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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

Sepsis / 敗血症

Sang-Oh Lee

Div. of Infectious Diseases

Gil Medical Center

Gachon Medical School

systemic response to stimuli
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 )

why sepsis trials fail
Why Sepsis Trials Fail?
  • enrolled patients were heterogenous
  • intervention may have come too late,
  • especially if multi-organ failure was

already in progress

Why?

sepsis syndrome
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

accp sccm consensus 1992
ACCP/SCCM Consensus, 1992
  • clarify the meaning of bacteremia or septicemia
  • new concept of SIRS !

Chest 101:1644-55, 1992

definition of sirs
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 !

sepsis is a continuum
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

definition of sepsis grade
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

dear sirs i m sorry
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

to sirs with love
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

the tower of babel

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.

slide15

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
slide17

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
slide18

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

slide19

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
thank you

Thank you !

Sang-Oh Lee

solee@ghil.com