Sepsis MD - MD SEMINAR Management of severe sepsis...

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1 MD SEMINAR Management of severe sepsis Dr.Partha Introduction z Incidence : 240/100000 (USA) z Leading cause of death in non cardiac ICU z Mortality : 20-50% z Average expenditure per patient : 22000 $ z Total annual cost :17 billion $ (USA) z SURVIVING SEPSIS CAMPAIGN (2002) launched through Barcelona declaration z Aim: To reduce mortality due to sepsis by 25% by 2009
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2 Definitions Organism SIRS : 2 of the following Temp. > 38ºC or < 36ºC Pulse rate > 90 bpm < 32 mmHg WBC > 12000/cumm or < 4000/cumm Or > 10% immature band forms Sepsis with 1 organ dysfunction Cardiovascular : SBP 90 mmHg or MAP 70 mmHg Renal : UO< 0.5 mL/kg/hr Respiratory : PaO 2 / FiO 2 250 or if lung is the only dysfunctional organ 200 Hematologic : Plt count < 80000/ μ Lor 50% over 3 days Unexplained metabolic acidosis : pH 7.30 or base deficit 5 Sepsis with hypotension (SBP<90 mmHgor Map < 65 mmHg or 40 mmHg less than baseline BP) for at least 1 hour despite adequate fluid resuscitation Diagnosis ¾ History Epidemiological risk factors Patient risk factors – Immune status Prosthetic devices Occupation Dietary proclivities Addictions H/o fever (absent in extremes of age, MI, shock, immunocompromised state) Focal symptoms of infection H/o complications H/o medication
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3 Diagnosis ¾ Examination z Vital signs z Temperature( oral/rectal) z Physical examination z Focal findings of infection Diagnosis ¾ Investigations Leukocytosis, neutrophilia, bandemia, leukopenia, neutropenia Dohle bodies, toxic granulations, vacuoles Haemoconcentration Thrombocytopenia DIC w/u Hyperlactatemia Biological markers (CRP, IL-6, procalcitonin,protein C) Cultures Organ dysfunction parameters
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4 Diagnosis Early goal directed therapy Goals (6 hrs) CVP : 8-12 mmHg MAP 65 mmHg UO 0.5 ml/Kg/hr ScvO 2 70% Rivers et al.NEJM 2001
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5 Resuscitation bundle-EGDT ¾ Fluid therapy z Targets- CVP: 8-12 mmHg; PAOP: 12-15mmHg z Isotonic crystalloids or iso-oncotic colloids equally effective when titrated to the same hemodynamic end points SAFE TRIAL, NEJM 2004 z Crystalloids: 0.9%NaCl, Ringers lactate z Colloids : 5% albumin, 6% HES solution z Crystalloids: 2-4 times more volume required and longer time to achieve goals but cheaper Resuscitation bundle-EGDT ¾ Complications of fluid therapy z Pulmonary edema: Colloids mitigate fluid efflux at higher filling pressures z Systemic edema z HES : Tubular injury, bleeding ¾ Resuscitation end points z Clinical : BP, HR ,UO,skin perfusion, mental status z Indices of tissue perfusion : Blood lactate, ScvO 2
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6 Resuscitation bundle-EGDT z Vasopressor therapy z Patients should be adequately fluid resuscitated z Dopamine and norepinephrine equally effective z
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Sepsis MD - MD SEMINAR Management of severe sepsis...

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