Sepsis (Septic Shock) Prognosis Prevention TREATMENT

TREATMENT Sepsis (Septic Shock)

• Admit in ICU
• Treat local site of infection
• Monitor hemodynamics.
• Sepsis is a clinical syndrome characterized by systemic inflammation due to infection.
• There is a continuum of severity ranging from sepsis to severe sepsis and septic shock.

Antimicrobial therapy in Sepsis (Septic Shock)

• Ceftriaxone 2gjday
• Ticarcillin – Clavulanate 3.1g 6 hrly
• Piperacillin – Tazobactam 3.375g 6 hrly
• Imipenem – Cilastatin 0.5g 6 hrly
• Meropenem – 19 8 hrly
• Cefepime – 2g 12 hrly
• Gentamycin, Tobramycin + any of the above Ciprofloxacin 400mg 12 hrly + Clindamycin 600mg 8 hrly
• Levofloxacin 500mg 12 hrly + Clindamycin 600mg 8 hrly
• Vancomycin 19 12 hrly for MRSA infections -(Methicillin resistant Staph aureus)
• Cefotaxime 2g 8 hrly
• Ceftriaxone 2g 12 hrly
• Covers gram positive and gram negative organisms till results of culture arrive.
• Give IV only, for at least 1 week.
• Adjust dose and drug for renal impairment.
• Removal of source of infection – Drainage of site Removal of catheters; and the tip is rolled over blood — agar plate for culture.
• New catheter is put in.
• Foley’s or drainage catheter replaced.
• In nasal intubation, look for paranasal sinusitis. In neutropenia, look for red tender sites.
• Look for ulcers, ureteral obstruction, perinephric ab­scess, renal abscess.
• CT and MRI of different regions is done. Hemodynamic, respiratory and metabolic support is given.
• Oxygen therapy is given.
• Organ perfusion should be adequate.
• IV fluids for hypotension – 1-2 litre of saline in 1-2 hours is given.
• CVP (Central venous pressure) or PWP (Pulmonary wedge pressure) should be monitored specially in refractory shock, renal or cardiac disease.
• CVP should be 10-12 cm water.
• PWP should be 12-16 mmHg
• Urine output should be more than 30 ml per hour Diuretics like Frusemide and spirinolactone can be used.
• Maintain systolic blood pressure more than 90 mmHg and cardiac index more than 4 litre per minute/m² by volume infusion.
• Inotropic therapy – Dopamine, dobutamine Vasopressors –:
• IV vasopressin
• For adrenal insufficiency and if hypotension persists IV hydrocortisone 50 mg 6 hourly is given.
• Circulatory adequlcy is seen clinically by assessment of mentation, skinPerfusion, urine output, SP0₂
• Ventilator Therapy is often needed for hypoxaemia, hypercapnia, muscular failure, neurological distur­bance.
• Respiratory rate more than 30/minute means impend­ing ventricular collapse.
• Mechanical ventilation is given at this stage for ad­equate oxygenation, to divert blood from respiratory muscles, prevent aspiration, decrease afterload.
• If Hb is less than 8 mg/dl blood transfusion or RBC concentrate is given.
• For metabolic acidosis, give bicarbonate if arterial pH less than 7.2
• DIC with bleeding treated with transfusion of FFP (Fresh Frozen Plasma) and platelets.
• Acidosis and DIC is reversed only if infection treated

General Support for Sepsis (Septic Shock)

• In sepsis more than 3 days, nutritional supplementa­tion reqUired by central route.
• Prevent skin infection, DVT (Deep vein thrombosis), nosocomial infection etc.

Patient Care:

• Specimens of blood and body fluids are collected and cultured.
• Two or three consecutive blood cultures are obtained while the patient is febrile.

Critical Care for Sepsis (Septic Shock)

• Invasive hemodynamic monitoring in patients with sepsis typically reveals an elevated cardiac index, decreased systemic vascular resistance, decreased oxygen delivery to tissues, and decreases in mixed venous oxygen saturation
• Fluid resuscitation with crystalloid or colloid:
• Initial therapy with fluid bolus (at least 20 mL/kg or 2 liters of crystalloid or 300–500 mL of colloid over 30 minutes)
• Use central venous pressure (CVP) of 8–12 mm Hg (12–15 mm Hg if on mechanical ventilation) as initial target of resuscitation
• Use caution in the presence of CHF.
• Vasopressors:
• Norepinephrine or dopamine
• Low-dose dopamine for renal protection is not recommended

Other measures

• · Anti endotoxin agents
• · Anti lipid A agents
• · Anti mediator agents
• · Methyl prednisolone
• · Recombinant IL-1ra
• · Anti TNFa
• · New drug – Anticoagulant agent recombinant activated protein C (aPe) may be used in severe.
• sepsis or septic shock. It may improve survival but may cause serious bleeding specially if plate­let count is less than 30,000/111 or there is men­ingitis. Dose is 24 119/kg/hr for four days.

Prognosis of Sepsis (Septic Shock)

• 60% patients die in 30 days to 6 months.

Prevention of Sepsis (Septic Shock)

• · Treat sepsis early
• · Avoid invasive procedures
• · Limit use of catheters
• · Avoid indiscriminate use of antimicrobials, glu­cocorticoids
• · Control of infections.