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8/6/2019 Treatment of Severe Sepsis and Septic Shock
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` Septic pt must be treated with emperical
antimicrobials with proper maintenance of
hemodynamics and respiratory status
` All severe sepsis and septic patients must be
treated in ICU.
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` 1.Eradicate infections
` 2.Reverse Shock
` 3.Provide support to other organ system
` 4.Provide nutritional support` 5.Neutralize toxic mediators,cytokines in
sepsis(still in the research phase)
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` Needs to tackle urgently as soon as clinical dx of
setic shock is made or even suspected
` Promptly send blood,urine,and any other cultures
that may be relevant-eg..from discharging wounds,loculated fluids and abscesses.
` Empiric antibiotics(Broad-spectrum )should
promptly started without awaiting results of
cultures and other inv.` Monotherapy as per c/s repots
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` Drainage of focal source of infection
` Replace foleys and drainage catheter
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` Immunocompromised & neutopenic adult with sepsis
` 1. ceftriaxone (2gm/day)/
` ticarcilllin- clavulinate (3.1gm 4-6hrly)/
` piparcillin- tazobactam (3.375 gm 8 hrly)` 2. imipenem cilastatin (500mg 6hrly)/
` meropenem (1gm 8 hrly)/
` cefepime (2gm 12 hrly)
PLUSgentamycin or tobramycin(5-7 mg/kg/day)
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Add vancomycin (15mg/kg 12 hrly) if :
o Fever not subside after 36-48 hrs
o infected vascular catheter
o MRSA suspectedo received intensive chemotherapy that
produces mucosal damage
Add AMPHOTERICIN B(if fever do not
subsides after 2-3d with above regime)
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` Cefotaxime (2gm 8 hrly)/
` Ceftriaxone ( 2gm 12 hrly)
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` (A)Use of antibiotics
` (B)Identification and direct treatment of source of
infection
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` Nafcillin/ oxacillin (2gm 8 hrly)
+Gentamycin ( 5-7mg / kg /day)
+/-
Vancomycin (15mg/kg )
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` Cefepime ( 2gm 8hrly)/
` Ticarcillin- Clavulinate (3.1gm 4 hrly)/
` Piparcillin- Tazobactam (3.375gm 8 hrly)
+` Tobramycin (5-7mg/kg/day)
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` NOTE- IF PATIENT ALLERGIC TO BETA
LACTAM AGENTS
` CIPROFLOXACIN
` LEVOFLOXACIN` +
` CLINDAMYCIN
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IF PREVALANCE OF MRSA
` VANCOMYCIN
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a) Restore and maintain altered haemodynamic
profile to as close to normal with efficient cardiac
support
b) Ensure adequate oxygen supply to meet tissue
needs (increase O2 transport)
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` Secure airway if respirations ineffective or patient unable to protect
his airway.
Patients with hypotension not responding promptly to acute
volume expansion should also be intubated to prevent respiratory
arrest.
Supplemental O2
` Fluid resuscitation- follow BP, respiration, pulse, UOP, mental status,
and CVP to assess response.
` If circulatory status fails to improve after 2-3 L or signs of fluid
overload develop consider vasoactive agents.
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` starting initially with dopamine in low doses (2-5mcg/kg/min) as this will not only improve perfusionpressure but may help preserve renal function.
` The dose can then be titrated upward or NE addedto achieve and maintain a MAP of at least 60 mmHg.
` Blood cultures and initial laboratory values which
assess end organ function should be sent off- CBC,PT/PTT, UA.
` This initial resuscitation should ideally beaccomplished within 1 hour.
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` Targeted goal to maintain perfusion
-PCWP(12-16mm Hg)
-CVP(8-12 cm H2o)
-MAP (>65 mm Hg)-Cardiac Index (>4L/M2)
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` No improvement in perfusion even with iv fluids
and vessopressors
` Think of ADRENAL INSUFFICIENCY
` Treat with hydrocortisone (50mg 6hrly)
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` INDICATIONS:
-progressive hypoxemia
-hypercapnea
-neurological deterioration-Respiratory muscle fatigue
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` Correct metabolic acidosis with Bicarbonate
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` Respiratory support
` Renal support
` Cardiac support
` G.I support
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` Nutritional support
` Prophylactic heparinization
` Manage hypo and hyperglycemia
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` Rec. activated protein C
Dose:24mcg/kg/hr ---96 hrs
Monitor clotting parameter:
-avoid in pt with PC
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` Endotoxin-neutralizing proteins
` Inhibition of cyclo-oxygenase and No synthetase
` Anticoagulants
` Polyclonal immunoglobulins` Glucocorticoids
` Antagonist to TNFa,IL-1,PAF,Bradykinin
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` 30% pt with severe sepsis and 40% to 70% with
septic shock has 30 days mortality.
` Prevention of septic shock is more important in
decreasing morbidity and mortality.
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` WITH EARLY DIAGNOSIS AND AGGRESSIVE
TREATMENT WITH ANTIBIOTICS AND
MAINTAINING PROPER PERFUSION ALONG
WITH CLOS
E MONITORING
MORTALITY DUETO SEPSISAND SEPTIC SHOCK CAN BE
REDUCED.
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` HARRISONS 17TH EDITION
` TEXT BOOK OF CRITICAL CARE
` NEMJ
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