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Sepsis Guidelines Mind Map
Regarding the sepsis guideline mind map, based on the summary of the 2018 China Sepsis/Shock Emergency Treatment Guidelines, a disease caused by an imbalance in the host response caused by infection leads to life-threatening organ dysfunction.
Edited at 2023-11-05 23:38:06
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sepsis guide
definition
sepsis
Dysregulated host response to infection leading to life-threatening organ dysfunction
septic shock
Sepsis combined with severe circulatory cellular and metabolic disorders
Diagnostic criteria
sepsis
qSOFA
At least 2 items
R＞22bpm
altered consciousness
Systolic blood pressure <100mmHg
SOFA
Score increased by ≥2 points from baseline
respiratory system
coagulation
liver
cardiovascular
central nervous system
kidney
septic shock
sepsis hypotension
MAP mean arterial pressure >65mmHg
Blood lactate＞2mmol/L
It is recommended to perform routine microbial culture without delaying antimicrobial treatment.
At least two sets of blood
Intravenous catheter left in place for more than 48 hours and the site of infection is unknown
Aerobic Anaerobic
suspected catheter infection
One group is percutaneous and one group is transcatheter
treat
fluid resuscitation
Septic shock requires early initiation of fluid resuscitation
Initial resuscitation with at least 30ml/kg crystalloid within 3 hours of suspected septic shock
After initial resuscitation, assess hemodynamic status to guide further fluid administration
Dynamic indicators predict liquid reactivity
Passive leg raising test
Capacity load test
Changes in stroke volume after rehydration
Systolic blood pressure changes
pulse pressure changes
Sensitivity and specificity are high
For patients with septic shock taking vasoactive drugs, a MAP65 mmHg is recommended as the initial resuscitation goal.
The lactic acid level is high. Use lactic acid to guide resuscitation. The lactic acid returns to normal.
Blood lactate <2mmol/L within 6 hours
Personalized MAP
Basic hypertension may require higher MAP
Crystalloids are recommended for fluid resuscitation and subsequent volume replacement
Recommended balanced crystalloids
Ringer's solution
Be careful to avoid hyperchloremia
Volume replacement therapy with hydroxyethyl starch is not recommended
During the fluid resuscitation and subsequent volume replacement phase, when large amounts of crystalloid are required, it is recommended to add albumin.
It is recommended that red blood cells can be transfused only when Hb is <70g/L and myocardial infarction, severe hypoxemia, and acute bleeding are excluded.
Prophylactic transfusion of fresh frozen plasma is not recommended for patients without bleeding or unplanned invasive procedures.
Anti-infective treatment
Antimicrobials are recommended as soon as possible after admission/diagnosis of sepsis
Best within 1 hour
The delay does not exceed 3 hours
Recommend empirical use of antimicrobials that may cover all pathogens
Early management of septic shock: empiric combined use of antibiotics is recommended
Routine combined antibiotic use is not recommended in patients with sepsis without shock or in patients with neutrophils↓
Typically a carbapenem or broad-spectrum penicillin/beta-lactamase inhibitor may be used
De-escalation of treatment is recommended after the etiological diagnosis and drug susceptibility results are clear or the clinical symptoms are sufficiently improved.
Minimize antimicrobial therapy
Antimicrobial drug dose optimization strategies should be based on pharmacodynamic/pharmacokinetic principles and drug characteristics
Need to consider
Hepatic and renal insufficiency
immune dysfunction
susceptibility to drug-resistant bacteria
Recovery due to initial capacity
The first dose of antibiotics should be used up to the highest loading dose
It is recommended that patients with sepsis/shock receive antibiotic treatment for 7-10 days.
For shock, it is recommended to de-escalate after the clinical symptoms improve or the infection is relieved after combined treatment.
Recommended daily assessment de-escalation
Can be used for long periods >10d
Clinical symptoms improve slowly
The source of infection is difficult to control
Staphylococcus aureus-associated bacteremia
fungal infection
It is recommended to use PCT levels to guide antimicrobial therapy
It is recommended to identify the source of infection as soon as possible
Generally no more than 6-12 hours after initial resuscitation
vasoactive drugs
Norepinephrine is recommended as the first choice, dopamine as the second choice
It is recommended to add vasopressin (maximum dose 0.03U/min) to norepinephrine to achieve the target MAP
It is recommended to use Shenfu Injection in addition to vasoactive drugs.
Patients with AKI benefit more from combined use of low-dose vasopressin
Low-dose dopamine is not recommended for renal protection
If hypoperfusion persists after adequate fluid resuscitation and vasoactive drugs, dobutamine is recommended.
Continuous arterial pressure measurement is recommended
Glucocorticoids
For patients with shock who remain hemodynamically unstable despite adequate fluid resuscitation and vasoactive drug therapy, intravenous corticosteroids are recommended.
Fluid and vasoactive drug therapy for more than 1 hour Systolic blood pressure <90mmHg
Hydrocortisone dose 200mg/d
anticoagulant therapy
Antithrombin is not recommended for the treatment of sepsis/shock
Heparin can be given early
Combined with DIC or coagulation disorder
Xuebijing Injection
renal replacement therapy
Combined with AKI, CRRT or intermittent RRT can be performed
RRT is not recommended when combined with AKI and only elevated creatinine or oliguria without other indications for dialysis.
Mechanical Ventilation
When sepsis-induced ARDS patients undergo mechanical ventilation
Recommended tidal volume 6ml/kg
The recommended upper limit of platform pressure is 30cmH2O
For moderate to severe ARDS, oxygen index <200mmHg, higher PEEP is recommended
It is recommended to use prone position ventilation when the oxygen index is <150mmHg. High-frequency oscillation ventilation is not recommended.
Prone position ventilation time＞16h/d
It is recommended to use muscle relaxants for less than 48 hours
For ARDS caused by sepsis
If there is no evidence of hypoperfusion, restrictive fluid therapy is recommended
In the absence of bronchospasm, beta-2 agonists are not recommended
Routine pulmonary artery catheterization is not recommended
Can tolerate offline. Offline solution is recommended.
Spontaneous breathing test recommended before planned weaning
Sedation and analgesia
Minimum doses of continuous or intermittent sedation are recommended for mechanically ventilated patients.
Limit sedatives
Use intermittent sedation
Opioids
short-acting drugs
propofol dexmedetomidine
blood sugar management
For ICU sepsis patients, it is recommended to monitor blood sugar every 1-2 hours
Start insulin treatment when blood glucose is measured twice consecutively >10mmol/L
Target blood sugar ≤10mmol/L
7.8-10
No significant hypoglycemia
6.1-7.8
Blood sugar level: Monitor blood sugar every 4 hours after insulin dosage stabilizes.
Arterial blood sugar is better than peripheral blood sugar
stress ulcer
For sepsis/shock patients with risk factors for gastrointestinal bleeding, stress ulcer prevention is recommended.
risk factors
coagulopathy
Mechanical ventilation＞48h