sepsis / 敗血症
DESCRIPTION
Sepsis / 敗血症. Sang-Oh Lee Div. of Infectious Diseases Gil Medical Center Gachon Medical School. Systemic Response to Stimuli. When in a fever not of the intermittent type dyspnoea and delerium come on, the case is mortal. Hippocrates (the 5 th century BC ). - PowerPoint PPT PresentationTRANSCRIPT
Sepsis / 敗血症Sang-Oh Lee
Div. of Infectious DiseasesGil Medical Center
Gachon Medical School
When in a fever not of the intermittent t
ype dyspnoea and delerium come on, t
he case is mortal.
Hippocrates (the 5th century BC )
Systemic Response to Stimuli
Bone RC. Sepsis – Gulliver in Laputa. JAMA 273:155-6, 1995
enrolled patients were heterogenous
intervention may have come too late,
especially if multi-organ failure was
already in progress
Why Sepsis Trials Fail?
Why?
INCLUSION CRITERIA clinical evidence of infection
rectal temperature > 101 °F or < 96 °F
tachycardia (> 90/min) / tachypnea (> 20/min)
at least one of inadequate organ functions
mental change / hypoxemia / oligouria /
lactic acidosis
Bone RC. Crit Care Med 17:389-93, 1989
Sepsis Syndrome
clarify the meaning of bacteremia or septicemia
new concept of SIRS !
ACCP/SCCM Consensus, 1992
Chest 101:1644-55, 1992
Systemic inflammatory response syndrome temperature > 38 °C or < 36 °C
tachycardia (> 90/min)
tachypnea (> 20/min) or PaO2 < 32 mmHg
WBC > 12,000/mm3, < 4,000/mm3, or
> 10% immature forms
two or more of criteria !
Definition of SIRS
not sepsis syndrome (include organ failure)
sepsis – severe sepsis – septic shock !
Sepsis is a Continuum !
2,527 Cases of SIRSJAMA 273:117-23, 1995
SEPSIS is SIRS + clinical infection SEVERE SEPSIS Sepsis + organ hypoperfusion or hypotension
(including but not limited to lactic acidosis,
oligouria, or mental change) SEPTIC SHOCK sBP < 90 mmHg or > 40 from baseline
despite adequate fluid resuscitation
Definition of Sepsis Grade
… to say that I don’t like you !
That means just a severe patient !
High sensitivity, but too low specificity !
No account of site or type of infection !
It is harmful to clinicians !
Vincent JL. Crit Care Med 25:372-4, 1997
Dear SIRS, I’m sorry …
SIRS is just a part of consensus definitions !
SIRS was intended to be extremely sensitive
and helpful at the bedside !
for earlier and more intensive attention !
As we move forward precise terms !
account of pathophysiology & organisms
Dellinger RP, Bone RC. Crit Care Med 26:178-9, 1998
To SIRS with Love …
The Tower of Babel …환자가 septic 해졌어요 !
보호자 warning 해 !
어쩌다 그렇게 됐어 ?
체온은 39 도 , 맥박은 분당 100회 , 호흡수는 분당 22 회입니다 . 임상적으로 UTI 가 의심되어 urosepsis 로 판단됩니다 .
혈압이 85mmHg 까지 떨어졌지만 NS 을 1L 가량 빠르게 주면서 혈압이 회복된 것으로 보아 아직은 severe sepsis 의 단계로 보입니다 .
Therapeutic Options Broad-spectrum, maximum dose of antibiotics
necessary but not sufficient
Removal of the source of infection
Hemodynaic support of vasodilatory shock
fluid resuscitation with CVP monitor !!!
vasoconstrictors & inotropics
Respiratory & metabolic support
Antibiotics & Removal of Source
Early Goal Directed Therapy ECV depletion due to peripheral vasodilations
Normal saline 1-2 L iv over 1-2 hr
Goal ; MABP (S+2D/3) > 60 / SBP > 90 mmHg
Cardiac Index > 4 L/min/m2
PCWP 12-16 mmHg / CVP 10-12 cmH2O
Urine output > 30 mL/hr
Vasoconstictors & Inotropics
Hemodynamic Support
1
1
Vasodilation – SVR
ContractilityLV dilated
DA-1
RBFDopamine
3-10 ug/kg/min
< 3
> 10
Dobutamine> 6 ug/kg/min
Nep / Phenylephrine / Epi
Respiratory & Metabolic Support Ventilator ; hypoxemia, hypercapnea, tachypnea
RBC transfusion ; if low Hb.
FFP / Platelet ; if DIC
Metabolib acidosis (pH < 7.2) ; bicarbonate ?
respiratory compensation by ventilator
Acute, unstable phase ; glucose ?
Enteral feeding to reduce protein catabolism
Adjunctive Therapy 1
Adjunctive Therapy 2
