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.
- 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.
- Norepinephrine or dopamine
- Low-dose dopamine for renal protection is not recommended
- · 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.