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Terms in this set (18)
Systemic Inflammatory Response Syndrome
Temperature: <36 °C (96.8 °F) or >38 °C (100.4 °F)
Heart rate: >90 beats/min
Respiratory rate: >20/min or PaCO2<32 mmHg (4.3 kPa)
WBC: <4x109/L (<4000/mm³), >12x109/L (>12,000/mm³), or 10% bands
Sepsis is defined as the presence (probable or documented) of
infection together with systemic manifestations of infection.
≥ 2 SIRS criteria with known or suspected infection
Severe sepsis is defined as sepsis plus sepsis-induced organ
dysfunction or tissue hypoperfusion.
-Lactate above upper limits laboratory normal
-Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
-Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
-Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
-Creatinine > 2.0 mg/dL (176.8 μmol/L)
-Bilirubin > 2 mg/dL (34.2 μmol/L)
-Platelet count < 100,000 μL
-Coagulopathy (international normalized ratio > 1.5)
Sepsis-induced hypotension is defined
as a systolic blood pressure (SBP) < 90 mm Hg or mean arterial pressure (MAP) < 70 mmHg or a SBP decrease > 40mmHg or less than two standard deviations below normal for age in the absence of other causes.
Sepsis Diagnostic: General Variables:
-Fever (> 38.3°C) or Hypothermia (core temperature < 36°C)
Heart rate > 90/min-1 or more than two sd above the normal value for age
-Altered mental status
-Significant edema or positive fluid balance(>20mL/kg/24hr)
-Hyperglycemia (glucose>140mg/dL or 7.7mmol/L) in the absence of diabetes
Sepsis Diagnostic: Inflammatory Variables
-Leukocytosis: WBC>12,000uL OR Leukopenia: WBC<4000uL
-Normal WBC count with > 10% immature forms (bands)
-Plasma C-reactive protein more than 2 times normal value
-Plasma procalcitonin more than 2 times normal value
Sepsis Diagnostic: Hemodynamic Variables
Arterial hypotension: (SBP<90mmHg, MAP<70mmHg, or SBP decrease>40mmHg)
Sepsis Diagnostic: Organ dysfunction variables
-Arterial hypoxemia: Pao/FiO2 < 300
-Acute oliguria: urine output < 0.5ml/dL for at least 2 hours despite fluid resuscitation.
-Creatinine increase > 0.5mg/dl or 44.2 umol/L
-Coagulation abnormalities: INR>1.5 or aPTT>60s
-Ileus: absent bowel sounds
-Thrombocytopenia: Platelets < 100,000uL
-Hyperbilrubinemia: >4mg/dL or 70umol/L
Sepsis Diagnostic: Tissue perfusion variables:
-Decreased capillary refill or mottling (discolored patches on the skin of humans as a result of cutaneous ischemia)
Initial Resuscitation Goals
-CVP 8-12mm Hg (__ if mechanically ventilated)
-MAP _> 65__ mm Hg.
-UOP __>0.5_ mL/kg/hr
-ScVO2 ( Central venous oxygen saturation)>70%
or SVO2 >65% (superior vena oxygen saturation (ScvO2))
What does CVP tell us? Why is there a different goal if the patient is ventilated?
right atrial pressure; RAP- describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system.It is a good approximation of right atrial pressure, which is a major determinant of right ventricular end diastolic volume. CVP has been, and often still is, used as a surrogate for preload.
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) greater than or equal to 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)*>8 mm Hg
- Measure central venous oxygen saturation (ScvO2>70mmHg)
7) Remeasure lactate if initial lactate was elevated*
Fluid Therapy of Severe Sepsis
1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock.
2. Don't use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock.
3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids.
4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30mL/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid may be needed in some patients.
5. Fluid challenge technique be applied wherein fluid administration is 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 (UG).
1. Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65 mm Hg (grade 1C).
2. Norepinephrine as the first choice vasopressor (grade 1B).
3. Epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure (grade 2B).
4. Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage (UG).
5. Low dose vasopressin is not recommended as the single initial vasopressor for treatment of sepsis-induced hypotension and vasopressin doses higher than 0.03-0.04 units/minute should be reserved for salvage therapy (failure to achieve adequate MAP with other vasopressor agents) (UG).
6. 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) (grade 2C).
7. Phenylephrine is not recommended in the treatment of septic shock except in circumstances where (a) norepinephrine is
associated with serious arrhythmias, (b) cardiac output is known to be high and blood pressure persistently low or (c) as salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target (grade 1C).
8. Low-dose dopamine should not be used for renal protection.
9. All patients requiring vasopressors have an arterial catheter placed as soon as practical if resources are available (UG).
1. 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 (grade 1C).
2. Don't a strategy to increase cardiac index to predetermined supranormal levels (grade 1B).
1. Not using intravenous hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor
therapy are able to restore hemodynamic stability (see goals for Initial Resuscitation). In case this is not achievable, we suggest
intravenous hydrocortisone alone at a dose of 200 mg per day.
2. Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone (grade 2B).
3. In treated patients hydrocortisone tapered when vasopressors are no longer required (grade 2D).
4. Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grade 1D).
5. When hydrocortisone is given, use continuous flow (grade 2D).
The ACTH test (also called the cosyntropin test, tetracosactide test or Synacthen test) is a medical test usually ordered and interpreted by endocrinologists to assess the functioning of the adrenal glands stress response by measuring the adrenal response to adrenocorticotropic hormone (ACTH). ACTH is a hormone produced in the anterior pituitary gland that stimulates the adrenal glands to release cortisol, Dehydroepiandrosterone (DHEAS) and aldosterone.
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