1. EGDT Gordon Finlayson

2. Case 45 year old male AML Febrile, tachycardic, tachypneic, hypotensive Diarrhea last 24 hours

3. Case 1st Priority: Early Identification of Sepsis Next Priorities: Identification of Source; Quantify Severity

4. Your JOB

5. Definitions of systemic inflammatory response syndrome (SIRS) and different degrees of severity of sepsis Condition Description Systemic inflammatory response syndrome Two or more of the following conditions: temperature >38.5°C or 90 beats/min; respiratory rate of >20 breaths/min or PaCO 2 of 12,000 cells/mL, 10 percent immature (band) forms Sepsis SIRS in response to documented infection (culture or Gram stain of blood, sputum, urine, or normally sterile body fluid positive for pathogenic microorganism; or focus of infection identified by visual inspection, eg, ruptured bowel with free air or bowel contents found in abdomen at surgery, wound with purulent discharge) Severe sepsis Sepsis and at least one of the following signs of organ hypoperfusion or organ dysfunction: areas of mottled skin; capillary refilling of ≥3 s; urinary output of 2 mmol/L; abrupt change in mental status or abnormal EEG findings; platelet count of <100,000 cells/mL or disseminated intravascular coagulation; acute lung injury/ARDS; and cardiac dysfunction (echocardiography) Septic shock Severe sepsis and one of the following conditions: systemic mean BP of 5 mcg/kg/min, or norepinephrine or epinephrine of 60 mm Hg (80 mm Hg if previous hypertension) Refractory septic shock Need for dopamine at >15 mcg/kg/min, or norepinephrine or epinephrine at >0.25 mcg/kg/min to maintain mean BP at >60 mm Hg (80 mm Hg if previous hypertension) WBC count: white blood cell count; BP: blood pressure. Data from: Annane, D, Bellissant, E, Cavaillon, JM. Septic shock. Lancet 2005; 365:63.

6. Identification of Sepsis Unexplained tachpnea/tachycardia Respiratory Alkalosis Confusion/Delirium

7. Quantifying Severity Compensated Vs Decompensated Shock Clincial/Lab marker of inadequate perfusion Identifying End-organ dysfunction

8. Source Idenfication Surgical Vs Non-surgical

9. Antibiotic Timeliness

10. Time to Source Control

11. Resuscitation

12. Fluid Type

14. Preload Responsiveness

16. Adjuvants Low Vt Ventilation APC Steroids Glycemic Control

18. APC

19. ?things don’t fit High CVP Narrowed pulse pressure Exaggerated systolic pressure variation/pulsus paradoxus high vasopressor requirements

20. things don’t fit Consider mixed shock/extra diagnosis ?Inadequate source control

21. Summary Identify sepsis early Antibiotics and source identification/control early, aggressive resuscitation -- defined end-points (lactate clearance/svo2) consider APC, steroids if failing ? mixed shock/inadequate source control