Full Report of Thai Sepsis Guideline 2557

1

severe sepsis septic shock ()

(severe sepsis and septic shock)

(service plan) .

early detection early resuscitation

2

severe sepsis septic shock

severe sepsis septic

shock

3

Strategy 5

Diagnosis 7

Early recognition and Initial assessment 9

Initial septic workup 12

Antibiotic therapy 14

Source control 18

Fluid therapy 20

Vasopressor and inotropes 23

Monitoring 26

Organ support

- Respiratory support

- Renal support

29

32

Other managements

- Glycemic control

- Sedation

- Other supportive care

34

36

37

4

1

Bundle for sepsis resuscitation .

38

2

Resuscitation Bundle severe sepsis

septic shock .

42

3

SOS score

47

4

severe sepsis

septic shock

48

5

protocol severe sepsis

septic shock .

51

6

(sepsis, severe sepsis and septic

shock) SOS score

53

7

55

5


3

1. (early recognition)

2. (early infection control, early resuscitation, and organ support)

3.

1. (early recognition)

(Sepsis watch) SOS score

2.

(early infection control, early resuscitation, and organ support)


Sepsis bundles

3.

6

Rapid response team, Medical

emergency team

1 sepsis

7

Diagnosis of Sepsis and Severe Sepsis

sepsis

organ dysfunction

sepsis systemic inflammatory

response syndrome (SIRS)

sepsis

sepsis SIRS 2

( 1)

severe sepsis sepsis tissue hypoperfusion organ dysfunction

hypotension ( 2)

septic shock sepsis systolic blood pressure < 90 mm Hg systolic blood

pressure > 40 mm Hg mean arterial pressure < 70 mm Hg

fluid resuscitation

criteria SIRS

Temperature >38C or 90 beats/min

Respiratory rate >20 /min PaCO2 12,000 /mm3, 10 %

8

2 tissue hypoperfusion organ dysfunction severe sepsis

Sepsis hypotension

blood lactate level upper limits laboratory normal

Urine output < 0.5 mL/kg/hr 2 .

Acute lung injury Pao2/Fio2 < 250 pneumonia

Acute lung injury Pao2/Fio2 < 200 pneumonia

Creatinine > 2.0 mg/dL (176.8 mol/L)

Bilirubin > 2 mg/dL (34.2 mol/L)

Platelet count < 100,000 L

Coagulopathy (international normalized ratio > 1.5)

sepsis , severe sepsis septic shock

surviving sepsis campaign: international guideline for management of severe sepsis and septic

shock 2012

SIRS criteria

tissue hypoperfusion organ dysfunction severe sepsis

metabolic acidosis

9

Early Recognition and Initial assessment

Level 1 ..

SIRS Criteria SOS score ()

sepsis

SIRS criteria 2 SOS score 3

sepsis

SOS score vital signs

sepsis sepsis

SOS score 5 severe sepsis septic shock

Lungs:clear

Level 2 .

SIRS Criteria SOS score sepsis


sepsis

SOS score vital signs ( blood

lactate level )

tissue hypoperfusion organ dysfunction

sepsis tissue hypoperfusion organ dysfunction

sepsis SOS score 5 severe sepsis septic

shock

10

Level 3 .

SIRS Criteria sepsis

4-6 . SOS score protocol (

) sepsis, severe sepsis septic shock


sepsis



blood lactate level tissue hypoperfusion ()


blood lactate level upper limits laboratory normal ( 4 mmol/L)


shock

Level 4 ./.

SIRS Criteria sepsis

4-6 . SOS score protocol (

) sepsis, severe sepsis septic shock

SIRS criteria SOS score

sepsis



blood lactate level tissue hypoperfusion

11


blood lactate level upper limits laboratory normal ( 4 mmol/L)


shock

tissue hypoperfusion resuscitation (

resuscitation )

SOS score

sepsis SOS score

SOS score

blood lactate level tissue hypoperfusion

4 mmol/L resuscitation tissue

hypoperfusion 2 3 mmol/L

tissue hypoperfusion

12

Initial Septic workup sepsis

Level 1 ..

Level 2 .

- -

- o Complete blood count

o Urine analysis/culture

o Blood culture 2 specimens o Chest x-rays

o clot blood serology

-

Level 3 .

-

- o Complete blood count

o Urine analysis/culture



- o Serology test

o

13

o ultrasound , , ,

o

Level 4 ./.

- -

o Complete blood count o Urine analysis/culture



-

o Serology test o

o ultrasound , , ,

o CT MRI

o

,

o

- neutropenia galactomannan PCR Aspergillus Candida

serology, PCR

14

Antibiotic therapy

Level 1 ..

1.

Level 2 .

1. (hemoculture) 2

Gram stain specimens sepsis

2. intravenous

1

sepsis

3.

2

Level 3 .

1. (hemoculture) 2


2. intravenous

1

sepsis .

3. combination

( 3)

15

3: combination

Neutropenia

prevalence multi-drug resistant bacteria Pseudomonas,

Acinetobacter, ESBL-producing organisms

Pseudomonas aeruginosa bacteremia septic shock & respiratory failure

Streptococcus pneumoniae bacteremia & septic shock

4.

sepsis

5.

6. sepsis exclude

7.

specimens

(De-escalation)

9. 7-10

-

- (undrainable focus of

infection)

- neutropenia

16

Level 4 ./.

1. (hemoculture) 2


2. intravenous

1

sepsis .

3. combination

( 3)

4.

sepsis

5.

6. sepsis exclude

7.

specimens

(De-escalation)

9. 7-10

-

17

- (undrainable focus of

infection)

- neutropenia

10. serum procalcitonin (PCT) 24

11. serum PCT

12. serum PCT serum PCT

18

Source control

Level 1 ..

(severe sepsis or septic

shock)

Level 2 .

(percutaneous drainage)

Level 3 .

percutaneous drainage

19

Level 4 ./.

percutaneous drainage

resuscitation resuscitation

infected peripancreatic necrosis

20

Fluid therapy

Level 1 ..

IV 18-20 1 load IV fluid

free flow ( load

)

Level 2 .

IV 18-20 2

load IV fluid 30 ml/kg 2 ( 3 )

60

load IV fluid 30 ml/kg ( 1.5 ) 60

10-15

crepitation

Level 3 .

IV 18-20 2

load IV fluid 30 ml/kg 2 ( 3 )

60


10-15 crepitation CXR pulmonary edema

central venous pressure, pulse pressure variation, IVC variation ultrasound

21

Level 4 ./.

IV 18-20 2

CVP line

load IV fluid 30 ml/kg 2 ( 3 ) 60


fluid responsiveness

central venous pressure, pulmonary capillary wedge pressure, pulse pressure

variation, IVC variation ultrasound, cardiac output, echocardiogram

30 ml/kg

10-15 crepitation CXR pulmonary edema plateau

pressure extravascular lung water

resuscitation NSS colloid

iv peripheral

central line iv peripheral 2

100 %

()

pulmonary

22

edema pulmonary edema

(3 3-6 .)

pulmonary edema

10-15

6

500-1,000 ml

shock severe

sepsis septic shock

23

Vasopressor and inotropes

Level 1 ..

(SBP< 90mmHg)

Level 2 .

Dopamine Norepinephrine

Dopamine 5%D/W(NSS) Dopamine 100mg 5%D/W 100ml

5 g/kg/min 3-5 MAP 65mmHg

20g/kg/min (

)

NIBP 3-5

15-30

Level 3 .

Norepinephrine Dopamine

central venous catheter

Norepinephrine 5%D/W ( NSS) Norepinephrine 4 mg

5%D/W 50-100 ml syringe pump ( central

venous catheter) Norepinephrine mg %D/W 250ml

infusion pump ( peripheral venous catheter)

MAP 65mmHg septic shock

0.1-0.3 g/kg/min 3-5

2 g/kg/min ( 5 g/kg/min)

()

24

Dopamine

Dobutamine

20g/kg/min

MAP 65mmHg Dopamine/

Norepinephrine Epinephrine

MAP 65mmHg

MAP mmHg Hydrocortisone

200-300mg/day 8

NIBP 3-5

-

continuous invasive arterial pressure

monitoring

Level 4 ./.

Norepinephrine ( Dopamine)


Dobutamine

MAP 65mmHg Norepinephrine /

Dopamine Epinephrine

MAP 65 mmHg

MAP 65mmHg Hydrocortisone

200-300mg/day 8

NIBP 3-5

15-30

25

continuous invasive arterial pressure

monitoring

Norepinephrine NSS central venous catheter

peripheral venous Dopamine 1:1 (

100 mg 5%D/W 100 ml ) Norepinephrine 4 mg 5%D/W 250 ml

tissue ischemia

MAP mmHg severe acidosis

shock

continuous invasive arterial pressure monitoring

26

Monitoring

Level 1 ..

(mean arterial pressure) .

Level 2 .

MAP . 15-30 ( NIBP 3-5

)

. ././.

pulse

oximetry %

Level 3 .

MAP . 15-30 ( NIBP 3-5

)

o . ././. o central venous catheter CVP

8 . ( . )

o central venous catheter central venous oxygen saturation (ScvO2) 70%

CVP vasopressor %

27

Dobutamine o central venous catheter ScvO2

Lactate Lactate

ScvO2

pulse

oximetry %

Level 4 ./.

6 o MAP . 15-30 (

NIBP 3-5

)

o . ././. o central venous catheter CVP

8 . ( . )

o central venous catheter central venous oxygen saturation (ScvO2) 70%

CVP vasopressor % Dobutamine

o central venous catheter ScvO2 Lactate Lactate

ScvO2

o . ././.

28

o arterial line (fluid

responsiveness) pulse pressure variation

()

o modified fluid challenge test , pulse pressure variation, stroke volume variation ,

IVC variation ultrasound, passive leg raising test continuous cardiac

output

Norepinephrine

pulse

oximetry %

systolic BP MAP (mean arterial pressure)

diastolic BP

29

Respiratory support

Level 1 ..

1. oxygen

2. oxygen nasal cannula 4-6

3. oxygen 6-10 reservoir

bag 10-15 oxygen nasal cannula 2.

Level 2 .

1. oxygen


3. respiratory paradox alternans

oxygen

4. oxygen pulse oxymeter

(arterial blood gases)

5. ICU

Level 3 .

1. oxygen

30



oxygen



5. ICU

6. (metabolic acidosis)

respiratory rate tidal volume respiratory

rate 20-30 tidal volume 10-12 ./.

hemodynamic

7. ARDS tidal volume 6 ./. plateau pressure 28-30 PEEP (positive end-expiratory

pressure) 48 .

(permissive hypercapnia)

Level 4 ./.

1. oxygen


31


oxygen



5. ICU

6. (metabolic acidosis)

respiratory rate tidal volume respiratory

rate 20-30 tidal volume 10-12 ./.

hemodynamic

7. ARDS tidal volume 6 ./. plateau pressure 28-30 PEEP (positive end-expiratory

pressure) 48 .

(permissive hypercapnia)

32

Renal Support

Level 1 ..

Level 2 .

1.5 30

6

Level 3 .

(pH < 7.2

15 mEq/L)

6.2 mEq/L

pericardial friction rub myoclonus

BUN 60 mg/dl

(CRRT) sustained low efficiency dialysis (SLED)

sustained low efficiency dialysis (SLED) intermittent hemodialysis (IHD)

(acute peritoneal dialysis)

33

Level 4 ./.

(pH < 7.2

15 mEq/L)

6.2 mEq/L

pericardial friction rub myoclonus

BUN 60 mg/dl

(CRRT) sustained low efficiency dialysis (SLED)

sustained low efficiency dialysis (SLED) intermittent hemodialysis (IHD)

(acute peritoneal dialysis)

cardiovascular SOFA 0-2 2

34

Glycemic control

Level 1 ..

Level 2 .

- (glucometer) (blood sugar)

o % glucose 50 dextrose rate

NSS resuscitation

o NSS resuscitation

o regular insulin glucometer -

Level 3 .

- (glucometer) (blood sugar)

o % glucose 50

dextrose rate

NSS resuscitation


regular insulin continuous intravenous infusion

-

35

o glycemic control protocol

Level 4 ./.

- (glucometer)

(blood sugar)

o % glucose 50

dextrose rate

NSS resuscitation


regular insulin continuous intravenous infusion

-

glycemic variability

o glycemic control protocol

o glycometer insulin infusion

o insulin mixed split premix

-

36

Sedation

Level ..

Level .

sedation hemodynamic

sedation

Level .


sedation

sedation scale protocol

continuous intermittent

Level 4 ./.


sedation

sedation scale protocol

continuous intermittent

37

Other supportive care

Level ..

Level .

Stress ulcer prophylaxis

DVT prophylaxis DVT

Level .


DVT prophylaxis DVT

Level 4 ./.


DVT prophylaxis DVT

38

1

Bundle for sepsis resuscitation .

Categories

/

SIRS

SIRS

systemic inflammation tissue perfusion2

(X rays, ultrasounds )

Oxygen

IV fluid

Airway care, oxygen,

respiratory support as

indicated

Hemoculture and culture

from infectious sources

Mean arterial

pressure > 65

mmHg

Urine output >

0.5 ml/kg/hr

NSS 3000 ml

1-3

Airway care, oxygen, respiratory support as indicated

Hemoculture and culture from infectious sources

Mean arterial pressure > 65 mmHg

Urine output > 0.5 ml/kg/hr

Reversal of tissue hypoxia

NSS 500-1,000 ml

3

norepinephrine MAP

lactate clearance ScvO24

39

dopamine

norepinephrine

tissue hypoxia

o Packed red cell hematocrit < 30%

o hematocrit > 30% dobutamine

(de-escalation)

1. Criteria of SIRS:

Temperature >38C or 90 beats/min

Respiratory rate >20 /min PaCO2 12,000 /mm3, 10 %

2. Criteria of sepsis SSC (surviving sepsis campaign: international guideline for management of severe

sepsis and septic shock 2012)

1 1

40

criteria sepsis

General variables

Fever (> .C)

Hypothermia (core temperature < C)

Heart rate > /min or more than two SD above the normal value for age

Tachypnea

Altered mental status

Significant edema or positive fluid balance (> mL/kg over hr)

Hyperglycemia (plasma glucose > mg/dL or . mmol/L) in the absence of diabetes

Inflammatory variables

Leukocytosis (WBC count > ,/L)

Leukopenia (WBC count < /L)

Normal WBC count with greater than % immature forms

Plasma C-reactive protein more than two SD above the normal value

Plasma procalcitonin more than two SD above the normal value

Hemodynamic variables

Arterial hypotension (SBP < mm Hg, MAP < mm Hg, or an SBP decrease > mm Hg in adults or less than two

SD below normal for age)

Organ dysfunction variables

Arterial hypoxemia (Pao/Fio < )

Acute oliguria (urine output < . mL/kg/hr for at least hrs despite adequate fluid resuscitation)

Creatinine increase > . mg/dL or . mol/L

41

Coagulation abnormalities (INR > . or aPTT > s)

Ileus (absent bowel sounds)

Thrombocytopenia (platelet count < , /L)

Hyperbilirubinemia (plasma total bilirubin > mg/dL or mol/L)

Tissue perfusion variables

Hyperlactatemia (> mmol/L)

Decreased capillary refill or mottling

3. intravascular volume

a. Clinical JVP,

b. CVP 12 cmH2O 15 cmH

2O

c. Volume responsive tests Pulse pressure variability, Response to straight leg raising, IVC

diameter variability

4. tissue perfusion

capillary refill 2

metabolic acidosis blood lactate 10-20% ScvO270%

42

2

Resuscitation Bundle severe sepsis septic shock .

Bundle ..

1. IV NSS load free flow 18-22 1

2. oxygen 20

3.

Note severe sepsis septic shock SOS score 3

Lungs:clear

( load )

Bundle .

. Take H/C specimen specimen

+ specimen culture

. IV - load NSS free flow

( )

> ( . )

-

crepitation

. Start IV ABO take H/C , culture

community acquired Ceftriaxone g

43

melioidosis Ceftazidime g

healthcare associated infection the most board spectrum antibiotic

. Start Dopamine mg + %D/W ml (:) 20 ml/hr fixed rate IV , ml 6

Titrate ml/hr

MAP , mmHg

Dopamine 60 ml/hr Norepinephrine*

. Retained Foley catheter

( bladder ) record I/O

6. oxygen 20 SpO2 sat < 92% RR > 30/min

intubate + respiratory support

7. physiologic score SOS score ( blood lactate )

Bundle .

1. Take H/C 2 specimen 1 specimen

+ specimen culture

2. IV 18-22 2 load NSS free flow

60 ( 3 )

> 60 ( 1.5 )

44

30 ml/Kg NSS 500-1,000 ml

6-12 .

3. Start IV ABO take H/C , culture

community acquired Ceftriaxone 2 g

melioidosis Ceftazidime 2 g


4. Norepinephrine Dopamine *

5. Retained Foley catheter



intubate+ respiratory support

7. physiologic score SOS score ( blood lactate )

8. ICU

* Norepinephrine Norepinephrine 5%D/W ( NSS)


Norepinephrine 4 mg 5%D/W 50-100 ml syringe pump

peripheral venous catheter

Norepinephrine 4 mg 5%D/W 250 ml infusion pump (

)

45


0.1-0.3 g/kg/min 3-5


Note central venous catheter

Bundle ./.

1. Take H/C 2 specimen 1 specimen

+ specimen culture

2. IV 18-22 2 load NSS free flow

30 ml/Kg NSS 500-1,000 ml

6-12 .

60 ( 3 )

> 60 ( 1.5 )

10-15

3. Start IV ABO take H/C , culture

community acquired Ceftriaxone 2 g

melioidosis Ceftazidime 2 g


4. Norepinephrine Dopamine *

46

5. Retained Foley catheter



intubate+ respiratory support

7. blood lactate level ( physiologic score SOS score

)

8. ICU

* Norepinephrine Norepinephrine 5%D/W ( NSS)


Norepinephrine 4mg 5%D/W 50-100 ml syringe pump

peripheral venous catheter

Norepinephrine 4 mg 5%D/W 250ml infusion pump (

)


0.1-0.3 g/kg/min 3-5


Note central venous catheter

47

3

SOS score (search out severity score)

-

- Record V/S, I/O .

- SOS score

-

-

Nurse Record V/S as usual + SOS

4

- Record V/S, I/O -

-

ICU

-

severe sepsis and septic shock / Acute MI /

Acute PTE etc.

- Monitor -

SOS < 4 stable

then monitor . . SOS < 4

then monitor . .

-

- incharge

- Extern /Intern

- Record V/S

- SOS score

severe sepsis and septic shock flow

48

4


. .

. . . /.

-

-

-

-

-

-

-

-

-

.

-

-

-

.

-

-SIRS Criteria

SOS score

-SIRS Criteria SOS

score

-

- tissue

hypoperfusion

organ dysfunction

-SIRS Criteria SOS

score

-

- tissue

hypoperfusion

organ dysfunction

-SIRS Criteria SOS

score

-

- tissue

hypoperfusion

organ dysfunction

-Oxygen

-IV fluid

-Airway care, oxygen,

respiratory support

-Hemoculture


respiratory support

-Hemoculture


respiratory support

-Hemoculture

- IV 18-22

1

- Load IV fluid free

flow

- IV 18-22

2

- Load IV fluid

3

- -

- IV 18-22

2

- Load IV fluid

3

- -

- IV 18-22

2

- CVP line

- Load IV fluid

49

-

3

- -

-

-

-

intravenous

1

1

-

intravenous

1

1

-De-escalation

3-5

-

-

intravenous

1

1

-De-escalation

3-5

-

-

- Dopamine

Norepinephrine

- Norepinephrine

MAP

- Dopamine

Dobutamine

- Norepinephrine

MAP

- Dopamine

Dobutamine

-Mean arterial

pressure mmHg -Urine output > .

ml/kg/hr

-SOS score 5

-Mean arterial

pressure mmHg -Urine output > .

ml/kg/hr

-Reversal of tissue

hypoxia and

hypoperfusion

-Mean arterial

pressure 65 mmHg -Urine output > 0.5

ml/kg/hr

-Reversal of tissue

hypoxia and

hypoperfusion

Monitoring -

MAP, urine

output SOS score

MAP, urine

output tissue

hypoxia and perfusion

MAP, urine

output tissue

hypoxia and perfusion

Respiratory support - oxygen - oxygen

-

- oxygen

-

- oxygen

-

50

Renal support -

-

-

CRRT SLED

-

SLED IHD

acute peritoneal

dialysis

-

-

CRRT SLED

-

SLED IHD

acute peritoneal

dialysis

-

-

80-180

- glycemic

control protocol

-

80-180

- glycemic

control protocol

Sedation -

hemodynamic

-

sedation

-

hemodynamic

-

sedation

- sedation scale

protocol

-

hemodynamic

-

sedation

- sedation scale

protocol

Full Report of Thai Sepsis Guideline 2557

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Transcript of Full Report of Thai Sepsis Guideline 2557