- Induced ARDS • Target a tidal volume of 6 mL/kg predicted body weight in patients with sepsis-induced ARDS. • Initial upper limit goal for plateau pressures in a passively inflated lung be ≤30 cm H2O. • PEEP be applied to avoid alveolar collapse at end expiration.
- 30. Blood Product Administration • Hemoglobin concentration decreases to <7.0 g/dL to target a hemoglobin concentration of 7.0 –9.0 g/dL in adults. • Prophylactic platelet transfusion when counts are < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding.
- 31. Sedation, Analgesia, and Neuromuscular Blockade • Continuous or intermittent sedation be minimized in mechanically ventilated sepsis patients, targeting specific titration endpoints. • A short course of NMBA of not greater than 48 hours for patients with early sepsis-induced ARDS and a Pao2/Fio2 < 150 mm Hg
- 32. • Glucose Control: Target an upper blood glucose ≤180 mg/dL rather than an upper target blood glucose ≤ 110 mg/dL. • Renal Replacement Therapy (RRT): Continuous RRT and intermittent hemodialysis are equivalent in patients with severe sepsis and acute renal failure. • Bicarbonate Therapy: in hypoperfusion- induced lactic acidemia with pH ≥7.15
- 33. • Deep Vein Thrombosis Prophylaxis: daily subcutaneous (LMWH) against venous thromboembolism (VTE). • Stress Ulcer Prophylaxis: using H2 blocker or proton pump inhibitor. • Prone position for sepsis-induced ARDS with PaO2/FiO2 ratio <150. • Elevate head of bed 30–45 degrees in mechanically ventilated patients, spontaneous breathing trials, and a weaning protocol. • Early enteral nutrition, against parenteral nutrition in the first 7 d
- 34. SSC recommends AGAINST • Low dose Dopamine for renal protection • Steroids (Only if on vasopressors – hydrocortisone 200mg/day) • Erythropoietin for sepsis related anemia • IV Immunoglobulins for sepsis or septic shock • High frequency oscillatory ventilation (HFOV) for sepsis induced ARDS • ß2 agonists for sepsis-induced ARDS without bronchospasm • PA Catheter for patients with sepsis-induced ARDS
- 35. • Sodium bicarb therapy to improve hemodynamics or to reduce vasopressor requirements • Stress ulcer prophylaxis in patients without risk factors for GI bleeding! • Parenteral nutrition alone or in combination with enteral feedings • Monitoring gastric residual volumes (only in feeding intolerance or high risk aspiration) • IV selenium, glutamine or arginine
- 36. Thank you…!!!