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Sepsis / 敗血症

Sepsis / 敗血症. Sang-Oh Lee Div. of Infectious Diseases Gil Medical Center Gachon Medical School. Systemic Response to Stimuli. When in a fever not of the intermittent type dyspnoea and delerium come on, the case is mortal. Hippocrates (the 5 th century BC ).

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Sepsis / 敗血症

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  1. Sepsis / 敗血症 Sang-Oh Lee Div. of Infectious Diseases Gil Medical Center Gachon Medical School

  2. Systemic Response to Stimuli When in a fever not of the intermittent type dyspnoea and delerium come on, the case is mortal. Hippocrates (the 5th century BC )

  3. Bone RC. Sepsis – Gulliver in Laputa.JAMA 273:155-6, 1995

  4. Why Sepsis Trials Fail? • enrolled patients were heterogenous • intervention may have come too late, • especially if multi-organ failure was already in progress Why?

  5. Sepsis Syndrome • INCLUSION CRITERIA clinical evidence of infection rectal temperature > 101 °F or < 96 °F tachycardia (> 90/min) / tachypnea (> 20/min) at least one of inadequate organ functions mental change / hypoxemia / oligouria / lactic acidosis Bone RC. Crit Care Med 17:389-93, 1989

  6. ACCP/SCCM Consensus, 1992 • clarify the meaning of bacteremia or septicemia • new concept of SIRS ! Chest 101:1644-55, 1992

  7. Definition of SIRS • Systemic inflammatory response syndrome temperature > 38 °C or < 36 °C tachycardia (> 90/min) tachypnea (> 20/min) or PaO2 < 32 mmHg WBC > 12,000/mm3, < 4,000/mm3, or > 10% immature forms two or more of criteria !

  8. Sepsis is a Continuum ! • not sepsis syndrome (include organ failure) • sepsis – severe sepsis – septic shock ! 2,527 Cases of SIRS JAMA 273:117-23, 1995

  9. Definition of Sepsis Grade • SEPSIS isSIRS + clinical infection • SEVERE SEPSIS Sepsis + organ hypoperfusion or hypotension (including but not limited to lactic acidosis, oligouria, or mental change) • SEPTIC SHOCK sBP < 90 mmHg or > 40 from baseline despite adequate fluid resuscitation

  10. Dear SIRS, I’m sorry … • … to say that I don’t like you ! That means just a severe patient ! High sensitivity, but too low specificity ! No account of site or type of infection ! • It is harmful to clinicians ! Vincent JL. Crit Care Med 25:372-4, 1997

  11. To SIRS with Love … • SIRS is just a part of consensus definitions ! • SIRS was intended to be extremely sensitive and helpful at the bedside ! • for earlier and more intensive attention ! • As we move forward precise terms ! account of pathophysiology & organisms Dellinger RP, Bone RC. Crit Care Med 26:178-9, 1998

  12. 환자가 septic 해졌어요! 어쩌다 그렇게 됐어? 보호자 warning 해! The Tower of Babel … 체온은 39도, 맥박은 분당 100회, 호흡수는 분당 22회입니다. 임상적으로 UTI가 의심되어 urosepsis로 판단됩니다. 혈압이 85mmHg까지 떨어졌지만 NS을 1L 가량 빠르게 주면서 혈압이 회복된 것으로 보아 아직은 severe sepsis의 단계로 보입니다.

  13. Therapeutic Options • Broad-spectrum, maximum dose of antibiotics necessary but not sufficient • Removal of the source of infection • Hemodynaic support of vasodilatory shock fluid resuscitation with CVP monitor !!! vasoconstrictors & inotropics • Respiratory & metabolic support

  14. Antibiotics & Removal of Source

  15. Early Goal Directed Therapy • ECV depletion due to peripheral vasodilations • Normal saline 1-2 L iv over 1-2 hr • Goal ; MABP (S+2D/3) > 60 / SBP > 90 mmHg Cardiac Index > 4 L/min/m2 • PCWP 12-16 mmHg / CVP 10-12 cmH2O • Urine output > 30 mL/hr • Vasoconstictors & Inotropics

  16. DA-1 RBF Hemodynamic Support 1 Contractility LV dilated Dobutamine > 6 ug/kg/min 3-10 ug/kg/min Dopamine < 3 1 > 10 Vasodilation – SVR Nep / Phenylephrine / Epi

  17. Respiratory & Metabolic Support • Ventilator ; hypoxemia, hypercapnea, tachypnea • RBC transfusion ; if low Hb. • FFP / Platelet ; if DIC • Metabolib acidosis (pH < 7.2) ; bicarbonate ? respiratory compensation by ventilator • Acute, unstable phase ; glucose ? • Enteral feeding to reduce protein catabolism

  18. Adjunctive Therapy 1

  19. Adjunctive Therapy 2

  20. Thank you ! Sang-Oh Lee solee@ghil.com

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