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SEPSIS

SEPSIS. M H MUMTAZ. INCIDENCE. USA 750,000 Whole wold 18 millions Mortality 1400 /day Growth rate 1.5%/year Mortality rate 30%-50% s. sepsis 50%-60% s. shock Cost $ 22,000 /case. Introduction.

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SEPSIS

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  1. SEPSIS M H MUMTAZ

  2. INCIDENCE USA 750,000 Whole wold 18 millions Mortality 1400 /day Growth rate 1.5%/year Mortality rate 30%-50% s. sepsis 50%-60% s. shock Cost $ 22,000 /case

  3. Introduction Complex interaction between; 1,micro-organisms = Bacteraemia 2,toxins = toxaemia 3,immune system = SIRS

  4. Pathophysiology Bacteraemia+Toxins+Immune. s. 1.cytokines production SIRS 2.PGs activation 3,activation of coagulation lead to;- 1, generalised endothelial injury ^ permeability___oedaema.ischaemia 2, coagulopathy M.O.F.

  5. Markers of Infection • 1,Bacterial products as markers a, bacterial products endotoxins exotoxins enzymes lipids b,bacterial DNA, RNA PCR (multiplex PCR, real time PCR) 2,Pro-inflammatory factors a, acute phase proteins, ( CRP)

  6. Markers of infection • b, proxima markers of the innate immune response 1L-6, 1L-8, C3a, sPLA2, c, macrophage products procalcitonin (Pct), neupterins, d, Neutrophil products Elastase, lactoferrin, e, coagulation markers tissue plasminogen activator (TPA)

  7. THERAPY 1, SPECIFIC a, antimicrobials b, Drotrecogin alpha(activated) 2, SUPPORTIVE (organ support) a, Haemodynamic support (fluids, vasopressors,inotropes) b, Ventilatory support 3, ADDITIONAL SUPPORT

  8. ADDITIONAL ADVANCED SUPPORT • Adrenal hormone replacement • Tight glycaemic control • Renal replacement • Blood purification

  9. Hypoglycaemia Stringent Normal Intermediate Liberal Hyperglycaemia <80 80—100 111—144 145---180 181---200 >201 GLYCAEMIC CONTROL

  10. SURVIVING SEPSIS COMPAIGN 2002, survey conducted by; ESICM,SCCM to have views on; “sepsis” “current definitions” “routes to dignosis” “treatment options” “ They revealed that most physcians find sepsis challeging & frustrating to diagnose & treat”.

  11. THE RESPONSE; to SSC • SCCM +ESICM +ISF 3Phase SSC First phase. 6 point action plan Second phase. Guide lines for sepsis management Third phase. Translating the guidelines into clinical practice

  12. IDENTIFYING PATIENTS • SEPSIS DEFINITIONS • 1,General variables; FEVER > 38.3 Hypothermia < 36.0 Heart rate >90/min Tachypnea Altered mental status Significant odema Hyperglycaemia >120mg/dl no diabetes

  13. SEPSIS DEFINITION • 2, Inflamatory variables Leukocytosis ( WBC > 12000) Leukopenia (WBC < 4000) Normal WBC with > 10% immature forms Plasma c-reactive proteins > 2SD Above N Plasma procalcitonin > 2SD above normal

  14. SEPSIS DEFINITION • Severe sepsis; organ dysfunction+ hypoperfusion or hypotension ORGAN DYSFUNCTION variables; Arterial hypoxaemia ( Pao2/FIO2 < 300) Acute oligurea Creatinine > 2.0mg/dl Coagulation abnormality (INR > 1.5 or APTT > 60 s Platelet count < 100,000 Bilirubin > 35 mmol/L OR > 2.0mg/dl

  15. SEPSIS DEFINITIONS TISSUE PERFUSION VARIABLES; Hyperlactataemia ( > 2mmol/L ) Haemodynamic Variables; Arterial hypotension SBP <90 MAP < 65 “Septic shock is acute circulatory failure unexplained by other causes. (persistant hypotension despite volume resuscitatation)”.

  16. GUIDELINES by SSC 2003 11 International organizations laid criteria; 1,Initial Resuscitation 11,Sedation/anal. 2,Diagnosis 12,Glucose control 3,Antibiotic therapy 14,Renal.R.T. 4,Source control 15,D.V.T. 5,Fluid therapy 16,HCO3 therapy 6,Vasopressors 17,Stress ulcer 7,Inotropic therapy Prophylaxis 8,Steroids 9,Blood products administration 10,Mechanical ventilation

  17. SEVERE SEPSIS BUNDLES • 1,Sepsis resuscitation Bundle Over first 6 hours 2,Sepsis management Bundle as soon as possible scored over first 24 hours

  18. 1. Sepsis resuscitation Bundle • Seven tasks within first 6 hours. 1,measure serum lactate. 2,Obtain blood culture. 3,Administer antibiotic,ED 3h, Non ED.1h. 4,Hypotension and/or Lactate > 4 mmol/L a,fluids 20ml/Kg b,Vasopressors (MAP > 65) 5,Persistant hypotension +or Lactate >4 a,achieve CVP > 8 b,achieve ScvO2 >70%

  19. 2.Sepsis management Bundle • 4 goals within 24 hours. 1, administer low dose steroids/ policy 2, administer drotecorgin alfa ( activated) 3, maintain glucose control > lower limit < 8.3 mmol/l 4, maitain inspiratory plateau pressure < 30 cm of H2O

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