Sepsis

Sepsis-3 (2016) : Survivingsepsis.org

หลักการ Diagnosis

Definition : Life-threatening organ dysfunction caused by dysregulated host response to infection.
Clinical criteria :

qSOFA ≥ 2
(Quick Sepsis Related Organ Failure Assessment)

  1. SBP ≤ 100 mmHg
  2. Alteration of conscious
  3. RR ≥ 22 /min

SOFA ≥ 2
(Sepsis Related Organ Failure Assessment)

SIRS ≥ 2 (ไม่ใช้แล้ว)
(Systemic Inflammatory Response Syndrome)

  1. Temp. > 38 °C or < 36°C
  2. HR > 90 bpm
  3. RR > 20 /min , or PaCO2 < 32 mmHg (4.3 kPa)
  4. WBC
    • > 12,000 /mm3 or < 4000 /mm3 or
    • > 10 % immature bands
พิจารณาเป็นพิเศษถ้าเป็น Immunocompromised host
  • HIV
  • Immunosuppression
    • Chemotherapy
    • steroid
    • leukopenia
    • transplantation
    • Malnutrition
  • Chronic disease
  • CKD
  • Liver disease

Lab work up

  • SOFA
    • CBC, BUN, Cr, Elyte
    • LFT (ดู Billirubin)​
    • ABG if มี hypoxia
  • Blood Lactate
  • Work up source
    • H/C x II
    • Sputum gr,culture,AFB*3 วัน
    • UA,UC,U gram
    • CXR PA upright
    • EKG 12 leads
    • Pus culture
    • ...

Term

  • Sepsis induced hypoperfusion = Sepsis + MAP < 65 mmHg or lactate ≥ 2 mmol/L
  • Septic shock = Sepsis induced hypoperfusion แล้วเรารักษาด้วย Load IV 30 mL/kg แล้วยังมี hypoperfusion อยู่ จนต้องให้ vasopressor เพื่อให้ MAP >65 mmHg

Medication

Drug Dose (Adult)(นน. ตัวปกติ) Dose (Ped)(นน. 35-40 Kg)

Adrenaline

(1:1,000) (1mg/1ml)

or Epinephrine
(กระตุ้น A receptor + Beta receptor)

0.2 - 0.5 mL
IM/IV stat q 5-15 min

Dose = 0.01 mg/kg/dose
IM ตำแหน่ง = ​anterolateral of thigh)

If BP drop / ไม่ response ต่อ IM

Adrenaline 1 ml + 5%D/W 250 ml
IV drip rate 15 - 60 ml/hr
(1 - 4 mcg/mim)

0.01 mg/kg/dose
IM/IV stat q 5-15 min
If BP drop / ไม่ response ต่อ IM

Adrenaline 1 ml + NSS 250 ml
IV drip rate 0.1*BW*6 / 1*250/100 ml/hr
(0.1 mcg/kg/min)

Dopamine

Vasopressors

2-20 mcg/kg/min
IV drip rate ___ mL/hr

Keep SBP > 90 mmHg

 2-20 mcg/kg/min
IV drip rate ___ mL/hr

Keep SBP > 90 mmHg
Additional
  • Keep Hb > 7 mg/dL (Except MI, Severe hypoxemia, Acute bleeding)
  • Platelet transfusion if
    • < 10,000/mm3 in All case
    • < 20,000/mm3 Risk bleeding
    • < 50,000/mm3 Active bleed,Surgery, Invasive procedure
  • Hydrocortisone 200 mg/day IV for unstable septic shock
  • If have risks of GI bleeding
    • Omeprazole 40 mg IV q 24 hr
    • Omeprazole (20 mg) 1 *1 po ac
    • Ranitidine (150 mg) 1*2 po pc
  • DTX Keep < 180 mg/dL --> ให้ RI sc when 2 consecutive hyperglycemia