Septic Shock & Sepsis¶

Bacteremia (fungemia)¶

- presence of viable bacteria (fungi) in the blood, as  evidenced by positive blood cultures

Sepsis—Suspected or confirmed infection with a new or increased Sequential Organ Failure Assessment (SOFA) score of 2 from baseline

- Sepsis + hypotensis <u>(requiring vasopressors) after fluid  loading plus lactate >2 mmol/L </u>

at least two of the following conditions
- oral temperature > 38°C (100.4°F) or < 35°C (95°F)
- respiratory rate > 20 breaths/min or partial pressure of arterial carbon dioxide (Paco2) < 32 mm Hg
- heart rate > 90 beats/min
- leukocyte count > 12,000/dL or < 4000/dL; or >10% bands

- proven or suspected microbial source

- dysfunction of more than  one organ, requiring intervention homeostasis

SOFA is the Sequential Organ Failure Assessment, a detailed scoring system used in intensive care units (ICUs) to assess organ function in critically ill patients.

qSOFA is a mortality predictor in ER
- Altered mental status
- RR >22/min
- ⋜ 100mmhg systolic BP

hypovolemia
- absolute hypovulemia
  - GI loss,tachypenea,sweating,decreased intake
- Relative hypovolumia
  - increased venous capaticance ,capillary leak => Right ventricualr filling
2.cardiovascular depression
- (TNF-α ), (IL-1β),(iNOS), as well as impairment in mitochondrial oxidative phosphorylation.
3.induction of systemic inflammation
- MODS by mictochondrial and microvascualr dysfunction => ARDS from capillary leak

Fluids resuscitation 20-30ml/kg
- increases preload EF, thereby improving the cardiac index.
Vasopressors/Ionotropes in Septic shock
find source of infection
Blood and pus cultures
check perfusion by Urine output and ABG lactate and base deficit
Ventialtor support
Early antibiotis
recheck fluid respone with urine ,BP, shock index
vasporesssors in Hypotension even after fluid therapy ,maintain 65mmHg MAP (OR) >90mmHg SBP
Bicarb

1.nor-epinephrine Drug of Choice
- initiated at 0.05 mcg/kg/ min, or 3 to 5 mcg/min
- titrated at 3 to 5 minute
- till mean arterial pressure is greater than 65 mm Hg.
2.Vasopressin as second vasopressor agent
- be initiated at 0.03 to 0.04 units/min
3. In tachy-arrythima pt on Nor-adre
- Vasopressin or phenylephrine can be a useful adjunct or alternative agent
4.Dobutamine + norepinephrine in Cardio & Septic shock
- mixed α and β-agonist for depressed cardiac index and persistent hypoperfusion even after IVF
- 2 mcg/kg/min to max 15 μg/kg/min titrate every 5-10min
- increase cardiac output and maintain adequate oxygen delivery
5.Adrenaline alone can work as Vassopressor & inonotropes
- 0.2 mcg/kg/min starting dose
6.Phenylephrine
- selective α1 agonist => TPR without change in cardiac output => can cause reflexive bradycardia or suppression in cardiac output
- use with Dopamine or Dobutamine
- 2–300 μg/min
7.Dopamine
- Precursor of Adre & Nor-adre
- α,β1,dopaminergic agonist.
- not used if othres available

Give
piperacillin- tazobactam, 4.5 g IV every 6 hours OR cefepime 2 g IV every 8 hours,
vancomycin, 30 mg/kg (maximum dose, 2 g) given every 12 hours, adjusted as appropriate for trough levels and renal failure.
for Double Courage with MDR
- ADD levofloxacin, 750 mg IV every 12 hours