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Table-II
General variables
Fever (> 38.3°C)
Hypothermia (core temperature < 36°C)
Heart rate > 90/min
Tachypnea
Altered mental status
Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
Inflammatory variables
Leukocytosis (WBC count > 12,000 ìL–1)
Leukopenia (WBC count < 4000 ìL–1)
Normal WBC count with greater than 10% immature forms
Increased plasma C-reactive protein
Increased plasma procalcitonin
Hemodynamic variables
Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults )
Organ dysfunction variables
Arterial hypoxemia (Pao2/Fio2 < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
Creatinine increase > 0.5 mg/dL or 44.2 ìmol/L
Coagulation abnormalities (INR > 1.5 or aPTT> 60 s)
Paralytic Ileus
Thrombocytopenia (platelet count < 100,000 ìL–1)
Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 ìmol/L)
Tissue perfusion variables
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill
207
Management of Sepsis: Recent Advancement MI Patwary et al.
Table-III
Severe Sepsis1
Sepsis-induced hypotension
Lactate above normal limit (more than 1 mmol/L)
Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
Creatinine> 2.0 mg/dL (176.8 ìmol/L)
Bilirubin > 2 mg/dL (34.2 ìmol/L)
Platelet count < 100,000 ìL
Coagulopathy (INR> 1.5)
208
Journal of Bangladesh College of Physicians and Surgeons Vol. 34, No. 4, October 2016
localization along the sepsis spectrum of illness helps measurable endpoints at the 3- and 6-h marks.1Values
to define the early goals of management. A key significantly below this may be suggestive of
distinction should be made between sepsis and severe hypovolaemia and the potential need for additional fluid
sepsis/septic shock (SS/SS), the latter of which are the resuscitation. This intervention alone has been shown
focus of the Surviving Sepsis Campaign guidelines. It to reduce mortality.21-22In ProCESS trial; aggressive fluid
is recommended that patients with SS/SS should resuscitation (an average of 4.4 L in the first 6 h in this
undergo a protocol-driven approach which is suggested study) causes reduce mortality.20
by Rivers study in 2001 and supported by meta analysis Fluid selection: Crystalloids as the initial fluid of choice
in 2008.18-19It is a goal-directed approach to therapy of in the resuscitation of severe sepsis and septic shock.
SS/SS patients (early goal-directed therapy, EGDT) and Albumin is needed in the fluid resuscitation of severe
demonstrates a 16% absolute reduction in sepsis and septic shock when patients require
hospitalmortality.18-19However, the ProCESS trial, a substantial amounts of crystalloids. Initial fluid challenge
recent multicenter randomized trial of over 1300 patients or goal in patients with sepsis-induced tissue
demonstrated no such benefit.20 hypoperfusion is to achieve a minimum of 30 mL/kg of
Initial resuscitation: The goals during the first 6 hrs of crystalloids.1, 21-22
resuscitation: 1 Vasopressors: Vasopressor therapy initially to target a
a) Central venous pressure 8–12 mm Hg mean arterial pressure (MAP) of 65 mm Hg
b) Mean arterial pressure (MAP) e” 65 mm Hg .Norepinephrine as the first choice vasopressor.
Epinephrine is added when an additional agent is needed
c) Urine output e” 0.5 mL/kg/hr to maintain adequate blood pressure. Vasopressin 0.03
d) Central venous (superior vena cava) or mixed units/minute can be added to norepinephrine (NE) with
venous oxygen saturation 70% or 65%, respectively intent of either raising MAP in refractory hypotension
In patients with elevated lactate levels targeting and have beneficial hemodynamic and renal function
resuscitation to normalize lactate.1 effects6.Dopamine is an alternative vasopressor to
norepinephrine only in highly selected patients. Low-
In such instances, a goal-directed approach to therapy dose dopamine should not be used for renal protection1
is recommended by consensus guidelines with
Table-IV
209
Management of Sepsis: Recent Advancement MI Patwary et al.
210
Journal of Bangladesh College of Physicians and Surgeons Vol. 34, No. 4, October 2016
211
Management of Sepsis: Recent Advancement MI Patwary et al.
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