SEPSIS
SEPSISGeneral Variables27/4/13Fever ( >38,30C) or Hypothermia
( 90x/min or more than 2 SD above the normal value of age130
x/minTachypnea28 x/minAltered mental statusAnxiousSignificant edema
or positive fluid balance ( 20 ml/kgBW/24 hr)Hyperglycemia (plasma
glucose >140 mg) in the absence of diabetesDiagnosis Criteria of
SepsisInflammatory Variables27/4/13Leukocytosis ( > 12000) or
Leukopenia ( 10% immature forms-Plasma CRP > 2 SD above the
normal value-Plasma PCT > 2 SD above the normal
value-Inflammatory Variables27/4/13Hypotension (SBP < 90 mmHg,
MAP < 70 mmHg, or an SBP > 40 mmHg or less than 2 SD below
normal for age-Organ Dysfunction Variables27/4/13Arterial hypoxemia
(PaO2/FiO2 < 300)Acute oliguria (urine output < 0,5 ml/kg/hr
for at least 2 hours despite adequate fluid
rescucitation)0Creatinine increase > 0,5 mg/dl 3.3Coagulation
abnormalities (INR > 1,5 or aPTT > 60s)-Ileus (absent bowel
sounds)-Thrombocytopenia (platelet count <
100000)Hyperbilirubinemia (plasma total bilirubin > 4
mg/dL)Diagnosis Criteria of SepsisTissue Perfusion
Variables27/4/13Hyperlactatemia ( > 1 mmol/L)12.7Decreased
capillary refill-
State of patientWe concluded that this pts was also suffering of
severe preeclampsiaThe sepsis was due to intrauterine infection
proved by physical examination: foul odor baby and amniotic
fluidThe sepsis process was comorbid by the PE also the long period
of hypoxia bad condition and irreversible
APACHE II SCORE
MANAGEMENT OF SEVERE SEPSIS
Sepsis Guidelines 2008EARLY GOAL-DIRECTED THERAPYSupplemental
oxygen +/-Endotracheal intubation andMechanical ventilationCentral
venous and Arterial catheterizationSedation,paralysis(if
intubated)Or bothCVPMAPScvO2Goalsachievedcrystalloidcolloid8-12
mmHgvasoactive agents>65 and>90mmHg70%300 mg daily should NOT
be used in septic shock or severe sepsis for the purpose of
treating shock In the absence of shock, corticosteroids should not
be used for treatment of sepsisSTEROIDS
Blood Product AdministrationGive RBC when Hb < 7.0 g/dl to
target HB 7.09.0 g/dl in adults.
Administer platelets when: platelet counts are < 5,000/mm3
regardless of bleeding. platelet counts are 5000 to 30,000/mm3 and
there is significant bleeding risk. platelet counts 50,000/mm3 are
required for surgery or invasive procedures.
Glucose Control Use IV insulin to control hyperglycemia in
severe sepsisKeep blood glucose < 150 mg/dl
Best results obtained when blood glucose was maintained between
80 and 110 mg/dL
Minimize the risk of hypoglycemia by providing a continuous
supply of glucose substrate (D5/D10) followed by initiation for
enteral feeding
Mortality During Intensive CareIn-Hospital MortalityMortality
(%)p = 0.01p < 0.04 (adjusted)n=783n=765ConventionalIntensive
Insulinn=783n=765van den Berghe G. N Engl J Med
2001;345:1359-1367.Glucose Control Intensive Insulin
25 P values were determined with the use of the chi-square test.
For the primary outcome variable (death during intensive care), the
P value has been corrected for the repeated interim analyses,
according to the method of Lan and DeMets; the unadjusted P value
is 0.005. Sequential interim analyses were not performed for the
other variables, and nominal (unadjusted) P values are given for
these comparisons. p. 1362Continuous hemofiltration offers easier
management of fluid balance in hemodynamically unstable septic
patients Renal Replacement Continuous venovenous hemofiltration and
intermittent hemodialysis are considered equivalent in acute renal
failure (in the absence of hemodynamic instability)
26There is no current evidence to support the use of continuous
venovenous hemofiltration for the treatment of sepsis independent
of renal replacement needs. p. 865H2 receptor blockers are more
efficacious than sucralfate and are the preferred agents Proton
pump inhibitors compared to H2 blockers have not been assessed
Stress Ulcer ProphylaxisStress ulcer prophylaxis should be given
to all patients with severe sepsis
27Proton pump inhibitors and H2 blockers equivalently lower
gastric pH.Other conditions that benefit from stress ulcer
prophylaxis that are also present in severe sepsis are
coagulopathy, mechanical ventilation, hypotension. Use a mechanical
prophylactic device or intermittent compression in patients with
contraindications to heparin Use a combination of pharmacological
and mechanical therapy in very high risk patients (eg, severe
sepsis and history of DVT)Deep Vein Thrombosis (DVT) Prophylaxis
DVT prophylaxis with either low-dose unfractionated heparin or low
molecular weight heparin should be used in severe sepsis
patients
28Examples of heparin contraindications: thrombocytopenia,
severe coagulopathy, active bleeding, and recent intracerebral
hemorrhage.Mehanical prophylactic device examples: graduated
compression stockings and intermittent compression
devices.Contraindication for use of mechanical prophylactic device
includes the presence of peripheral vascular disease.There are no
studies performed specifically in patients with severe sepsis;
however, large trials confirm the benefit of DVT prophylaxis in
general ICU populations that included significant numbers of septic
patients.
