1. Yadegarynia, D. MD.

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

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

4. Survival decreased by 7.6% for each hour on delay

5. 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

6. 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

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

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

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

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

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

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

13. 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

14. Inotropic therapy
Dobutamin is used for patients with low cardiac index

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

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

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

18. 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)

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

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

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

22. Metabolic and nutritional therapy
Blood glucose
bicarbonate PH<7.15
Initiate enteral nutrition following stabilization

23. sedation Use minimal sedation necessary Benzodiazepines
low –dose narcotics

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

25. Deep venous thrombosis prophylaxis
Low –molecular weight heparin