🔹️Rapid overview
🔹️Common sources and Definition
🔹️Antibiotics Selection
▪️Sepsis:
• Suspected or confirmed infection
plus
• SOFA score ≥2 points, indicating organ dysfunction.
💡SOFA(Sequential Organ Failure Assessment) assesses respiratory, cardiovascular, hepatic, renal, coagulation, and neurological systems.
▫️For rapid bedside screening and early identification of infected patients:
NEWS(high risk>6) OR qSOFA(≥2)can be used (≥2 of):
• RR ≥22/min
• Altered mentation (GCs <15)
• Systolic BP ≤100 mmHg
▪️Septic Shock:
• Sepsis
plus
• Persistent hypotension requiring vasopressors to MAP ≥65 mmHg and
• Serum lactate level >2 mmol/L despite adequate fluid resuscitation.
📝 ED #order
▪︎Imp: Sepsis
▪︎Cond: Emergency
▪︎Diet: NPO
▪︎Act: CBR- bed sides up
▪︎Pos: semi sitting
▪️IV line fix
▪︎C.V.S
▪︎CM and POM
▪︎ECG stat
▪︎check serum lactate, CBC, basic electrolytes, kidney function, liver function, lipase, coagulation studies ,VBG
*Some centers measure procalcitonin when CAP suspected.
▪︎Foley catheter + I/O chart
▪︎bedside sonography
* including assessment of fluid status (eg, IVC diameter) and organ systems as clinically indicated (eg, hydronephrosis, cholecystitis, pulmonary fluid/consolidation).
▪︎Consider imaging based on suspected sources of infection
▪︎Blood culture ×2 from 2 distinct sites. (aerobic and anaerobic)
* obtain other cultures as clinically indicated (eg, urine, wound, sputum, CSF, indwelling vascular access devices).
▪︎Consider sources control
*(eg, abscess/empyema drainage, infected/necrotic tissue debridement, potentially infected indwelling hardware/catheter removal, ongoing microbial contamination control).
▪︎Oxygen therapy if needed
*to maintain sat>92 (90-96%)
▪︎IV fluid isotonic crystalloid( eg, lactated ringer) 500-1000 ml IV bolus stat.
• Boluses are repeated based on clinical response
• started by one hour and completed within 3hours following presentation.
• Volume totals of 30 mL/kg(generally 2L in average adult) in first hours after presentation are reasonable, but clinical circumstances may warrant larger (eg, severe diarrhea) or smaller (eg, heart failure) volumes.
💡Treatment goals include MAP ≥65, sysBP≥90 mmHg and urine output ≥0.5 mL/kg per hour.
•Reassess patient's volume status after initial bolus. Auscultate for pulmonary edema. Evaluate peripheral circulation. Consider IVC ultrasound
❗High volume (5+ L) resuscitation associated with increased mortality
▪︎Drip NEp IV 5-15 mcg/min as necessary.
* If hemodynamic response to IV fluids is inadequate or constrained by fluid overload (eg, heart failure) .Peripheral IV may be used temporarily for administration pending placement of central venous catheter.
*اول مایع بدیم توی یه ساعت اول، سریع نریم سراغ وازوپرسور(نور اپینفرین و..) زدن. دادن اپینفرین توی ساعت اول در شوک، مورتالیتی رو بالا میبره چون تخمین مایع رو مختل میکنه.
▪︎Antibiotic
* give empiric, broad-spectrum IV, ideally within 1 hour of presentation, targeted at suspected source(s) of infection.
💡Maximal dosing should be used.
▫️Amp Vancomycin: 15 mg/kg IV q8-12h
*(consider a loading dose of 25-30 mg/kg for severe illness) to cover MRSA
Plus
▫️Amp Meropenem: 1 g IV q8h
OR
▫️Amp Piperacillin-tazobactam: 4.5 g IV q6h
OR
▫️Amp Cefepime: 2 g IV q8h
OR
▫️Amp Ceftriaxone 1-2 gr IV once daily
▪︎trans P.C if hb<7
▪︎Amp hydrocortisone 100mg IV if indicated
* If adrenal insufficiency suspected or refractory shock present (eg, multiple vasopressors at high doses required.)
▪︎vasopressin 0.03 units/minute fixed dose) can be added to norepinephrine
* If hypotension persists despite adequate IV fluid resuscitation and vasopressor therapy,
▪︎Dobutamine (2-20mcg/kg/min) may be added if:
*Myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output.
*Ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP
*Beta-2 agonism causes vasodilation, therefore needs to be used in conjunction with vasopressors
▪︎consider appropriate sedation and analgesics