severe sepsis ??? septic shock - dms.moph.go.th

1 severe sepsis septic shock severe sepsis septic shock septic shock r o n n n o n o o n o n invasive devices o n n n o o septic shock n o n n r o o n o o n septic shock o Systemic Inflammatory Response Syndrome ( SIRS) o n n n inflammatory stimuli n n burns SIRS o n o n n o 2 :1.

2 C C2. 90 / 3. 20 / PaCO2 32 . 4. 12,000 / .. 4,000 / .. band form 10% o o o o n o n n n o o n sepsis n SIRS n severe sepsis sepsis n ( organ dysfunction ) ( hypoperfusion ) ( hypotension ) lactic acidosis o o o Septicshock sepsis o n o o o o n n n ( hypoperfusion )

3 Lactic acidosis o o o n o o hypoperfusion o inflammatory foci n o n endotoxin ,exotoxin , peptidoglycans o o host defense system monocyte ,neutrophil endothelial cell o mediator n tumor necrosis factor (TNF), IL-1 o n TNF, IL-1 o o cytokine TNF, IL-1,IL-2 o complement pathway, coagulation system,platlet activating factors inflammatory response n Systemic inflammation n n o n o n microcirculation vasoconstriction, vasodilatation vascular leakage myocardialdepression septic shock o n n o oxygen r r n o o mixedvenous oxygen saturation(SvO2)

4 Oxygen extraction ratio o n red blood cells red blood cellsdeformability acidosis , mediators white cell arteriovenous shunting o hemolysis white blood cell microcirculation r o endotoxin cell endothelium enzyme permeability disseminated intravascular coagulation o coagulation cascade microthombosis deposition fibrin microcirculation multiorgan failure endothelium microvascular permeability n o o

5 Arteriolarvasoconstriction vasodilation o o severe sepsis septic shock shock SIRS n n 3 :1. n 2. Intensive life support3. o n o Septicshock 1) o n 4 o n body fliud exudate n n o n septic shock hemoculture 2 o n septic schock o o n n n o n n ( gram s stain, AFB ) o o n o n o o n o n febrile neutropenia o n o n n SIRS 1.

6 Drain infected fluid collection2. debridement infected solid tissue3. medical device ( ) ( central venous catheter) o 4. n n 2) Intensive life support o ( Fluid therapy) vasopressure hemodynamic renal pulmonary o ( Fluid therapy) o o crystalloid normalsaline solution lactated s ringer solution (LRS) 500-1,000 ml 15 60 o n o n n intravascular volume n n n o n o n o n venous pressure o n n o n central venous catheter (CVP)

7 CVP Pulmonary artery catheter PCWP fluid challenge fluid challengeGuided byCVPPCWPI nfusion( cmH20 )( mmHg )Start< 8< 10200 ml/ 10 min< 12< 14100 ml /10 min 12 1450 ml/ 10 minDuring infusion 5 7 StopAfter 10 min 2 3 Continue2 53 7 Wait 10 min 5 7 StopAfter waiting 10 minStill 2 Still 3 Stop 2 vasopressure therapy n o n o n o n n o o o hemodynamic profile Dopamine:1-5 ./ ./ ( ) inotropic 20 ./ ./ : dopamine renal blood flow n o o renal perfusion Norepinephrine: n splanchnic blood flow tachycardia therapyDobutaminne.

8 O o n cardiac output o n o o n o o n n vasopressure Inotrope Vasopressure septic shockDrugDose( g/kg/minor g/min*)CardiacStimulation( 1)VasoconstrictionVasodilatation( 2)DopaminergicDopamine1-1010-20+++++++++ ++++++0 Norepinephrine2-10*+++++++00 Epinephrine1-8*++++++++00 Dobutamine1-10+++++ Hemodynamic monitoring resuscitrate septic shock o o o n 6 Early goal-directed therapy o hemodynamic monitoring n Central venous pressure 8-12 mmHg o n o n 12-15mmHg o n n n Mean arterial pressure ( MAP) 65 output > ml/ Central venous mixed venous oxygen saturation (ScvO2 SvO2) n 70% (ScvO2) 65% (SvO2) renal support n n n hypercatabolic state septicshock o o optimized volume status o n o n renal replacement therapy pulmonary support n Acute lung injury Acute respiratory distress syndrome septic shock o low tidal volume 6 ml/kg of predicted body weight Plateaupressure 30 cmH20 o o n hypercapnea Plateau pressure ( Permissive hypercapnea ) , PEEP ( Positive end expiratory pressure)

9 O n oxygen Fi02 Ventilator management Assist control mode-volume ventilation Reduced tidal volume to 6 mL/kg predicted body weight Keep Ppla < 30 cm H20 Maintain Sao2/Spo2 88-95% Anticipated PEEP setting at varius Fi02 1820-24 Predicted Body Weight CalculationMale: 50 + (height (inches) 60) or 50 + (height(cm) )Female: + (height (inches) 60) or + (height(cm) ) n o n o n n semirecumbent o 45 o ventilator-associated pneumonia n o n o n o ( spontaneousbreathing trial pressure support n PEEP 5 cmH20 T-piece) o o n n :1. 2. ( vasopressur)3.

10 Serious 4. ventilation end-expiratory pressure 5. Fi02 o mask nasal cannula Use of spontaneous breathing trail in weaning ARDS patientsOriginal illness resolving : no new illnessOff vasopressure and sedative , Cough durning suctioningPaO2/FiO2>200 mm Hg , PEEP < 5 cm H2 OMinute ventilation <15 L/min , F/Tv ratio < 105 durning 2-min spontaneous breathing trialSpontaneous breathing trial ( 30-120 min)( include: T-piece , continuous positive airway pressure 5 cm H2O ,or low-level( 5-10cm H2O ) pressure support ventilation )Respiratory rate > 35/min , Oxygen saturation < 90 Pluse > 140 /min or change > 20 % , SBP > 180 mm Hg or < 90 mm HgAgitation, diaphoresis , or anxietyF/Tv ratio > 105 NoYesCough adequate to clear secretionsAble to protect airwayYesNoExtubateReturn to maintenance MV3) o o o n refractory septic shock ( adequate intravascular volume vasopressure o n ) adrenal insufficiency septicshock hydrocortisone 200-300 mg/day 3-4 7 ( hydrocortisone 300 mg/day )