update management of sepsis dhani redono - management sepsis 6.pdf · patients with sepsis or...
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Update Management of Sepsis
Dhani Redhono
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Treatment of Septic Shock
Infection ControlHemodynamic Stabilization
FluidsVasoactive
agentsAntibiotics
Source control
Steroid .....
Modulation of the septic response
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Lactate levels and mortality rates
Shapiro et al Lactate 0-2.4 mmol/L 2.5-3.9 mmol/L >4 mmol/L
Mortality 4.9% 9.0% 28.4%
Mikkelsen et al Lactate <2 mmol/L 2-3.9 mmol/L >4 mmol/L
Mortality 8.7% 16.4% 31.8%
Bhat et al Lactate <2 mmol/L 2-4 mmol/L >4 mmol/L
Mortality 12.7% 19..5% 24.6%
1. Most studies used lactate >4 mmol/L increased mortality 2. The exact lactate level that should trigger aggressive resuscitative
effort remains unknown3. An intermediate lactate level that associated with a sudden increase
in mortality not clear
West J Emerg Med. 2019;20(2)185-190
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Severe Sepsis Bundle
Activate Within ONE hour of presentation• Blood cultures x 2 sets
– Drawn before antibiotic and within 1 hr after TOP (time of presentation)
– 4 bottles total with minimum 8-10 mL/bottle
• IV Broad Spectrum Antibiotic
– Start within 1 hr after TOP unless given within past 24 hours
• Lactate
– Drawn within 1 hr after TOP
– Require 2-5mL blood in GREY top tube: Immediately put sample on ICE & transport to lab for analysis.
– If initial Lactate >18, then repeat within 3 hrs after 1st lactate draw
• IV fluid bolus (0.9% NS or LR)
– Min 30 mL/kg only if Septic Shock present
– Start within 1 hr after TOP and complete within 3 hrs
7
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• Patients given Antibiotics within 3 hours of TOP are ~80-85% more likely to survive
• In both the Pediatric & Adult patient population, after the first hours of severe sepsis or septic shock, every additional hour Antibiotics are delayed significantly increases the patient’s risk of mortality by 8-12% per hour!
1 - Andrew T. Levinson, M.D., M.P.H., Brian P. Casserly, M.D., Mitchell M. Levy, M.D.DisclosuresSemin Respir Crit Care Med. 2011;32(2):195-205.
Antibiotic Timing
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Initial Resuscitation
• Resuscitation from sepsis-induced hypoperfusion, at least 30ml/kg of intravenous crystalloid fluid be given within the first 3 hours.
• Following initial fluid resuscitation, additional fluids be guided by frequent reassessment of hemodynamic status.
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Diagnosis
• Routine microbiologic cultures (including blood) be obtained before starting antimicrobial therapy in patients with suspected sepsis and septic shock.
• Microbiologic cultures always include at least two sets of blood cultures (aerobic and anaerobic).
Diagnosis
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Sepsis Facts
1. Blood Cultures (X 2 Sets) • Blood Cultures are used to detect microorganisms
such as bacteria and fungi present in blood.
COLLECTION: Aerobic bottle FIRST then anaerobic bottle
- Adults require 8-10 mL per bottle X 4 bottles
- Pediatrics require 5 mL per bottle X 4 bottles *
– One BC from each vascular access in place >48 hrs
– Culture other sites as clinically indicated
- Blood cultures should always be drawn prior to start of antimicrobial therapy
*NOTE: Because microorganisms may only be intermittently present in blood, a series of blood cultures is usually done before the result can be considered negative.
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• Administration of IV antimicrobials be initiated as soon as possible after recognition and within 1 h for both sepsis and septic shock.
• Empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens.
Antibiotic
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Antibiotics
• Empiric combination therapy aimed at the most likely bacterial pathogen(s) for the initial management of septic shock.
• Combination therapy not be routinely used for on-going treatment of most other serious infections, including bacteremia and sepsis without shock.
Antibiotics
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Antimicrobial Therapy
Empiric antimicrobial therapy be narrowed once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted
Antimicrobial treatment duration of 7-10 days is adequate for most serious infections associated with sepsis and septic shock.
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Bacteria cause sepsis
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Antimicrobial Therapy
Daily assessment for de-escalation of antimicrobial therapy in patients with sepsis and septic shock.
Measurement of procalcitonin levels can be used to support shortening the duration of antimicrobial therapy in sepsis patients.
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Procalcitonin Guided Antibiotic Therapy
Póvoa, Salluh Annals of Intensive Care 2012, 2:32
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Guideline recommendations
Combination empirical therapy for the following patients (grade 2B):• Neutropenic with severe sepsis and for patients
with difficult-to-treat, multidrug-resistant bacterial pathogens (Acinetobacter or Pseudomonasbacteremia)
• Severe infections associated with respiratory failure and septic shock (Pseudomonas bacteremia)
• Septic shock from bacteremic Streptococcus pneumoniae
Crit Care Med 2013;41:580-637
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Combination therapy vs. monotherapy for
septic shock
Crit Care Med 2010;38:1773-85
Mortality rate *
Monotherapy(n=1223)
Combination Rx (n=1223)
HR (95% CI)
28-Day, % 36.3 29 0.77 (0.67 – 0.88)
ICU, % 35.7 28.8 0.75 (0.63 – 0.88)
Hospital, % 47.8 37.4 0.69 (0.59 – 0.81)
* Propensity score adjusted
# deaths
All Gram + , % 39.9 30.7 0.73 (0.58 – 0.92)
All Gram - , % 34.5 28.2 0.79 (0.67 – 0.94)
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Sepsis from pulmonary source
Infection Example antibiotic regimens
CAP β-lactam1 + azithromycinβ-lactam1 + respiratory FQ2
HCAP antipseudomonal β-lactam3
+ aminoglycoside4 or antipseudomonal FQ5
+ vancomycin or linezolid
1 ceftriaxone, cefotaxime, ampicillin/sulbactam2 levofloxacin, moxifloxacin3 piperacillin/tazobactam, cefepime, meropenem, imipenem, doripenem4 gentamicin, tobramycin, amikacin5 levofloxacin, ciprofloxacin
Clin Infect Dis 2007;44:S27-72
Am J Respir Crit Care Med 2005;171:388-416
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Sepsis from Biliary Tract Infection
Infection Example antibiotic regimens
E coli, Klebsiella, Enterococ
Ampicillin/sulbactam, meropenem, imipenem, piperacillin/tazobactam
With Diabetes Anaerobes antibiotic
Burke 2017
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Sepsis from Intra abdominal & Pelvic
Infection
Infection Example antibiotic regimens
Aerobes gram negative, B fragilis,
Monotherapy :
Ampicillin/sulbactam, meropenem, imipenem, tigecyclinepiperacillin/tazobactam
Combination therapy : Clindamycin or metronidazole
+ Aztreonam, levofloxacin or aminoglycoside
Burke 2017
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Sepsis from catheter-related bloodstream
infection (CRBSI)
Infection Example antibiotic regimens
CRBSI vancomycin or daptomycin1
+ antipseudomonal β-lactam2,3
+/- aminoglycoside4
Fungemiarisk factors
+ fluconazole or echinocandin5
1 if high rates of vancomycin MIC ≥ 2 µg/mL2 piperacillin/tazobactam, cefepime3 meropenem, imipenem, doripenem4 gentamicin, tobramycin, amikacin5 caspofungin, micafungin, anidulafungin
Clin Infect Dis 2009;49:1-45
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Sepsis from urosepsis
Infection Example antibiotic regimens
Aerobic Gram negative, Pseudomonas aeruginosa, Enterobacter sp
Monotherapy :
Levofloxacin, Aminoglycoside3rd or 4th Cephalosporin,
EnterococciVRE
Community acquired
Nosocomial urosepsis
Ampicilin or vancomycinLinezolid or daptomycin
Levofloxacin, azteronam or aminoglycoside
Piperacillin/tazobactamImipenem or meropenem
Int J Urol 2013; Burke 2017.
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Sepsis from unknown source
Infection Example antibiotic regimens
Unknown (
GI, GU Tract,
Pelvis)
Monotherapy :
Meropenem, imipenem, tigecyclinepiperacillin/tazobactam
Combination therapy : Metronidazole
+ Aztreonam or cefepime
Clin Infect Dis 2009;48:503-35 ; Burke 2017
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Cunha BA. Et al.Crit Care Clin 24 (2008) 313–334
Antimicrobial Treatment of Sepsis
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Fluid Therapy
• Crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock.
• Albumin in addition to crystalloids when patients require substantial amounts of crystalloids
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We recommend an initial target mean arterial pressure of 65 mmHg in patients with septic shock requiring vasopressors. (Strong recommendation; moderate quality of evidence)
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Vasoactive agents
• Norepinephrine as the first choice vasopressor
• Vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine with the intent of raising MAP to target, or adding vasopressin (up to 0.03 U/min) to decrease norepinephrine dosage.
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3
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Manajemen hemodinamik
1. Resusitasi cairan
2. Inotropik → ↑ Cardiac Output (CO)
3. Vasopresor → ↑ Tekanan darah ( TD )
Crit Care Clin 25 (2009) 781-802
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Nutrition• Early initiation of enteral feeding rather than a
complete fast or only IV glucose in critically ill patients with sepsis or septic shock who can be fed enterally.
• Early trophic/hypocaloric or early full enteral feeding in critically ill patients with sepsis or septic shock; if trophic/hypocaloric feeding is the initial strategy, then feeds should be advanced according to patient tolerance.
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Nutrition
• Parenteral nutrition alone or in combination with enteral feeds (but rather to initiate IV glucose and advance enteral feeds as tolerated) over the first 7 days in critically ill patients with sepsis or septic shock in whom early enteral feeding is not feasible.
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Nutrition
• Routinely monitoring gastric residual volumes in critically ill patients with sepsis or septic shock.
• Use of prokinetic agents in critically ill patients with sepsis or septic shock and feeding intolerance
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36
Glycerol
30g
Amino acid
Glucose
360g
Fatty acid
Fuel Source Fuel Consumption
Adipose tissue160g
Glucose-
genesis
Brain
Kidney
Inflammatory Mass
76g
144g
Lactate 136g
8g
170g
Muscle Protein
250g
Sepsis Berat
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Kebutuhan energi pada kondisi stres metabolik
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Metabolisme protein • Metabolisme saat
sepsis :
– Metabolic rate ↑
hipermetabolik
– Keseimbangan
nitrogen negatif
– Resistensi insulin
– Hiperglikemia
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Metabolisme protein Sepsis
Critical ill (trauma, sepsis, luka bakar, postop) protein otot dipecah
kemudian diubah menjadi AA dan AA ini dipakai untuk sintesis protein dan
glukoneogenesis.
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Basal Energy Expanditure
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Thank You!