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130 x/min
Tachypnea
28 x/min
Anxious
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41000
Inflammatory Variables
Hypotension (SBP < 90 mmHg, MAP < 70 mmHg, or
an SBP > 40 mmHg or less than 2 SD below
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27/4/13
3.3
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12.7
State of
patient
APACHE II SCORE
Initial
Resuscitation
Diagnosis
Antibiotic
Therapy
Source Control
Fluid Therapy
Vasopressors
Corticosteroids
Recombinant
Human Activated
Protein C (rhAPC)
Inotropic Therapy
Blood Product
Administration
EARLY GOAL-DIRECTED
THERAPY
CVP
Minimize VO2
<8-12mmHg
>65 and>90mmHg
ScvO2
>70%
No
Goals
achieved
Volume load
colloid
8-12 mmHg
MAP
crystalloid
<65mmHg
<90mmHg
<70%
vasoactive agents
Transfusion of red cells
Until hematocrit >30%
Inotropic agents
>70%
<70%
Vasoactive drugs
O2 carrying
capacity
&
Inotrope
Initial Resuscitation
(First 6 hrs)
Resuscitation goals:
CVP 812 mm Hg
MAP 65 mm Hg
Urine output 0.5 mL/kg/hour
Central venous O2 saturation
70%,
or mixed venous 65%
60
50
49.2%
40
P = 0.01*
33.3%
30
20
10
0
Standard Therapy
EGDT
n =133
n=130
*Key difference was in sudden CV collapse, not MODS
Antibiotic
Therapy
Begin antibiotics as
early as possible, and
always within the first
hour of recognizing
severe sepsis and
septic shock.
Source Control
Drainage
Examples
Intra-abdominal abscess
Thoracic empyema
Septic arthritis
Debridement
Pyelonephritis, cholangitis
Infected pancreatic necrosis
Intestinal infarction
Mediastinitis
Device removal
Fluid
Therapy
Fluid-resuscitate using
crystalloids or colloids.
VASOPRESSOR
VASOPRESSOR
INOTROPIC
STEROIDS
Low-Dose Steroids: 28-day Mortality
28-day Mortality
100%
80%
100%
P=0.04
40%
53%
60%
N=114
N=115
20%
0%
0%
61%
N=36
40%
20%
Low-dose Steroids
P=0.96
80%
63%
60%
Placebo
53%
N=34
STEROIDS
Blood Product
Administration
Give RBC when Hb < 7.0
g/dl to target HB 7.09.0
g/dl in adults.
Administer platelets
when:
platelet counts are <
5,000/mm3 regardless of
bleeding.
platelet counts are 5000 to
30,000/mm3 and there is
significant bleeding risk.
platelet counts
50,000/mm3 are required for
surgery or invasive
Glucose Control
Use IV insulin to control
hyperglycemia in severe
sepsis
Keep blood glucose < 150
mg/dl
Best results obtained when blood glucose was
maintained between 80 and 110 mg/dL
Minimize the risk of hypoglycemia by providing a
continuous supply of glucose substrate (D5/D10)
followed by initiation for enteral feeding
Mortality (%)
15%
p < 0.04
(adjusted)
In-Hospital Mortality
15%
p = 0.01
10,9%
10%
7,2%
4,6%
5%
0%
10%
8,0%
n=783
n=765
Conventional
van den Berghe G. N Engl J Med 2001;345:1359-1367.
5%
0%
n=783
Intensive Insulin
n=765
Renal Replacement
Continuous venovenous hemofiltration and
intermittent hemodialysis are considered
equivalent in acute renal failure (in the absence
of hemodynamic instability)
Continuous hemofiltration
offers easier management
of fluid balance in
hemodynamically
unstable septic patients