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Guidelines for Management of Severe Sepsis and Septic Shock-2

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H. Steroids. Grade C ... Decrease dosage of steroids after resolution of septic shock. ... maintenance steroid therapy or to using stress dose steroids. ... – PowerPoint PPT presentation

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Title: Guidelines for Management of Severe Sepsis and Septic Shock-2


1
Guidelines for Management of Severe Sepsis and
Septic Shock-2
  • G. Inotropic Therapy

2
Grade E
  • Low CO? Dobutamine
  • Low CO Low BP? Dobutamine vasopressor therapy
    (norepinephrine or dopamine)

3
  • Low CO with adequate LV filling pressure and
    adequate MAP? Dobutamine ( first choice inotrope)
  • Hypotensive Pt with severe sepsis ?
    low/normal/high CO ?inotrope
    vasopressor(norepinephrine or
    dopamine)

4
Grade A
  • Achieve an arbitrarily elevated level of cardiac
    index is not recommended
  • CI CO / BSA
  • The goal of resuscitation should be to achieve
    adequate levels of oxygen delivery or avoid
    flow-dependent tissue hypoxia

5
H. Steroids
6
Grade C
  • In patient with septic shock and requires
    vasopressor therapy to maintain BP ?
    intravenous corticosteroids (hydrocortisone
    200300 mg/day for 7 day in three or four divided
    doses or by continuous infusion)

7
  • Patient with relative adrenal insufficiency
    (post-ACTH cortisol increase ?9µg/dL) ?
    significant shock reversal and reduction of
    mortality rate

8
Grade E
  • 250 µg ACTH stimulation test to identify
    responder (gt9 µg/dL increase in cortisol 3060
    mins)? discontinue therapy
  • Do not wait for ACTH stimulation results

9
  • Steroids improved survival in nonresponders.
    Steroid therapy was ineffective in responders.
  • Dexamethasone does not interferer with cortisol
    assay (but hydrocortidone does)

10
Grade E
  • Decrease dosage of steroids after resolution of
    septic shock.
  • No comparative study between a fixed duration and
    clinically guided regimen.

11
Grade E
  • Tapering the dose of corticosteroids at the end
    of therapy.
  • Hemodynamic and immunologic rebound effects after
    abrupt cessation of corticosteroids

12
Grade E
  • Add fludrocortisone (50 µg orally four times per
    day)
  • Hydrocortisone has intrinsic mineralocorticoid
    activity (controversy)

13
Grade A
  • Doses of corticosteroids gt300 mg hydrocortisone
    daily should not be used.
  • For therapy of severe sepsis or septic shock,
    high-dose corticosteroid therapy is ineffective
    or harmful.

14
Grade E
  • Corticosteroids should not be administered for
    the treatment of sepsis in the absence of shock.
  • No contraindication to continue maintenance
    steroid therapy or to using stress dose steroids.

15
I. Recombinant Human Activated Protein C (rhAPC)
16
Grade B
  • rhAPC is recommended in patients at high risk of
    death.
  • No absolute contraindication or relative
    contraindication.
  • rhAPC? endogenous anticoagulant with
    anti-inflammatory properties.

17
J. Blood Product Administration
18
Grade B
  • Once tissue hypoperfusion has resolved, RBC
    transfusion should occur only when Hb lt 7.0g/dL
    to target a Hb of 7.09.0g/dL
  • Hb of 79g/dL is adequate for most critically ill
    patients. (do not increase mortality rate)
  • RBC transfusion increases O2 delivery but does
    not increase O2 consumption.

19
Grade B
  • EPO is not recommended as a specific treatment of
    anemia associated with severe sepsis. (renal
    failure is accepted)

20
Grade E
  • Routine use of fresh frozen plasma in the absence
    of bleeding or planned invasive procedures is not
    recommended.

21
Grade B
  • Antithrombin administration is not recommended.
  • On 28-day all-cause mortality in adults with
    severe sepsis and septic shock, it shows no
    beneficial effect.

22
Grade E
  • Platelets count lt 5000/mm3 ? administered
    (regardless of apparent bleeding)
  • Platelets count 500030000/mm3 ?may be considered
    (significant risk of bleeding)
  • Platelets count ? 50000/mm3 ?typically required
    for surgery or invasive procedures.

23
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