Sepsis
台中榮總 兒童醫學部
林明志 醫師
Systemic Inflammatory
Response Syndrome (SIRS)
Infection Non-infection disease
(e.g., acute illness or trauma)
Tissue injury
Adequate support
Inadequate resuscitation
Excessive Inflammation
Systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction
syndrome (MODS) Recovery
Recovery
定義
• SIRS: >=2 criteria
– 發燒 Core Temp > 38.5 or < 36 ℃
– 心跳加速Unexplained tachycardia or bradycardia < 1 y – 喘 Tachypnea or mechanical ventilation for an acute
process
– 白血球降低或上升band form
• Leukopenia or 10% immature neutrophiles
• Sepsis: 感染相關的SIRS
• Severe sepsis:
– Cardiac vascular dysfunction – ARDS
– >= 2 organs dysfunctions
• Septic shock:
– sepsis and cardiovascular organ dysfunction
流行病學
• SIRS/sepsis 750,000 American adults, mortality 28~60%
• Children 0.56 cases/1000 person-year
• In-hospital mortality 10%
• Death rate increased with the numbers of organ failure
– 7% single organ, 53.1% four organ
• Mean length of stay 31 days
• Cost US$ 40,600, annually $1,970,000,000
Organ dysfunction
系統 表現
心血管系統 在fluid bolus >= 40 mL/kg in 1 hr仍 低血壓
需使用強心劑
或以下兩個以上：
1. 代謝性酸中毒
2. 乳酸升高兩倍以上 3. 寡尿
4. 微血管回填>=5 sec
5. 中心與周邊體溫差大於3度
呼吸1. PaO2/FiO2 < 300
2. PaCO2 > 65 mmHg or 20 mmHg above baseline
>50% FiO2 to maintain O2Sat > 92%
神經系統
GCS <=11 or change >=3
血液
Plt < 80000 mm3 or decline > 50%, or INR > 2
腎臟
Cr >= 上限兩倍，或兩倍上升
肝臟
Bil. Total > 4 mg/dL （NB例外）or ALT 兩倍上升
JAMA 1995; 273: 117
2008戰勝敗血症，黃金六小時
N engl J Med 2001: 345: 1368
第一小時
1. Monitor ECG, SpO2, NIBP
2. Consider intubation and mechanical ventilation if respiratory failure
3. Artery-line placement & ABP monitor
4. Placement of a CVP catheter (PreSep CVP with ScvO2 is preferred) 5. Obtain smear and related cultures
Obtain 2 or more blood culture
(Previous colonized fungus → fungus culture)
6. Check CBC+DC, INR/PTT, AST, ALT, Bil T/D, Glu, electrolytes, BUN/Cr,CRP or Procalcitonin as needed 7. Check chest x-ray or other image study as needed
8. Check ABG, electrolytes, and lactate
9. Initiate empiric broad spectrum and adequate dose antibiotics therapy
10. Start early goal-directed treatment for shock Goals: MAP > 65 mmHg, ScvO2>70%
Urine output > 1 ml/kg/h
11. Fluid supplement to target CVP as needed CVP→ 8-12 mmHg (12-15 mmHg if intubated)
Push NS or colloid 20 ml/kg first, repeated over 60cc/kg as needed 12. If MAP still < 65 mmHg after adequate fluid supplement:
1st line Dopamine 5-20 mcg/kg/min
Dobutamine 2-20 mcg/kg/min (if low cardiac output and elevated systemic vascular resistance states) 2nd line Levophed 0.5-2 mcg/kg/min, or
Epinephrine 0.04-0.2 mcg/kg/min
1-6 hour
1. Ongoing early goal-directed treatment for shock
2. If shock is refractory to vasopressor and inotropic,
may use Solu-Cortef 50 mg/m2/24hr if at risk for absolute adrenal insufficiency, remember to taper down steroid once the shock is resolved
3. If MAP > 65 mmHg, but ScvO2 < 70%
Consider further fluid supplement as tolerated PRBC supplement for Hct < 30%
4. If shock persisted, evaluate heart function
Check cardiac echo, PiCCO, PAC, or CCO as needed 5. Control blood sugar < 150 mg/dL
5. Check ABG, electrolytes, and lactate as needed
6-24 hour
1. Ongoing goal-directed treatment for shock
2. Recheck ABG, electrolytes, and lactate as needed 3. Remove source of infection if possible
Site:____________________________
Intervention: _____________________
4. Protective ventilation strategy
If PaO2/FiO2<300, PC mode, VT 6-8 mL/kg,
Adequate PEEP, peak airway pressure < 35 cmH2O Head of bed raised to 30 - 45 °
5. RRT for acute renal failure
CVVH for hemodynamic unstable patient SLED-f for hemodynamic stable patient
6. Prevent stress ulcer - Zantac 2-4mg/kg/day divided Q6-8H If ulcer history or being bleeding now - Losec 1mg/kg QD 7. Analgesia and sedation as needed
8. At 12-24h, check Modified PRISM III-APS score: _____
9. Control blood sugar
24-48 hour
1. Narrow antibiotics by available report and clinical improvement
2. If clinical condition deteriorated, consult ID doctor 3. Reassess removal of infection source
Site:____________________________
Intervention: _____________________
4. RRT for acute renal failure 5. Nutrition support
If enteral feeding is allowed and condition improved (like shock resolved, lactate < 3 mmol/L), start enteral feeding
TPN for NPO patients
6. Analgesia and sedation as needed
Perform daily interruption for continuous sedation
7. Prevent DVT and PE in postpubertal children with severe sepsis Low risk - choose one of the followings,
(1) heparin loading 2000U then 100 U/h IV t itration to keep aPTT > 50 sec, (2) compressing stocking, or (3) intermittent pneumatic compression device
High risk - combine heparin and mechanical device 8. Discuss advance care plan with patient & family
9. IVIG may be considered in children with severe sepsis
10. ECMO be limited to refractory pediatric septic shock and/or respiratory failure that cannot be supported by conventional therapies
