1

.
..
..

severe sepsis septic shock ( ) .. 2558

severe
sepsis septic shock

severe sepsis septic shock ( ) .. 2558

...

..

..
...

...

..

..
..

severe sepsis septic shock ( ) .. 2558

(severe sepsis) (septic

shock)
(service plan) .

Strategy

Diagnosis

10

Early recognition and Initial assessment

12

Initial septic workup

15

Antibiotic therapy

17

Source control

21

Fluid therapy

23

Vasopressor and inotropes

26

Monitoring

29

Organ support
- Respiratory support

32

- Renal support

35

Other managements
- Glycemic control

37

- Sedation

39

- Other supportive care

40

severe sepsis septic shock

41

1
Sepsis Resuscitation Bundle
.
2
SOS score
3
severe sepsis
septic shock
4
protocol

-
-
5
-

- parameter

42

64

51
52

56
59
62
63

severe sepsis septic shock
3
1. (early recognition)
2.
(early infection control, early resuscitation, and organ support)
3.

1. (early recognition)



(Sepsis watch) SOS score

2.
(early infection control, early resuscitation, and organ support)

severe sepsis septic shock
Sepsis bundles
3.

Rapid response team, Medical

emergency team

1 sepsis

10

Diagnosis of Sepsis and Severe Sepsis

sepsis
organ dysfunction
sepsis systemic inflammatory
response syndrome (SIRS)
sepsis
sepsis SIRS 2
( 1)
severe sepsis sepsis tissue hypoperfusion organ dysfunction ( 2)
hypotension
septic shock sepsis systolic blood pressure < 90 mm Hg systolic blood
pressure > 40 mm Hg mean arterial pressure < 70 mm Hg
fluid resuscitation

criteria SIRS
Temperature >38C or <36C
Heart rate > 90 beats/min
Respiratory rate >20 /min PaCO2 <32 mm Hg
WBC >12,000 /mm3, <4000 /mm3, band form neutrophil >10 %

11

2 tissue hypoperfusion organ dysfunction severe sepsis

Sepsis hypotension
blood lactate level upper limits laboratory normal
Urine output < 0.5 mL/kg/hr 2 .
Acute lung injury Pao2/Fio2 < 250 pneumonia
Acute lung injury Pao2/Fio2 < 200 pneumonia
Creatinine > 2.0 mg/dL (176.8 mol/L)
Bilirubin > 2 mg/dL (34.2 mol/L)
Platelet count < 100,000 L
Coagulopathy (international normalized ratio > 1.5)

sepsis , severe sepsis septic shock
surviving sepsis campaign: international guideline for management of severe sepsis and septic
shock 2012
SIRS criteria
tissue hypoperfusion organ dysfunction severe sepsis


metabolic acidosis

12

Early Recognition and Initial assessment

Level 1 ..
SIRS Criteria SOS score ()
sepsis
SIRS criteria 2 SOS score 3

sepsis
SOS score vital signs
sepsis sepsis
SOS score 5 severe sepsis septic shock

Level 2 .
SIRS Criteria SOS score sepsis
SIRS criteria 2 SOS score 3

sepsis

SOS score vital signs ( blood
lactate level )
tissue hypoperfusion organ dysfunction
sepsis tissue hypoperfusion organ dysfunction
sepsis SOS score 5 severe sepsis septic
shock

13

Level 3 .
SIRS Criteria sepsis
4-6 . SOS score
sepsis, severe sepsis septic shock
SIRS criteria 2 SOS score 3

sepsis

SOS score vital signs
tissue hypoperfusion organ dysfunction
blood lactate level tissue hypoperfusion ()
sepsis tissue hypoperfusion organ dysfunction
blood lactate level upper limits laboratory normal ( 4 mmol/L)
sepsis SOS score 5 severe sepsis septic
shock
Level 4 . /.
SIRS Criteria sepsis
4-6 . SOS score
sepsis, severe sepsis septic shock
SIRS criteria SOS score

sepsis

SOS score vital signs
tissue hypoperfusion organ dysfunction
blood lactate level tissue hypoperfusion

14

sepsis tissue hypoperfusion organ dysfunction

blood lactate level upper limits laboratory normal ( 4 mmol/L)
sepsis SOS score 5 severe sepsis septic
shock
tissue
hypoperfusion resuscitation (
resuscitation )

SOS score
sepsis SOS score
SOS score

15

Initial Septic Workup sepsis

Level 1 ..

Level 2 .



o Complete blood count
o Urine analysis/culture
o Blood culture 2 specimens
o Chest x-rays
o clot blood serology

Level 3 .


o Complete blood count
o Urine analysis/culture
o Blood culture 2 specimens
o Chest x-rays
o clot blood serology

o Serology test

16

o
o ultrasound , , ,

o
Level 4 . /.


o Complete blood count
o Urine analysis/culture
o Blood culture 2 specimens
o Chest x-rays
o clot blood serology

o Serology test
o
o ultrasound , , ,

o CT MRI

o
neutropenia
galactomannan
PCR Aspergillus Candida

17

Antibiotic therapy
Level 1 ..

Level 2 .
(hemoculture) 2
Gram stain specimens
sepsis


intravenous
1
sepsis


Level 3 .
(hemoculture) 2
Gram stain specimens
sepsis


intravenous
1
sepsis .

18

combination
( 3)
3 combination
Neutropenia
prevalence multi-drug resistant bacteria Pseudomonas,
Acinetobacter, ESBL-producing organisms
Pseudomonas aeruginosa bacteremia septic shock respiratory failure
Streptococcus pneumoniae bacteremia septic shock

sepsis

sepsis exclude


specimens
(De-escalation)
7-10

-
-

(undrainable focus of
infection)
- neutropenia

19

Level 4 . /.
(hemoculture) 2
Gram stain specimens
sepsis


intravenous
1
sepsis .

combination
( 3)

sepsis

sepsis exclude


specimens
(De-escalation)
7-10

-

20

(undrainable focus of
infection)
- neutropenia
serum procalcitonin (PCT)

21

Source control
Level 1 ..

(severe sepsis or septic

shock)

Level 2 .





(percutaneous drainage)

Level 3 .

percutaneous drainage

22

Level 4 . /.

percutaneous drainage

resuscitation

resuscitation
infected peripancreatic necrosis

23

Fluid therapy
Level 1 ..
IV 18-20 1 load IV fluid
free flow ( load
)
Level 2 .
IV 18-20 2
load IV fluid 30 ml/kg 2 ( 3 )
60
load IV fluid 30 ml/kg ( 1.5 ) 60

10-15
crepitation
Level 3 .
IV 18-20 2
load IV fluid 30 ml/kg 2 ( 3 )
60
load IV fluid 30 ml/kg ( 1.5 ) 60

10-15
crepitation CXR pulmonary edema


central venous pressure, pulse pressure variation, IVC variation ultrasound

24

Level 4 . /.
IV 18-20 2
CVP line
load IV fluid 30 ml/kg 2 ( 3 )
60
load IV fluid 30 ml/kg ( 1.5 ) 60


fluid responsiveness
central venous pressure, pulmonary capillary wedge pressure, pulse pressure
variation, IVC variation ultrasound, cardiac output, echocardiogram
30 ml/kg
10-15
crepitation CXR pulmonary edema plateau
pressure extravascular lung water


resuscitation NSS colloid
IV peripheral
central line IV peripheral
2

100 %
()

pulmonary

25

edema pulmonary edema

(3 3-6 .)
pulmonary edema

10-15
6
500-1,000 ml

shock severe
sepsis septic shock

26

Vasopressor and inotropes

Level 1 ..
(SBP< 90 .)


Level 2 .
Norepinephrine Dopamine

Dopamine Dopamine 5%D/W( NSS)

Dopamine 250 mg 5%D/W 250 ml 5 g/kg/min
3-5 MAP 65 . 20g/kg/min
()
NIBP 3-5
15-30
Level 3 .
Norepinephrine Dopamine
central venous catheter
Norepinephrine 5%D/W ( NSS) Norepinephrine 4 mg
5%D/W 50-100 ml syringe pump ( central
venous catheter) Norepinephrine mg %D/W 250ml
infusion pump ( peripheral venous catheter)
MAP 65 . septic shock
0.1-0.3 g/kg/min 3-5
2 g/kg/min ( 5
g/kg/min) ()

27

Dopamine
Dobutamine 20g/kg/min
MAP 65 . Dopamine/
Norepinephrine Epinephrine
MAP 65 .

MAP . Hydrocortisone
200-300mg/day 8
NIBP 3-5
-
continuous invasive arterial pressure
monitoring
Level 4 . /.
Norepinephrine ( Dopamine)
central venous catheter

Dobutamine
MAP 65 . Norepinephrine
/ Dopamine Epinephrine
MAP 65 .

MAP 65 . Hydrocortisone
200-300mg/day 8
NIBP 3-5
15-30

28

continuous invasive arterial pressure

monitoring

Norepinephrine NSS
central venous catheter
peripheral venous Dopamine 1:1
( 250 mg 5%D/W 250 ml ) Norepinephrine 4 mg 5%D/W 250 ml
tissue ischemia
. High drug alert
MAP
. severe acidosis
shock


continuous invasive arterial pressure monitoring

29

Monitoring
Level 1 ..
(mean arterial pressure)
.

Level 2 .
MAP . 15-30
( NIBP 3-5
)
. ././.

pulse
oximetry %
Level 3 .
MAP . 15-30
( NIBP 3-5
)
. ././.
central venous catheter CVP
8 . ( . )

central venous catheter central venous oxygen saturation (ScvO2)
70%
CVP
vasopressor
%

30

Dobutamine
central venous catheter ScvO2
Lactate Lactate
ScvO2

pulse
oximetry %
Level 4 . /.
6
o MAP . 15-30 (
NIBP 3-5
)
o . ././.
o central venous catheter CVP
8 . ( . )

o central venous catheter central venous oxygen saturation
(ScvO2) 70%
CVP
vasopressor
%
Dobutamine
o central venous catheter ScvO2
Lactate Lactate
ScvO2

o . ././.

31

o arterial line
(fluid
responsiveness) pulse pressure variation
o
modified fluid challenge test, pulse pressure variation, stroke
volume variation, IVC variation ultrasound, passive leg raising test
continuous cardiac output ()
Norepinephrine

pulse
oximetry %

systolic BP MAP (mean arterial pressure)
diastolic BP

32

Respiratory support
Level 1 ..

oxygen

oxygen nasal cannula 4-6

oxygen 6-10 reservoir
bag 10-15 oxygen nasal cannula 4-6
Level 2 .

oxygen

oxygen nasal cannula 4-6

respiratory paradox
oxygen
oxygen pulse oxymeter
(arterial blood gases)

ICU
Level 3 .

oxygen

33

oxygen nasal cannula 4-6

respiratory paradox
oxygen
oxygen pulse oxymeter
(arterial blood gases)
ICU

(metabolic acidosis)

respiratory rate tidal volume respiratory
rate 20-30 tidal volume 10-12 ./.
hemodynamic
ARDS tidal volume 6 ./.
plateau pressure 28-30 PEEP (positive end-expiratory
pressure) 48 .

(permissive hypercapnia)
Level 4 . /.

oxygen

oxygen nasal cannula 4-6

34

respiratory paradox
oxygen
oxygen pulse oxymeter
(arterial blood gases)
ICU

(metabolic acidosis)

respiratory rate tidal volume respiratory
rate 20-30 tidal volume 10-12 ./.
hemodynamic
ARDS tidal volume 6 ./.
plateau pressure 28-30 PEEP (positive end-expiratory
pressure) 48 .

(permissive hypercapnia)

35

Renal Support
Level 1 ..

Level 2 .

1.5 30
6
Level 3 .

(pH < 7.2
15 mEq/L)

6.2 mEq/L

pericardial friction
rub myoclonus
BUN 60 mg/dl

(CRRT)
sustained low efficiency dialysis (SLED)
sustained low
efficiency dialysis (SLED) intermittent hemodialysis (IHD)
(acute peritoneal dialysis)

36

Level 4 . /.

(pH < 7.2
15 mEq/L)

6.2 mEq/L

pericardial friction
rub myoclonus
BUN 60 mg/dl

(CRRT)
sustained low efficiency dialysis (SLED)
sustained low
efficiency dialysis (SLED) intermittent hemodialysis (IHD)
(acute peritoneal dialysis)

cardiovascular
SOFA 0-2 2

37

Glycemic control
Level 1 ..

Level 2 .
(glucometer)
(blood sugar)
o % glucose 50
dextrose rate
NSS resuscitation
o 180 NSS resuscitation

o
180 regular
insulin glucometer
Level 3 .
(glucometer)
(blood sugar)
o % glucose 50
dextrose rate
NSS resuscitation
o
180 regular
insulin glucometer
regular insulin continuous intravenous infusion
-

38

o glycemic control protocol

Level 4 . /.
(glucometer)
(blood sugar)
o % glucose 50
dextrose rate
NSS resuscitation
o
180 regular
insulin glucometer
regular insulin continuous intravenous infusion
-

glycemic variability
o glycemic control protocol
o glycometer
insulin infusion
o insulin mixed split premix

-

39

Sedation
Level ..

Level .
sedation hemodynamic
sedation
Level .
sedation hemodynamic
sedation
sedation scale protocol
continuous intermittent
Level 4 . /.
sedation hemodynamic
sedation
sedation scale protocol
continuous intermittent

40

Other supportive care

Level ..

Level .
Stress ulcer prophylaxis
DVT prophylaxis DVT
Level .
Stress ulcer prophylaxis
DVT prophylaxis DVT
Level 4 . /.
Stress ulcer prophylaxis
DVT prophylaxis DVT

41

Level ..
SOS score 38.5
90/60 .
. 60
Level .
Hemoculture
30 ml/kg 1.5 1
1
Level .
Hemoculture
30 ml/kg 1.5 1
1
severe sepsis septic shock 3 (sepsis
fast track)
severe sepsis septic shock . (community acquire sepsis)
Level 4 . /.
Hemoculture
30 ml/kg 1.5 1
1
severe sepsis septic shock 3 (sepsis
fast track)
severe sepsis septic shock . (community acquire sepsis)

42

1
sepsis resuscitation bundle .
Categories

SIRS

SIRS

systemic inflammation tissue perfusion2

(X rays, ultrasounds )

Oxygen

IV fluid

Airway care, oxygen,

respiratory support as
indicated

Airway care, oxygen, respiratory support as indicated

Hemoculture and culture from infectious sources

Hemoculture and culture

from infectious sources

Mean arterial pressure > 65 mmHg

Urine output > 0.5 ml/kg/hr

Reversal of tissue hypoxia

Mean arterial
pressure > 65
mmHg

Urine output >

NSS 500-1,000 ml

0.5 ml/kg/hr

NSS 3000 ml

1-3

norepinephrine MAP

lactate clearance ScvO24

43

dopamine

tissue hypoxia

o Packed red cell

norepinephrine

hematocrit < 30%

o hematocrit > 30%
dobutamine

(de-escalation)

1. Criteria of SIRS:
Temperature >38C or <36C
Heart rate > 90 beats/min
Respiratory rate >20 /min PaCO2 <32 mmHg
WBC >12,000 /mm3, <4000 /mm3, band form neutrophil >10 %
2. Criteria of sepsis SSC

(surviving sepsis campaign: international guideline for management of severe

sepsis and septic shock 2012)

1
1

44

criteria sepsis

General variables
Fever (>

C)

Hypothermia (core temperature < C)

Heart rate > /min or more than two SD above the normal value for age
Tachypnea
Altered mental status
Significant edema or positive fluid balance (> mL/kg over hr)
Hyperglycemia (plasma glucose >

mg/dL or

mmol/L) in the absence of diabetes

Inflammatory variables
Leukocytosis (WBC count > , /L)
Leukopenia (WBC count <

/L)

Normal WBC count with greater than

% immature forms

Plasma C-reactive protein more than two SD above the normal value
Plasma procalcitonin more than two SD above the normal value
Hemodynamic variables
Arterial hypotension (SBP < mm Hg, MAP < mm Hg, or an SBP decrease > mm Hg in adults or less than two SD
below normal for age)
Organ dysfunction variables
Arterial hypoxemia (Pao /Fio <

Acute oliguria (urine output < . mL/kg/hr for at least hrs despite adequate fluid resuscitation)
Creatinine increase > . mg/dL or

mol/L

45

Coagulation abnormalities (INR > . or aPTT > s)

Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < , /L)
Hyperbilirubinemia (plasma total bilirubin > mg/dL or mol/L)
Tissue perfusion variables
Hyperlactatemia (> mmol/L)
Decreased capillary refill or mottling

3.

intravascular volume

a. Clinical

JVP, ,

b. CVP 12 cmH2O 15 cmH2O

c. Volume responsive tests Pulse pressure variability, Response to straight leg raising, IVC
diameter variability

4.

tissue perfusion

capillary refill 2

metabolic acidosis blood lactate 10-20% ScvO270%

46

1 ()
Resuscitation Bundle severe sepsis septic shock .
Bundle ..
1. IV NSS load free flow 18-22 1
2. oxygen 20
3.
Note severe sepsis septic shock SOS score 3

( load )

Bundle .
. Take H/C specimen specimen
+ specimen culture
. IV - load NSS free flow

( )

> ( . )
-
crepitation
. Start IV ABO take H/C , culture
community acquired Ceftriaxone g

47

melioidosis Ceftazidime g
healthcare associated infection the most board spectrum antibiotic
. Start Dopamine

mg + %D/W

ml ( : ) 20 ml/hr fixed rate IV ,

ml

Titrate ml/hr
MAP , mmHg
Dopamine 60 ml/hr Norepinephrine*
. Retained Foley catheter Record I/O
( bladder )
6. oxygen 20 SpO2 sat < 92% RR > 30/min
intubate + respiratory support
7. physiologic score SOS score ( blood lactate )

Bundle .
1. Take H/C 2 specimen 1 specimen
+ specimen culture
2. IV 18-22 2 load NSS free flow
60

( 3 )

> 60 ( 1.5 )
30 ml/Kg NSS 500-1,000 ml

6-12 .

48

3. Start IV ABO take H/C , culture

community acquired Ceftriaxone 2 g
melioidosis Ceftazidime 2 g
healthcare associated infection the most board spectrum antibiotic
4. Norepinephrine Dopamine *
5. Retained Foley catheter Record I/O
( bladder )
6. oxygen 20 SpO2 sat < 92% RR > 30/min
intubate+ respiratory support
7. physiologic score SOS score ( blood lactate )
8. ICU
* Norepinephrine Norepinephrine 5%D/W ( NSS)
central venous catheter
Norepinephrine 4 mg 5%D/W 50-100 ml syringe pump
peripheral venous catheter
Norepinephrine 4 mg 5%D/W 250 ml infusion pump (
)
MAP 65mmHg septic shock
0.1-0.3 g/kg/min 3-5
2 g/kg/min ( 5 g/kg/min)
Note central venous catheter

49

Bundle . /.
1. Take H/C 2 specimen 1 specimen
+ specimen culture
2. IV 18-22 2 load NSS free flow
30 ml/Kg NSS 500-1,000 ml

6-12 .
60

( 3 )

> 60 ( 1.5 )
10-15

3. Start IV ABO take H/C , culture
community acquired Ceftriaxone 2 g
melioidosis Ceftazidime 2 g
healthcare associated infection the most board spectrum antibiotic
4. Norepinephrine Dopamine *
5. Retained Foley catheter Record I/O
( bladder )
6. oxygen 20 SpO2 sat < 92% RR > 30/min
intubate+ respiratory support

50

7. blood lactate level ( physiologic score SOS score

)
8. ICU
* Norepinephrine Norepinephrine 5%D/W ( NSS)
central venous catheter
Norepinephrine 4mg 5%D/W 50-100 ml syringe pump
peripheral venous catheter
Norepinephrine 4 mg 5%D/W 250ml infusion pump (
)
MAP 65mmHg septic shock
0.1-0.3 g/kg/min 3-5
2 g/kg/min ( 5 g/kg/min)
Note central venous catheter

51

2
SOS score (search out severity score)

Nurse Record V/S as usual + SOS

0-1

2-3

4
-

- Record V/S

- Record V/S

- SOS score

- SOS score

. I/O - 8 .

- incharge
- Extern /Intern

- Record V/S, I/O

-
ICU
-

severe sepsis and septic shock / Acute MI /

Acute PTE etc.

severe sepsis and septic shock flow

- Monitor

SOS < 4 stable

then monitor

. . SOS < 4

then monitor

. .

52

3
severe sepsis septic shock

..

. /.

-
-
-

-
-
-

-
-

-SIRS Criteria
SOS score

-Oxygen
-IV fluid

- IV 18-22
1

- Load IV fluid free
flow

-
-

.
-

-SIRS Criteria SOS -SIRS Criteria SOS -SIRS Criteria SOS
score
score
score
-
-
-
- tissue
- tissue
- tissue
hypoperfusion
hypoperfusion
hypoperfusion
organ dysfunction
organ dysfunction
organ dysfunction

-Airway care, oxygen, -Airway care, oxygen, -Airway care, oxygen,

respiratory support
respiratory support
respiratory support



-Hemoculture -Hemoculture -Hemoculture

- IV 18-22 - IV 18-22 - IV 18-22

2
2
2
- Load IV fluid
- Load IV fluid
- CVP line
30 ml/kg*
30 ml/kg*

- - - - - Load IV fluid
-
30 ml/kg*
- -

53

-
intravenous

1
1
*

- Norepinephrine
Dopamine
MAP

Monitoring

Respiratory support

-Mean arterial
pressure mmHg
-Urine output > .
ml/kg/hr
-SOS score 5

MAP, urine
output SOS score

- oxygen - oxygen
-

-
intravenous

1
1
*
-De-escalation
3-5

- Norepinephrine
MAP

- Dopamine
Dobutamine



-Mean arterial
pressure mmHg
-Urine output > .
ml/kg/hr
-Reversal of tissue
hypoperfusion and
hypoxia*
MAP, urine
output tissue
perfusion

- oxygen
-

-

*
-
intravenous

1
1
*
-De-escalation
3-5

- Norepinephrine
MAP

- Dopamine
Dobutamine

-Mean arterial
pressure 65 mmHg
-Urine output > 0.5
ml/kg/hr
-Reversal of tissue
hypoperfusion and
hypoxia*
MAP, urine
output tissue
perfusion

- oxygen
-

54

Renal support

-


80180

Sedation

-
hemodynamic

-

sedation

Other supportive care

-Stress ulcer
prophylaxis
-DVT prophylaxis

-
SOS score

38.5

90/60 .
-
.
60

-
Hemoculture

-
30
ml/kg 1.5
1
-

-

CRRT SLED
-

SLED IHD
acute peritoneal
dialysis
-


80180
- glycemic
control protocol
-
hemodynamic

-

sedation
- sedation scale
protocol
-Stress ulcer
prophylaxis
-DVT prophylaxis

-

CRRT SLED
-

SLED IHD
acute peritoneal
dialysis
-


80180
- glycemic
control protocol
-
hemodynamic

-

sedation
- sedation scale
protocol
-Stress ulcer
prophylaxis
-DVT prophylaxis

-
Hemoculture

-
30
ml/kg 1.5
1
-

1
-

-
Hemoculture

-
30
ml/kg 1.5
1
-

1
-

55

3
(sepsis fast track)
-
severe sepsis
septic shock
. (community
acquire sepsis)

3
(sepsis fast track)
-
severe sepsis
septic shock
. (community
acquire sepsis)

56

4
protocol
4.1 protocol
( )
SIRS (systemic inflammatory response syndrome) 2
[ ] Temperature >38C or <36C
[ ] Heart rate > 90 beats/min
[ ] Respiratory rate >20 /min PaCO2 <32 mmHg
[ ] WBC >12,000 /mm3, <4000 /mm3, band form neutrophil >10 %
Hypotension
[ ] SBP < 90 MAP < 70 mmHg HT
[ ] SBP baseline > 40 mmHg HT
MAP (mean arterial pressure) = [(SBP-DBP) / 3] + DBP
Signs of hypoperfusion
[ ]
[ ]
[ ] capillary refilling time 2
[ ] metabolic acidosis
Sepsis = SIRS + evidence of infection
Severe sepsis = sepsis organ dysfunction, hypoperfusion hypotension

57

infection
[ ] Respiratory

[ ] GI

[ ] GU

[ ] Soft tissue [ ] CNS

[ ] Cardiovascular [ ] Tropical infection [ ] Other

SEVERE SEPSIS SEPTIC SHOCK
[ ] take H/C 2 specimen 1 specimen
[ ] IV 2 ( cut down)
[ ] Foley catheter ( bladder )
[ ] specimen tube culture
[ ] specific treatment - start antibiotic take culture
[ ] community acquired - Ceftriaxone 2 g
[ ] melioidosis - Ceftazidime 2 g
[ ] healthcare associated infection - the most appropriate board spectrum antibiotic
[ ] supportive treatment
[ ] IV fluid: NSS 1,000 ml x 2 IVF ~ 3 L (>60 IVF 1.5 L)
[ ] Urine output > 30 ml/hr ( )
[ ] Dopamine 100 mg + 5%D/W 100 ml (1:1) 20 ml/hr
[ ] SpO2 sat < 92% RR > 30/min intubate+ respiratory support
[ ] ICU
surgical condition septic shock

58

record vital sign refer

( 5-10
Temp ()
HR (/)
RR (/)
BP (.)
Urine output
Ward _______
Urine output ( ) _____ ml IV fluid _______ ml
Sepsis Resuscitation _________.
ward ________.

Dopamine ________ ml

59

4.2 protocol
( )
( . . . )

SIRS (systemic inflammatory response syndrome)

2

[ ] Temperature > 38C or < 36C

[ ] Heart rate
[ ] Respiratory rate >
[ ] WBC , band form neutrophil >10 %

Age

Heart rate

Respiratory

WBC

Tachycardia Bradycardia

rate

(mm3)

(/min)

(/min)

(/min)

0 d-1 wk

>180

<100

>50

>34000

1 wk-1 mo

>180

<100

>40

>19500
<5000

1 mo-1 yr

>180

<90

>34

>17500
<6000

2-5 yr

>140

NA

>22

>15500
<6000

6-12 yr

>130

NA

>20

>13500
<4500

13-18 yr

>110

NA
=

>20

>11000
<4500

60

Hypotension
[ ] SBP < 60 mmHg in term neonate (0-28 days)
< 70 mmHg in infant (1-12 months)
< 70 mmHg + (2*age in year) in children 1 to 10 years
< 90 mmHg in children 10 years of age
Signs of hypoperfusion
[ ]
[ ]
[ ] capillary refilling time 2
[ ]
metabolic acidosis

infection
[ ] Respiratory

[ ] GI

[ ] GU

[ ] Cardiovascular

[ ] Tropical infection

[ ] Soft tissue

[ ] CNS

[ ] Others .

SEVERE SEPSIS and SEPTIC SHOCK

[ ] take H/C 1 specimen
[ ] IV 2 ( cut down)
[ ] Foley catheter (
bladder )
[ ] specimen tube culture

[ ] specific treatment start antibiotic

take culture
( antibiotic sepsis )
[ ] community acquired Ceftriaxone 50 mg/kg/dose (max. 2gm)

[ ] supportive treatment
[ ] IV fluid: NSS or RLS 20 ml/kg 10 load 3 CVP
[ ] Urine output > 0.5ml/kg/hr ()
[ ] Dopamine 10 mcg/kg/min
(Dopamine [6 * BW (kg)] mg + NSS upto 100 ml IV drip 10 ml/hr
ideal body weight )
[ ] sign of respiratory failure full concious intubation
( Endotracheal tube )

[ ]
( surgical condition septic shock )

61

record vital sign refer

Ward .............................

Urine output (

) ____ ml

IV fluid _______ ml

Dopamine ________ ml

sepsis resuscitation _________.

Ideal body weight

6 2 : +9 = kg
2
2- 6 : (*2)+8 = kg
7-12 : (*7)-5 = kg
2
Endotracheal tube
1. Uncuffed endotracheal tube

1 : 3.5 mm
1-2 : 4 mm
2 Uncuffed endotracheal tube ID(mm) = 4+(age/4)
2. Cuffed endotracheal tube

1 : 3.0 mm
1-2 : 3.5 mm
2 Cuffed endotracheal tube ID(mm) = 3.5+(age/4)

62

TROL concept
T = Type of fluid crystalloid colloid
R = Rate of fluid administration
inadequate tissue perfusion fluid bolus
cardiac output cardiac output tissue perfusion fluid
maintenance ongoing loss fluid bolus

O = Objective Goal to be achieved

inadequate tissue perfusion oxygen delivery
inadequate tissue perfusion
L = Limits safety limits
(risk vs benefit)
pulmonary edema, brain edema

63

parameter

inadequate
tissue perfusion

Clinical judgement
Thirst/diminished skin
turgor/dry mouth/cool
extremities
Perioperative therapy
(fasting/insensible/hemorrhagic
losses)
Hypernatremia
Use of vasopressor
Tachycardia
Oliguria < 0.5 ml/kg/hr
Systolic BP < 90 mmHg
Cardiac index < 2.5 l/min/m2

CVP 15 mmHg
CVP changes with spontaneous
respiration
PAOP < 18 mmHg
Serum lactate > 2 mmol/l
ScvO2 < 70%
DO2i < 600 ml/min/m2
Corrected flow time(FTc) < 400
ms
Stroke volume variability
13%
Systolic pressure variability >
10%
Pulse pressure variability
13%
Response to straight leg raising
IVC diameter variability

safety
limits

X
X
X
X
X
X
X

X
X
X
X
X
X

X
X
X
X
X

X
X
X

X
X

X
X

64

Levophed

0.01 3 mcg/kg/min
monitoring
- BP , HR
urine output
-
8
Dopamine

2.5 20 mcg/kg/min
monitoring
- BP , HR
urine output
-
8
Dobutamine

2.5 20 mcg/kg/min
monitoring
- BP , HR
urine output
- side effect
N/V ,

concentration
8 mg in 100 ml

16 mg in 100 ml

100 mg in 100 ml
(1 : 1)

200 mg in 100 ml
(2 : 1)

100 mg in 100 ml
(1 : 1)

200 mg in 100 ml
(2 : 1)

10

12

0.38
0.34
0.32
0.74
0.68
0.62

14

0.43
0.39
0.37
0.85
0.78
0.71

16

0.49
0.44
0.41
0.96
0.87
0.80

18

0.54
0.49
0.46
1.06
0.97
0.89

20

0.59
0.54
0.50
1.17
1.07
0.98

22

0.65
0.59
0.55
1.27
1.16
1.07

24

0.70
0.64
0.60
1.38
1.26
1.16

26

0.76
0.69
0.64
1.49
1.36
1.25

28

0.81
0.73
0.69
1.59
1.46
1.34

30

0.86
0.78
0.73
1.70
1.55
1.42

32

0.92
0.83
0.78
1.80
1.65
1.51

34

0.97
0.88
0.83
1.91
1.75
1.60

36

1.03
0.93
0.87
2.02
1.84
1.69

38

1.08
0.98
0.92
2.12
1.94
1.78

40

2
0.32
0.29
0.27
0.64
0.58
0.53

20

0.27
0.24
0.23
0.53
0.49
0.45

17.5

0.22
0.20
0.18
0.43
0.39
0.36

15

0.16
0.15
0.14
0.32
0.29
0.27

12.5

0.11
0.10
0.09
0.21
0.19
0.18

10

20

7.5

17.5

60
72
84
30
36
42

15

52.5
63
73.5
26.26
31.5
36.75

2.5

12.5

45
54
63
22.5
27
31.5

60
72
84
30
36
42
10

37.5
45
52.5
19
22.5
26

52.5
63
73.5
26.25
31.5
36.75
7.5

30
36
42
15
18
21

45
54
63
22.5
27
31.5
5

22.5
27
31.5
11
13.5
16

37.5
45
52.5
19
22.5
26
2.5

15
18
21
7.5
9
10.5

30
36
42
15
18
21
1

7.5
9
10.5
4
4.5
5

22.5
27
31.5
11
13.5
16
0.5

3
3.6
4.2
1.05
1.8
2.1

15
18
21
7.5
9
10.5

1.5
1.8
2.1
0.75
0.9
1.05

7.5
9
10.5
4
4.5
5

0.05
0.05
0.04
0.11
0.10
0.09

Rate(ml/hr)

50
55
60
50
55
60

50
60
70
50
60
70

50
60
70
50
60
70

65

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