CTI SEPSIS PROTOCOLO

Sepsis is the body's response to an infection. The symptoms can include: Fever and shaking chills Reduced mental alertness, sometimes with confusion Nausea and vomiting Diarrhea Increased heart rate, greater than 90 beats per minute Increased respiratory rate, greater than 30 breaths per minute High or low white blood cell count Low blood pressure Altered kidney or liver function Sepsis can develop quickly. The sooner it is diagnosed and treated, the better. The most frequent sites of infection leading to sepsis are the lung, urinary tract, abdomen, and pelvis. In up to 30 percent of patients, however, a definite source of infection cannot be identified. The course of the disease may be unpredictable. Some patients may deteriorate quickly, while others suffer from varying degrees of organ dysfunction or failure, but most will recover with treatment. Sepsis Management Bundle Evidence-based goals that must be completed within 24 hours for patients with severe sepsis, septic shock and/or lactate >4 mmol/L (36 mg/dl). For patients with severe sepsis, as many as four bundle elements must be accomplished within the first 24 hours of presentation. Some items may not be completed if the clinical conditions described in the bundle do not prevail, but clinicians must assess for them. The goal is to perform all indicated tasks 100 percent of the time within the first 24 hours from presentation. Please note that efforts to accomplish these goals should begin immediately, but may be completed within 24 hours to qualify in the database. Changes for Improvement Bundle Element 1 Administer low-dose steroids for septic shock in accordance with a standardized ICU policy. If not administered, document why the patient did not qualify for low-dose steroids based upon the standardized protocol.

Bundle Element 2 Maintain adequate glycemic control. Click here to see SSC Statement on Glucose Control in Severe Sepsis (2009) Bundle Element 3 Prevent excessive inspiratory pleateau pressures on mechanically ventilated patients. Corticoide Tips 1. Use the Interim Low-Dose Glucocorticoid Policy until your institution is able to devise an appropriate policy. 2. Create a an ICU protocol that standardizes the use of low-dose steroids in septic shock to eliminate variation in care. 3. Use a sufficient dose of glucocorticoid for efficacy, for example, hydrocortisone 50 mg IV every 6 hours. 4. Resist deferring the use of low-dose steroids for fear of worsening infection in patients who remain hypotensive despite both adequate volume resuscitation and application of vasopressors. 5. An ACTH stimulation test is not recommended to ascertain whether septic shock patients should receive low-dose steroids. Vasopressor Tips 1. Include the use of vasopressors on a standardized protocol for the treatment of hypotension not responding to fluid administration. 2. Be sure that emergency department and intensive care nurses and staff are familiar with the appropriate dosing of dopamine, dobutamine, and norepinephrine. 3. Do not wait to start vasopressors until a fluid challenge or bolus of intravenous fluid is completed before using vasopressor agents if severe hypotension is present. 4. If you are unable to wean vasopressors, consider other diagnosis such as depressed cardiac function, adrenal insufficiency, tension pneumothorax or cardiac tamponade, etc. culturas Two or more blood cultures are recommended. (1) In patients with suspected catheter-related infection, a pair of blood cultures obtained through the catheter hub and a peripheral site should be obtained simultaneously. If the same organism is recovered from both cultures, the likelihood that the organism is causing the severe sepsis is enhanced. In addition, if the culture drawn through the vascular access device is positive much earlier than

the peripheral blood culture (i.e., > 2 hours earlier), it may offer support that the vascular access device is the source of the infection. (2) Volume of blood may also be important. (3) Fever, chills, hypothermia, leukocytosis, left shift of neutrophils, neutropenia, and the development of otherwise unexplained organ dysfunction, e.g., renal failure or signs of hemodynamic compromise, are specific indications for obtaining blood for culture. Blood cultures should be taken as soon as possible after the onset of fever or chills. While it remains difficult to predict bacteremia in patients with sepsis (4), a number of clinical and laboratory parameters are independently correlated with the presence of bacteria in the blood of patients when infection is suspected. These include chills, hypoalbuminemia, the development of renal failure, and a diagnosis of urinary tract infection 1.Create a standardized protocol to manage severe sepsis that includes reminders to draw blood cultures before administering antibiotics. 2.Place prompts in locations near antibiotic storage querying staff regarding whether blood cultures have been drawn. Inicio dos antibioticos rapidamente uided by the susceptibility of likely pathogens in the community and the hospital, as well as any specific knowledge about the patient, including drug intolerance, underlying disease, the clinical syndrome. The regimen should cover all likely pathogens since there is little margin for error in critically ill patients. The antimicrobial regimen should always be reassessed after 4872 hours on the basis of microbiological and clinical data with the aim of using a narrow-spectrum antibiotic to prevent the development of resistance, to reduce toxicity, and to reduce costs. Once a causative pathogen is identified, there is no evidence that combination therapy is more effective than monotherapy. The duration of therapy should typically be 710 days and guided by clinical response. The Surviving Sepsis Campaign recommends that intravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock (GRADE 1B) and severe sepsis without septic shock (1D). Appropriate cultures should be obtained before initiating antibiotic therapy, but should not prevent prompt administration of antimicrobial therapy (1D). 1. Establish a standardized clinical protocol that includes the empiric administration of antibiotics in severe sepsis within 3 hours of presentation for ED admissions and 1 hour for ICU admissions. 2. Do establish a pre-mixed quantity of broad-spectrum antibiotics available in the emergency department and ICU, in order to avoid

delays involving pharmacy acquisition of the antibiotic. 3. Do infuse antibiotics through multiple lines as available in order to speed delivery of agents. 4. Do cover both Gram-positive and Gram-negative organisms. 5. Do consider specific knowledge about the patients past organism burden if available (including fungal infection), the setting from which the patient arrived in the emergency department (for example, another institution that may harbor resistant organisms), and community and hospital resistance patterns in making choices. 6. Consider double antibiotic coverage for Pseudomonas if clinical suspicion warrants, although there is no evidence-based definitive answer on this issue.

Saturacao Venosa Central

Create a standardized protocol that includes a goal CVP > 8 mm Hg for patients with lactate > 4 mmol/L or hypotension not responding to initial fluid resuscitation (septic shock). Stress the importance of prioritization: initial fluid challenge as defined, followed by central line placement, followed by assessment of CVP; if CVP is low, the addition of PRBCs is appropriate if hematocrit is less than 30% and MAP remains < 65 mg Hg, followed by further fluid challenges to keep CVP > 8 mm Hg. If your emergency department does not commonly perform these techniques, provide in-service training to emergency department personnel regarding CVP monitoring and the importance of leveling equipment relative to the patients heart. Do not wait for transfer to the ICU to initiate CVP monitoring.

Controle glicemico

Glucose control maintained > lower limit of normal, but < 180 mg/dL (10 mmol/L).

Pressao Plateau Create a standardized protocol that prompts users to use tidal volumes no greater than 6 mL/kg IBW and to maintain plateau pressures less than 30 cm H20.

Make execution of an ARDSnet-like protocol the primary responsibility of the respiratory therapists, if possible. Have stakeholders work in concert with the respiratory therapy department to create and deploy a clinical protocol for ALI/ARDS ventilation. Avoid synchronized intermittent mandatory ventilation (SIMV) during the acute phase of illness. Instead, use mandatory modes of ventilation such as assist control (ACV) or pressure control (PCV) to prevent spontaneously large tidal volumes. Do not allow peak pressures to govern ventilator management. The key value is the plateau pressure. The weight for determining the Vt should be the ideal body weight, not the fat or over-hydrated weight. The ideal body weight is calculated from the patients height. Do not worry about the pCO2 unless the pH is less than a threshold the clinical team cannot accept. Some intensivists are comfortable with pH as low as 7.10. Most clinicians like to see pH greater than 7.21. Timid clinicians use pH in the range of 7.25 or 7.30. Where renal dysfunction prevents compensation, bicarbonate can be used to help maintain the pH. However, constant bicarbonate infusions can also contribute to CO2 production. THAM does not have this side effect. Provide adequate supplemental oxygen to maintain a pulse oximetric saturation of > 90 percent. A minimum amount of PEEP should be set to prevent lung collapse at end expiration. Setting PEEP based on severity of oxygenation deficit and guided by the FIO2 required to maintain adequate oxygenation is one acceptable approach.

Lactato Serum lactate must be available in your institution with rapid turnaround time (within minutes) to effectively treat severely septic patients. An arterial blood gas analyzer located in the clinical laboratories usually accomplishes this. However, any means of rapid turnaround time will be acceptable. It is essential for hospitals to invest in adequate equipment in order to meet present standards of care for septic patients. The technique of obtaining serum lactate by venipuncture typically carries a 24- to 48-hour turnaround time and will not be suitable to care for septic patients. This technique also requires special collection conditions, such as without the use of tourniquet, hindering clinical care.

Fluidos In the event of hypotension and/or lactate > 4 mmol/L (36 mg/dL) deliver an initial minimum of 20 mL/kg of crystalloid (or colloid

equivalent). 1. The Surviving Sepsis Campaign recommends fluid resuscitation with either natural/artificial colloids or crystalloids. There is no evidence-based support for one type of fluid over another (Grade 1B). Rationale. The SAFE study indicated albumin administration was safe and equally effective as crystalloid [1]. There was an insignificant decrease in mortality rates with the use of colloid in a subset analysis of septic patients (p= 0.09). Previous metaanalyses of small studies of ICU patients had demonstrated no difference between crystalloid and colloid fluid resuscitation [24]. Although administration of hydroxyethyl starch may increase the risk of acute renal failure in patients with sepsis, variable findings preclude definitive recommendations [7,8]. As the volume of distribution is much larger for crystalloids than for colloids, resuscitation with crystalloids requires more fluid to achieve the same end points and results in more edema. Crystalloids are less expensive. 2. The Surviving Sepsis Campaign recommends fluid resuscitation initially target a CVP of at least 8 mm Hg (12 mm Hg in mechanically ventilated patients). Further fluid therapy is often required (Grade 1C). 3a. The Surviving Sepsis Campaign recommends that a fluid challenge technique be applied, wherein fluid administration is continued as long as the hemodynamic improvement (e.g., arterial pressure, heart rate, urine output) continues. (Grade 1D) 3b. The Surviving Sepsis Campaign recommends fluid challenge in patients with suspected hypovolemia be started with at least 1000 mL of crystalloids or 300-500 mL of colloids over 30 min. More rapid administration and greater amounts of fluid may be needed in patients with sepsis-induced tissue hypoperfusion (Grade 1D) 3c. The Surviving Sepsis Campaign recommends the rate of fluid administration be reduced substantially when cardiac filling pressures (CVP or pulmonary artery balloon-occluded pressure) increase without concurrent hemodynamic improvement (Grade 1D). Rationale. Fluid challenge must be clearly separated from simple fluid administration; it is a technique in which large amounts of fluids are administered over a limited period of time under close monitoring to evaluate the patients response and avoid the development of pulmonary edema. The degree of intravascular volume deficit in patients with severe sepsis varies. With venodilation and ongoing capillary leak, most patients require continuing aggressive fluid resuscitation during the first 24 hours of management. Input is typically much greater than output, and input/output ratio is of no utility to judge fluid resuscitation needs during this time period. The above category 1 recommendations are strong recommendations for care based on a number of qualitative considerations. B level evidence generally derives from randomized control trials with certain limitations or very well-done observational or cohort studies. C level evidence reflects well-done observational or

cohort studies with controls. D level evidence generally reflects case series data or expert opinion. 4. If the patient is not responding to vigorous volume resuscitation, think of other causes of hypotension such as depressed myocardial function, adrenal insufficiency, tension pneumothorax, cardiac tamponade, etc. 2. Do not delay the beginning of fluid administration for placement of central access.

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