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` Septic pt must be treated with emperical

antimicrobials with proper maintenance of

hemodynamics and respiratory status

` All severe sepsis and septic patients must be

treated in ICU.

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` 1.Eradicate infections

` 2.Reverse Shock

` 3.Provide support to other organ system

` 4.Provide nutritional support` 5.Neutralize toxic mediators,cytokines in

sepsis(still in the research phase)

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` Needs to tackle urgently as soon as clinical dx of

setic shock is made or even suspected

` Promptly send blood,urine,and any other cultures

that may be relevant-eg..from discharging wounds,loculated fluids and abscesses.

` Empiric antibiotics(Broad-spectrum )should

promptly started without awaiting results of

cultures and other inv.` Monotherapy as per c/s repots

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` Drainage of focal source of infection

` Replace foleys and drainage catheter

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` Immunocompromised & neutopenic adult with sepsis

` 1. ceftriaxone (2gm/day)/

` ticarcilllin- clavulinate (3.1gm 4-6hrly)/

` piparcillin- tazobactam (3.375 gm 8 hrly)` 2. imipenem cilastatin (500mg 6hrly)/

` meropenem (1gm 8 hrly)/

` cefepime (2gm 12 hrly)

PLUSgentamycin or tobramycin(5-7 mg/kg/day)

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Add vancomycin (15mg/kg 12 hrly) if :

o Fever not subside after 36-48 hrs

o infected vascular catheter

o MRSA suspectedo received intensive chemotherapy that

produces mucosal damage

Add AMPHOTERICIN B(if fever do not

subsides after 2-3d with above regime)

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` Cefotaxime (2gm 8 hrly)/

` Ceftriaxone ( 2gm 12 hrly)

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` (A)Use of antibiotics

` (B)Identification and direct treatment of source of

infection

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` Nafcillin/ oxacillin (2gm 8 hrly)

+Gentamycin ( 5-7mg / kg /day)

+/-

Vancomycin (15mg/kg )

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` Cefepime ( 2gm 8hrly)/

` Ticarcillin- Clavulinate (3.1gm 4 hrly)/

` Piparcillin- Tazobactam (3.375gm 8 hrly)

+` Tobramycin (5-7mg/kg/day)

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` NOTE- IF PATIENT ALLERGIC TO BETA

LACTAM AGENTS

` CIPROFLOXACIN

` LEVOFLOXACIN` +

` CLINDAMYCIN

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IF PREVALANCE OF MRSA

` VANCOMYCIN

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a) Restore and maintain altered haemodynamic

profile to as close to normal with efficient cardiac

support

b) Ensure adequate oxygen supply to meet tissue

needs (increase O2 transport)

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` Secure airway if respirations ineffective or patient unable to protect

his airway.

Patients with hypotension not responding promptly to acute

volume expansion should also be intubated to prevent respiratory

arrest.

Supplemental O2

` Fluid resuscitation- follow BP, respiration, pulse, UOP, mental status,

and CVP to assess response.

` If circulatory status fails to improve after 2-3 L or signs of fluid

overload develop consider vasoactive agents.

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` starting initially with dopamine in low doses (2-5mcg/kg/min) as this will not only improve perfusionpressure but may help preserve renal function.

` The dose can then be titrated upward or NE addedto achieve and maintain a MAP of at least 60 mmHg.

` Blood cultures and initial laboratory values which

assess end organ function should be sent off- CBC,PT/PTT, UA.

` This initial resuscitation should ideally beaccomplished within 1 hour.

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` Targeted goal to maintain perfusion

-PCWP(12-16mm Hg)

-CVP(8-12 cm H2o)

-MAP (>65 mm Hg)-Cardiac Index (>4L/M2)

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` No improvement in perfusion even with iv fluids

and vessopressors

` Think of ADRENAL INSUFFICIENCY

` Treat with hydrocortisone (50mg 6hrly)

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` INDICATIONS:

-progressive hypoxemia

-hypercapnea

-neurological deterioration-Respiratory muscle fatigue

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` Correct metabolic acidosis with Bicarbonate

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` Respiratory support

` Renal support

` Cardiac support

` G.I support

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` Nutritional support

` Prophylactic heparinization

` Manage hypo and hyperglycemia

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` Rec. activated protein C

Dose:24mcg/kg/hr ---96 hrs

Monitor clotting parameter:

-avoid in pt with PC

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` Endotoxin-neutralizing proteins

` Inhibition of cyclo-oxygenase and No synthetase

` Anticoagulants

` Polyclonal immunoglobulins` Glucocorticoids

` Antagonist to TNFa,IL-1,PAF,Bradykinin

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` 30% pt with severe sepsis and 40% to 70% with

septic shock has 30 days mortality.

` Prevention of septic shock is more important in

decreasing morbidity and mortality.

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` WITH EARLY DIAGNOSIS AND AGGRESSIVE

TREATMENT WITH ANTIBIOTICS AND

MAINTAINING PROPER PERFUSION ALONG

WITH CLOS

E MONITORING

MORTALITY DUETO SEPSISAND SEPTIC SHOCK CAN BE

REDUCED.

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` HARRISONS 17TH EDITION

` TEXT BOOK OF CRITICAL CARE

` NEMJ

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