Yadegarynia, D. MD.

Severe sepsis remains a leading cause of mortality among commuting – and hospital acquired infections

International guidelines recommend that appropriate therapy should be started up to 1 hour after presentation of severe symptoms

Survival decreased by 7.6% for each hour on delay

Antimicrobial stewardship is an approach that is promoted to enhance the quality of antimicrobial therapy by encouraging the appropriate selection , dosing, route and duration of such case

Systemic inflammatory response syndrome (SIRA) At least 3 of the following clinical syndrome (SIRS) Tachycardia Tachypnea (or requirement for mechanical ventilation ) Hyperthermia or hypothermia Leukocytosis or leukopenia

Sepsis Is identified when SIRS is due to known or suspected infection ,30-35% of patients with Sepsis are culture negative

Severe sepsis is identified when sepsis is associated with one or more organ failure Respiratory Cardiovascular renal Coagulation Hepatic CNS

Septic shock If hypotension (SBP<90( Is present and unresponsive The fluid loading

Fluid therapy Fluid challenges in patients With perfusion deficits are given rapidly 1000ml over 30min for crystalloid 500ml over 30min for colloid

Antibiotic therapy Antibiotics are initiated within 1hour Of recognition of severe sepsis

Source control Evaluate the patient for an identifiably focus of infectious and initate source control as soon as identified

Vasopressin therapy (nor epinephrine) Vasopressor therapy is indicated the following conditions are met. Hypotension (MAP<60-65) Completed fluid resuscitation Normal or elevated Cardiac index or lack of peripheral vasoconstriction on physical exam

Inotropic therapy Dobutamin is used for patients with low cardiac index

Endocrinologic therapy Consider hydrocortisone 50mg Q 6H in patients with hyperdynamic vasopressor – dependent shock despite adequate fluid resuscitation

Recombinant activated proteinc Patients with septic shock requiring vasopressors Patients with 3 or more sepsis-related organ failurs

Therapeutic plasma exchange Severe vasopressor – dependent septic shock Elevated lactate level(>4mm/c) that persists following initial resuscitation

Blood product administration Red blood cells Coronary artery disease with recent angina or coronary syndrome (to achieve a target of 12 g/dl) Acute ongoing hemorrhags in the face of anemia (bgb<9)

Blood product administration Erythropoietin 40000 units for typical adults With additional dose on day 4 for (hgb<11)

Blood product administration FFP Clinical bleeding Need to undergo an invasive procedures

Platelets Platelets for counts<10000 <30000 and there is risk of bleeding For invasive procedures platelet count >50000

Metabolic and nutritional therapy Blood glucose 80-110 bicarbonate PH<7.15 Initiate enteral nutrition following stabilization

sedation Use minimal sedation necessary Benzodiazepines low –dose narcotics

Stress ulcers prophylaxis Omeprazole 40mg daily H2 antagonists (Second line choice)

Deep venous thrombosis prophylaxis Low –molecular weight heparin