Enumerates the latest advancements in the management of sepsis and the search into its pathophysiology.

1. SEPSIS DR UNNIKRISHNAN P / CCU

2. . “SEPSIS AT ITS INCEPTION IS DIFFICULT TO RECOGNIZE BUT EASY TO TREAT; LEFT UNATTENDED IT BECOMES EASY TO RECOGNIZE BUT DIFFICULT TO TREAT” Machiavelli

4. INFECTION .

5. BACTEREMIA

6. SYSTEMIC INFLAMMATORY RESPONSE SYNDROME Generalized inflammatory response of the body to a variety of clinical conditions including infection, but not limited to infection 2 or more of the following

7. SIRS

8. SEPSIS SIRS due to infection

9. SEVERE SEPSIS Sepsis associated with organ dysfunction, hypoperfusion or hypotension May include lactic acidosis,oliguria,altered mentation

10. ORGAN DYSFUNCTION Arterial hypotension SBP<90 MAP<70 x 1hour despite fluid resuscitation perfusion abnormalities (that could include,lactic acidosis, oliguria, and/or acute change in mental status).

11. ORGAN DYSFUNCTION Thrombocytopenia drop by >30% within 24 hrs OR count <100G/L

12. ORGAN DYSFUNCTION Arterial hypoxaemia PaO2 < 75 mm of Hg (room air) OR PaO2 /FiO2 < 250 (oxygen supplimentation)

13. ORGAN DYSFUNCTION Renal dysfunction Urine output < 0.5 ml/ kg x 2 hrs despite fluid loading OR S. creatinine > 2x reference range

14. ORGAN DYSFUNCTION Metabolic acidosis BE < 5 mmol/L OR S.lactate > 1.5 x upper value

15. MODS Presence of altered organ function lasting for > 24 hrs in an acutely ill patient, such that homeostasis cant be maintained without intervention.

16. Organ wise…

17. HOW?

18. True or false…..? The immune response by the host is minimal in sepsis..

19. Sepsis and septic shock Bacterial infection Excessive host response Host factors lead to cellular damage Organ damage Death

20. PATHOGENESIS

21. The events…..

22. Coagulation and sepsis

23. .

24. MANAGEMENT

25. Be on the lookout for disaster

26. INITIAL RESUSCITATION [1st 6 hrs] Central venous pressure (CVP): 8–12 mm Hg / 12-15 if mechanical ventilation Mean arterial pressure (MAP) >65 mm Hg Urine output >0.5 mL/kg/hour Central venous (superior vena cava) or mixed venous oxygen saturation >70% or >65%, respectively

27. if central venous oxygen saturation not achieved FLUID PRBC ( Hct>30) DOBUTAMINE : max 20µ/kg/min

28. DIAGNOSIS

29. BLOOD CULTURE

30. ANTIBIOTICS

31. SOURCE IDENTIFICATION/CONTROL

32. HEMODYNAMIC SUPPORT

33. VASOPRESSORS

34. INOTROPES

35. STEROIDS Poorly responsive hypotension Hydrocortisone > dexamethasone Hydrocortisone <300 mg / day Fludrocortisone 50 µg OD optional Weaned when no vasopressors No steroid if no shock

36. Recombinant Activated Protein C APACHE II >25

37. BLOOD PRODUCTS

38. PLATELETS

39. MECHANICAL VENTILATION-ARDS

40. MECHANICAL VENTILATION-ARDS

41. SEDATION- ANALGESIA- NMB

42. GLUCOSE CONTROL

43. GLUCOSE CONTROL

44. RENAL REPLACEMENT Intermittent HD = CVVH CVVH if hypotension

45. Bicarbonate therapy Not for hypoperfusion induced lactic acidemia with pH >7.15

46. DVT PROPHYLAXIS

47. STRESS ULCER PROPHYLAXIS

48. SEPSIS RESUSCITATION BUNDLE- 6 h

49. SEPSIS MANAGEMENT BUNDLE – 24HR

50. OUTCOME IMPROVED BY Early goal directed therapy Lung protective ventilation Appropriate antibiotic coverage Activated protein C Tight control of sugars 80-100mg/dl Steroids

51. A clinician, armed with the sepsis bundles, attacks the three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction

52. THANK YOU .

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