SEPSIS MANAGEMENT

....................................................................................................... STAGES AND MANAGEMENT OF SEPSIS ....................................................................................................... :: SIRS :: Diagnostic criteria : Presence of any two.... 1. Temp. :- < 36 °C (96.8 °F) or > 38 °C (100.4 °F) 2. HR :- > 90/min. 3. Respiratory :- RR > 20/min. OR PaCO2 < 32 mm of Hg (4.3 kPa) 4. WBC :- < 4000/mm³ or > 12000/mm³ or 10% bands Marker : CRP raised but procalcitonin (PCT) not raised in absence of infection. Management : "SIRS in absence of infection" to be manged as other non infective systemic inflammatory conditions. ....................................................................................................... :: SEPSIS :: Diagnostic criteria : SIRS (at least 2 signs) + Infection (presumptive or diagnosed). Infection marker : CRP and procalcitonin (PCT) both are raised significantly in bacterial infections. But in fungal infection PCT raised little though CRP raised significantly. In sepsis CRP is usually above 100 and PCT above 2 indicate severe sepsis with possibility of organ dysfunction. PCT is a costly test. Management : "In absence of End Organ Dysfunction" treated as other non sepsis infection cases. But try to find out the infection source and put on appropriate treatment within 12 hrs of presentation otherwise may progress to advance sepsis. ....................................................................................................... :: SEVERE SEPSIS :: Diagnostic criteria : Sepsis + End Organ Dysfunction. End Organ Dysfunction : Known by SOFA or qSOFA Scoring. 1. qSOFA Scoring (Done where no better lab facilities available) :- Presence of any two indicate EOD. -SBP < 100 mm of Hg -RR > 22 beats/min. -Altered mentation (GCS < 15) 2. SOFA Scoring (Done in ICU having good lab facilities. Sensitive than qSOFA) :- Score 2 or more (Presence of any of these) indicate EOD. -GCS 12 or less (Not rousable by voice. Atleast pain is needed to rouse.) -PaO2/FiO2 < 300 mmHg (Arterial hypoxaemia). -SBP < 90 mmHg or MAP < 65 mmHg or Fall in SBP > 40 mmHg from baseline or Vasopressor required -Bilirubin 2.0 or high -Platelets < 100 × 10³ / mm³ OR INR > 1.5 OR aPTT > 60 -Creatinine 2.0 mg /dl or high. -Lactate > 2.0 mmol/L :: SEPTIC SHOCK :: Criteria for diagnosis :- Severe sepsis + Persistent hypotension even after initial crystalloid administration @ 30 ml/kg (SBP < 90 or MAP < 65 or SBP fall more than 40 from baseline) OR Tissue hypoperfusion evidenced by Lactate level 4.0 mmol/L or high. MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK : (a) 3-HOUR SEPSIS BUNDLE OF MANAGEMENT (within 3 hours of presentation)...... 1. Measure serum Lactate 2. Blood drawn for culture prior to antibiotics. 3. Broad spectrum or other antibiotics administered. 4. Administration of Crystalloid fluid bolus @ 30 ml/Kg within 3-Hour of presentation of septic shock. (b) 6-HOUR SEPSIS BUNDLE OF MANAGEMENT (within 6 hours of presentation)...... 1. Repeat Lactate level measurement ONLY IF initial Lactate level elevated is > 2.0 mmol/L. 2. Apply Vasopressor if hypotension persists even after initial crystalloid administration. 3. If hypotension persists OR initial Lactate 4.0 mmol/L or high Repeat volume status and Tissue perfusion assessment. Assessment consists of .... EITHER, A focused exam on -Vital signs -Cardiopulmonary exam -Capillary refill evaluation -Peripheral pulse evaluation -Skin exam OR, Any two of the following four -Central Venous Pressure measurement (achieve > 8 mmHg) -Central Venous Oxygen saturation (achieve > 65%) -Bedside cardiovascular ultrasound -Passive leg raise by physician or fluid challenge given (5000 - 1000 ml Crystalloids over 30 minutes or 300 - 500 ml Colloids over 30 minutes. Repeat based on response. Most patient requires aggressive fluid resuscitation during the first 24 hrs). (c) 12-HOUR SEPSIS BUNDLE OF MANAGEMENT (within 12 hours of presentation)......Pin point infection source and put on proper treatment to prevent MODS and DEATH. (d) 24-HOUR SEPSIS BUNDLE OF MANAGEMENT (within 24 hours of presentation)...... 1. Vitamin C 1.5 gm IV every 6hrs, Hydrocortisone 50 mg IV every 6 hrs, Thiamine 200 mg IV every 12 hrs. (Exclusions - Age < 18 Yrs, Pregnancy, PCT < 2 ng/ml). 2. APC if indicated. 3. Tight glycemic control. 4. Maintain plateau pressure < 30 ....................................................................................................... :: ANTIBIOTICS AND VASSOPRESSORS USED IN SEPSIS :: CMS APPROVED MONOTHERAPY ANTIBIOTICS : Moxifloxacin, Ertapenem, Meropenem, Imipenem/Cilastatin, Cefepime, Ceftriaxone, Ceftaroline fosamil, Ampicillin/Sulbactum, Piperacillin/Tazobactum. ANTIBIOTICS NOT ACCEPTED IN MONOTHERAPY : Cefazolin, Cefuroxime, Ciprofloxacin, Clindamycin, Vancomycin (can be given in c.diff) ,Daptomycin, Linezolid. CMS APPROVED COMBINATION ANTIBIOTICS : Aztreonam OR Ciprofloxacin OR Aminoglycosides + Cephalosporin (Cefazolin, Cefuroxime, Cefoxitin) OR Clindamycin OR Vancomycin OR Daptomycin OR Linezolid OR Macrolides (Azithromycin, Erythromycin). VASOPRESSORS : Dopamine, Dobutamine, Norepinephrine, Epinephrine, Phenylephrine, Vasopressin. .......................................................................................................

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Nicely narrated about the diagnostic criteria and principles of management both pre sepsis and sepsis preliminary to severe stages. Nice and very helpful in field of daily practise. Thanks for the post.

Thank you sir.
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Comprehensive observations and well drafted and detailed discussion.good. Keep it up ,

Thank you doctor
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Informative

Thank you doctor
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