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

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 29

- Renal support 32

Other managements

- Glycemic control 34

- Sedation 36

- Other supportive care 37

 4

1 38
Bundle for sepsis resuscitation .
2 42
Resuscitation Bundle severe sepsis
septic shock .
3 47
SOS score
4 48
severe sepsis
septic shock
5 51
protocol severe sepsis
septic shock .
6 53

(sepsis, severe sepsis and septic
shock) SOS score
7 55

severe sepsis septic shock

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)

severe sepsis septic shock
Sepsis bundles

3.

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 <36C

Heart rate > 90 beats/min

Respiratory rate >20 /min PaCO2 <32 mmHg

WBC >12,000 /mm3, <4000 /mm3, band form neutrophil >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

SIRS criteria 2 SOS score 3

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
SIRS criteria 2 SOS score 3

sepsis

SOS score vital signs
tissue hypoperfusion organ dysfunction
blood lactate level tissue hypoperfusion ()
sepsis tissue hypoperfusion organ dysfunction
blood lactate level upper limits laboratory normal ( 4 mmol/L)
sepsis SOS score 5 severe sepsis septic
shock

Level 4 . /.

SIRS Criteria sepsis

4-6 . SOS score protocol (
) sepsis, severe sepsis septic shock
SIRS criteria SOS score

sepsis

SOS score vital signs
tissue hypoperfusion organ dysfunction
blood lactate level tissue hypoperfusion
 11

sepsis tissue hypoperfusion organ dysfunction

blood lactate level upper limits laboratory normal ( 4 mmol/L)
sepsis SOS score 5 severe sepsis septic
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 Blood culture 2 specimens
o Chest x-rays
o clot blood serology

-
o Serology test
o
 13

o ultrasound , , ,

o
Level 4 . /.

-
-
o Complete blood count
o Urine analysis/culture
o Blood culture 2 specimens
o Chest x-rays
o clot blood serology

-
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
Gram stain specimens sepsis

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
Gram stain specimens sepsis

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
load IV fluid 30 ml/kg ( 1.5 ) 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
load IV fluid 30 ml/kg ( 1.5 ) 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)
central venous catheter

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
2.
oxygen nasal cannula 4-6

3.

respiratory paradox alternans
oxygen
4. oxygen pulse oxymeter
(arterial blood gases)
5.
ICU

Level 3 .

1.
oxygen
 30

2.
oxygen nasal cannula 4-6

3.

respiratory paradox alternans
oxygen
4. oxygen pulse oxymeter
(arterial blood gases)
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
2.
oxygen nasal cannula 4-6

 31

3.

respiratory paradox alternans
oxygen
4. oxygen pulse oxymeter
(arterial blood gases)
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
o
regular
insulin glucometer -

regular insulin continuous intravenous infusion
-
 35

o glycemic control protocol

Level 4 . /.

- (glucometer)
(blood sugar)
o % glucose 50
dextrose rate
NSS resuscitation
o
regular
insulin glucometer -

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 hemodynamic
sedation
sedation scale protocol
continuous intermittent

Level 4 . /.

sedation hemodynamic
sedation
sedation scale protocol
continuous intermittent
 37

Other supportive care

Level ..

Level .

Stress ulcer prophylaxis

DVT prophylaxis DVT

Level .

Stress ulcer prophylaxis

DVT prophylaxis DVT

Level 4 . /.

Stress ulcer prophylaxis

DVT prophylaxis DVT

 38

Bundle for sepsis resuscitation .

Categories /

SIRS
SIRS
systemic inflammation tissue perfusion2

(X rays, ultrasounds )

Oxygen Airway care, oxygen, Airway care, oxygen, respiratory support as indicated
respiratory support as
IV fluid
indicated
Hemoculture and culture from infectious sources

Hemoculture and culture
from infectious sources

Mean arterial pressure > 65 mmHg

Urine output > 0.5 ml/kg/hr

Mean arterial Reversal of tissue hypoxia

pressure > 65
mmHg

Urine output > NSS 500-1,000 ml

0.5 ml/kg/hr
3

norepinephrine MAP
NSS 3000 ml
1-3
lactate clearance ScvO24
 39

dopamine tissue hypoxia

o Packed red cell
norepinephrine
hematocrit < 30%

o hematocrit > 30%

dobutamine

(de-escalation)

1. Criteria of SIRS:

Temperature >38C or <36C

Heart rate > 90 beats/min

Respiratory rate >20 /min PaCO2 <32 mmHg

WBC >12,000 /mm3, <4000 /mm3, band form neutrophil >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 cmH2O

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

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

healthcare associated infection the most board spectrum antibiotic

4. Norepinephrine Dopamine *

5. 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 )

8. ICU

* Norepinephrine Norepinephrine 5%D/W ( NSS)

central venous catheter

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

MAP 65mmHg septic shock

0.1-0.3 g/kg/min 3-5
2 g/kg/min ( 5 g/kg/min)

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

healthcare associated infection the most board spectrum antibiotic

4. Norepinephrine Dopamine *
 46

5. Retained Foley catheter

( bladder ) record I/O

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

intubate+ respiratory support

7. blood lactate level ( physiologic score SOS score

)

8. ICU

* Norepinephrine Norepinephrine 5%D/W ( NSS)

central venous catheter

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

peripheral venous catheter

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

)

MAP 65mmHg septic shock

0.1-0.3 g/kg/min 3-5
2 g/kg/min ( 5 g/kg/min)

Note central venous catheter

 47

SOS score (search out severity score)

Nurse Record V/S as usual + SOS

- 4

-
- Record V/S - Record V/S, I/O . - incharge
- SOS score - SOS score - Extern /Intern
-
- - Record V/S, I/O -

-

ICU
-
severe sepsis and septic shock / Acute MI /
Acute PTE etc.
- Monitor -

severe sepsis and septic shock flow SOS < 4 stable

then monitor . . SOS < 4

then monitor . .
 48

severe sepsis septic shock

. . . . . /.

- - - -
- - -
-
- -

-
-

. .
-

-SIRS Criteria -SIRS Criteria SOS -SIRS Criteria SOS -SIRS Criteria SOS
SOS score score score score
- - -
- tissue - tissue - tissue
hypoperfusion hypoperfusion hypoperfusion
organ dysfunction organ dysfunction organ dysfunction




-Oxygen -Airway care, oxygen, -Airway care, oxygen, -Airway care, oxygen,
-IV fluid respiratory support respiratory support respiratory support

-Hemoculture -Hemoculture -Hemoculture


- IV 18-22 - IV 18-22 - IV 18-22 - IV 18-22
1 2 2 2
- Load IV fluid - Load IV fluid - CVP line
- Load IV fluid free 3 3
flow - - - - - Load IV fluid
 49

- 3
- -
-


- - - -
intravenous intravenous intravenous


1 1 1
1 1 1

-De-escalation -De-escalation
3-5 3-5


- -



- - Dopamine - Norepinephrine - Norepinephrine
Norepinephrine MAP MAP


- Dopamine - Dopamine
Dobutamine Dobutamine


-Mean arterial -Mean arterial -Mean arterial
pressure mmHg pressure mmHg pressure 65 mmHg
-Urine output > . -Urine output > . -Urine output > 0.5
ml/kg/hr ml/kg/hr ml/kg/hr
-SOS score 5 -Reversal of tissue -Reversal of tissue
hypoxia and hypoxia and
hypoperfusion hypoperfusion
Monitoring - MAP, urine MAP, urine MAP, urine
output SOS score output tissue output tissue
hypoxia and perfusion hypoxia and perfusion

Respiratory support - oxygen - oxygen - oxygen - oxygen
- - -
 50

Renal support - - -

- -

CRRT SLED CRRT SLED
- -

SLED IHD SLED IHD
acute peritoneal acute peritoneal
dialysis dialysis
- - -


80-180 80-180

- glycemic - glycemic
control protocol control protocol
Sedation - - -
hemodynamic hemodynamic hemodynamic

- - -

sedation sedation sedation
- sedation scale - sedation scale
protocol protocol