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SEPSIS FAST TRACK คปสอ วานรนิวาส

SEPSIS FAST TRACK คปสอ วานรนิวาส. นพ . สาธิต กาสุริย์. SEPSIS and It’s Disease spectrum. Various stages of disease Bacteremia SIRS Sepsis syndrome Sepsis shock : early and refractory. Definition. Infection Presence of microorganisms in a normally sterile site. Bacteremia

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SEPSIS FAST TRACK คปสอ วานรนิวาส

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  1. SEPSIS FAST TRACKคปสอ วานรนิวาส นพ.สาธิต กาสุริย์

  2. SEPSIS and It’s Disease spectrum • Various stages of disease • Bacteremia • SIRS • Sepsis syndrome • Sepsis shock : early and refractory

  3. Definition • Infection • Presence of microorganisms in a normally sterile site. • Bacteremia • Cultivatable bacteria in the blood stream. • Sepsis • The systemic response to infection. If associated with proven or clinically suspected infection, SIRS is called “sepsis”. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee. Crit Care Med. 1992;20:864-874.

  4. SIRS (Systemic Inflammatory Response Syndrome) • The systemic response to a wide range of stresses. • Temperature >38°C (100.4°) or <36°C (96.8°F). • Heart rate >90 beats/min. • Respiratory rate >20 breaths/min or PaCO2 <32 mmHg. • White blood cells > 12,000cells/ml or < 4,000 cells/ml or >10% immature (band) forms. • Note • Two or more of the following must be present. • These changes should be represent acute alterations from baseline in the absence of other known cause for the abnormalities. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee. Crit Care Med. 1992;20:864-874.

  5. Severe Sepsis • Sepsis with organ hypoperfusion one of the followings : • SBP < 90 mmHg • Acute mental status change • PaO2 < 60 mmHg on RA (PaO2 /FiO2 < 250) • Increased lactic acid/acidosis • Oliguria • DIC or Platelet < 80,000 /mm3 • Liver enzymes > 2 x normal American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee. Crit Care Med. 1992;20:864-874.

  6. MODS(Multiple Organ Dysfunction Syndrome) • Sepsis with multiorgan hypoperfusion Two or more of the followings: • SBP < 90 mmHg • Acute mental status change • PaO2 < 60 mmHg on RA (PaO2 /FiO2 < 250) • Increased lactic acid/acidosis • Oliguria • DIC or Platelet < 80,000 /mm3 • Liver enzymes > 2 x normal American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee. Crit Care Med. 1992;20:864-874.

  7. Relationship between SIRS and Sepsis Bone RC et al, Chest1992;101:164-55.

  8. Severe Sepsis Septic Shock SIRS Sepsis The Sepsis Continuum • A clinical response arising from a nonspecific insult, with 2 of the following: • T >38oC or <36oC • HR >90 beats/min • RR >20/min • WBC >12,000/mm3or <4,000/mm3 or >10% bands SIRS with a presumed or confirmed infectious process Sepsis with organ failure Refractory hypotension SIRS = systemic inflammatory response syndrome Chest 1992;101:1644.

  9. Mortality rate in SIRS Rangel-Frausto, et al. JAMA 273:117-123, 1995.

  10. Inflammatory Response to Sepsis NEJM 2006;355:1699-1713.

  11. Procoagulant Response in Sepsis NEJM 2006;355:1699-1713.

  12. Pathogenesis of sepsis and septic shock Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

  13. Pathogenesis of Severe Sepsis Infection Microbial Products (exotoxin/endotoxin) Cellular Responses Platelet Activation Cytokines TNF, IL-1, IL-6 CoagulationActivation Kinins Complement Oxidases Coagulopathy/DIC Vascular/Organ System Injury Endothelial damage Endothelialdamage Multi-Organ Failure Death

  14. Risk factors of sepsis • aggressive oncological chemotherapy and radiation therapy • use of corticosteroid and immunosuppressive therapies for organ transplants and inflammatory diseases • longer lives of patients predisposed to sepsis, the elderly, diabetics, cancer patients, patients with major organ failure, and with granulocyopenia. • Neonates are more likely to develop sepsis (ex. group B Streptococcal infections). • increased use of invasive devices such as surgical protheses, inhalation equipment, and intravenous and urinary catheters. • indiscriminate use of antimicrobial drugs that create conditions of overgrowth, colonization, and subsequent infection by aggressive, antimicrobial-resistant organisms. Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

  15. Patients at increased risks of developing sepsis • Underlying diseases: neutropenia, solid tumors, leukemia, dysproteinemias, cirrhosis of the liver, diabetes, AIDS, serious chronic conditions. • Surgery or instrumentation: catheters. • Prior drug therapy: Immuno-suppressive drugs, especially with broad-spectrum antibiotics. • Age: males, above 40 y; females, 20-45 y. • Miscellaneous conditions: childbirth, septic abortion, trauma and widespread burns, intestinal ulceration. Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

  16. Source(usually an endogenous source of infection) • intestinal tract • oropharynx • instrumentation sites • contaminated inhalation therapy equipment • IV fluids. • Most frequent sites of infection: Lungs, abdomen, and urinary tract. • Other sources include the skin/soft tissue and the CNS. Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

  17. Diagnosis • History • community or nosocomially acquired infection • immunocompromised patient • exposure to animals, travel, tick bites, occupational hazards, alcohol use, seizures, loss of consciousness, medications • underlying diseases ; specific infectious agents • Some clues to a septic event include • Fever or unexplained signs with malignancy or instrumentation • Hypotension • Oliguria or anuria • Tachypnea or hyperpnea • Hypothermia without obvious cause • Bleeding Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

  18. Specific Infectious agents • Splenectomy(traumatic or functional) • S pneumoniae, H influenzae, N meningitidis • Neutropenia (<500 neutrophil/ml) • Gram-negative, including P aeruginosa, gram-positives, including S aureus • Fungi, especially Candida species • Hypogammaglobulinemia (e.g.,CLL) • S pneumoniae, E coli • Burns • MRSA, P aeruginosa, resistant gram-negatives MacArthur RD, et al. Mosby, 2001:3-10. Wheeler AP, et al. NEJM 1999;340:207-214. Chaowagul W, et al. J Infect Dis 1989;159:890-899.

  19. Specific Infectious agents • Aids • P aeuginosa (if neutropenic), S aureus, PCP pneumonia • Intravascular devices • S aureus, S epidermidis • Nosocomial infections • MRSA, Enterococcus species, resistant gram-negative, Candida species • Septic patients in NE of Thailand • Burkholderiapseudomallei MacArthur RD, et al. Mosby, 2001:3-10. Wheeler AP, et al. NEJM 1999;340:207-214. Chaowagul W, et al. J Infect Dis 1989;159:890-899.

  20. Diagnosis • Physical Examination • essential • In all neutropenic patients and in patients with as suspected pelvic infection the physical exam should include rectal, pelvic, and genital examinations • perirectal, and/or perineal abscesses • pelvic inflammatory disease and/or abscesses, or prostatitis Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

  21. Signs and Symptoms • Nonspecific symptoms of sepsis : not pathognomonic • fever • chills • constitutional symptoms of fatigue, malaise • anxiety or confusion • absent symptoms in serious infections, especially in elderly individuals Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

  22. Complications • Adult respiratory distress syndrome (ARDS) • Disseminated Intravascular Coagulation (DIC) • Acute Renal failure (ARF) • Intestinal bleeding • Liver failure • Central Nervous System dysfunction • Heart failure • Death Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

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