The golden hours.

Dansk Selskab for Intern Medicin. Årsmødet den 3. marts 2006 Akut Infektionsmedicin Initial behandling af sepsis Dansk Selskab for Infektionsmedicin Overlæge Merete Storgaard

Sepsis definitioner Sepsis SIRS SIRS med dokumenteret infektion. systemisk inflammatorisk respons syndrom mindst 2 af 4 kriterier skal være opfyldt: Temperatur større end 38,0 eller mindre end 36,0. Puls > 90/min. Respirationsfrekvens > 20/min. Leukocytter > 12,0 x 109 eller < 4,0 x 109 eller venstreforskydning med > 10 % stavkernede eller andre umodne former. Sepsis SIRS med dokumenteret infektion. Alvorlig sepsis: Sepsis med hypotension eller tegn til organ hypoperfusion. Septisk shock: Sepsis med hypotension trods adækvat volumensubstitution eller med behov for pressorstøtte. Hypotension: systolisk BT < 90 mm Hg eller et vedvarende systolisk BT-fald > 40 mm Hg i mere end 1 time

Epidemiology of sepsis in Norway in 1999. Hans Flaatten   Critical Care 2004, 8: R180-R184   

Proportion of survivors according to systemic response Leibovici I et større arebjde fra Israel for pt med gram-neg. bakteriemi at dødeligheden for pt I dækkende antibiotika beh. Var 18 % og 34 % hvis ikke. 2124 pt. Valles, J. et al. Chest 2003;123:1615-1624 Community-Acquired Bloodstream infection in Critically ill Adult patients

Survival rate according to the presence of shock and empiric antibiotic treatment (log-rank test, p < 0.001) Valles, J. et al. Chest 2003;123:1615-1624 Community-Acquired Bloodstream Infection in Critically ill Adult Patients

Median time to effective anti-microbial therapy was 6,25 hours. Duration of hypotension prior to antimicrobial administration is a critical determinant of outcome in human septic shock K-415/ ICAAC 2004 2100 pt with septic shock. Overall mortality 53,3 %. Median time to effective anti-microbial therapy was 6,25 hours. Odds ratio of death increased progressively with delays in initiation of appropriate therapy with 5-10% decrease in survival with every hour of delay over the first 6 hours.

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock Emanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S., Bernhard Knoblich, M.D., Edward Peterson, Ph.D., Michael Tomlanovich, M.D., for the Early goal-Directed Therapy Collaborative Group Volume 345:1368-1377      November 8, 2001

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock, by Rivers 2001

Mortality Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock, by Rivers 2001, NEJM 2001

. Rivers, E. et al. N Engl J Med 2001;345:1368-1377 Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock, by Rivers 2001, NEJM 2001

Instrukser for behandling af sepsis på danske medicinske afdelinger I Antal senge Empirisk antibiotika behandling ved ukendt fokus Instruks for volumen terapi 1 192 Ampicillin plus gentamycin Nej 2 76 Albumin plus NaCl 3 25 Cefuroxim plus gentamycin 4 33 Ja 5 66 Penicillin plus gentamycin 6 90 7 43 Ingen anbefaling 8 96 9 102 10 29 11 142 Under udarbejdelse

Instrukser for behandling af sepsis på danske medicinske afdelinger II Antal senge Empirisk antibiotika behandling ved ukendt fokus Instruks for volumen terapi 12 112 Ampicillin plus gentamycin Anviser volumenterapi 13 107 Instruks findes Ja 14 122 15 28 Penicillin plus gentamycin Nej 16 76 17 40 Ingen anbefaling 18 100 Cefuroxim plus gentamycin 19 103 20 85 21 114

Optimering af behandling af sepsis Hurtig identifikation af sepsis patienter. Målrettet strategi med fokus både på effekt mål og tidsfaktor. Initial behandling bestående af 3 elementer: Bredspektret antibiotika ved ukendt fokus Volumenterapi Udredning med henblik på fokus

Antibiotika behandling Antibakterielle spektrum Pharmakokinetik / pharmakodynamik Kliniske studier Økologi

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