This document discusses sepsis, including definitions of sepsis, severe sepsis, septic shock, and the signs of systemic inflammatory response syndrome (SIRS). It outlines the STOP bundle strategies for treating sepsis, including starting broad-spectrum antibiotics within 1 hour, achieving hemodynamic and lactate goals within 6 hours, and monitoring for organ dysfunction. It provides recommendations for fluid resuscitation and vasopressor therapy, favoring crystalloids as the initial fluid, with norepinephrine as the first vasopressor and adding epinephrine if needed to maintain blood pressure. Low-dose vasopressin can be considered as an adjunct to norepinephrine.

1. Stop Sepsis
邱振峰 醫師

2. What is Sepsis ?
 Sepsis 是什麼 ?
 如何處理 Sepsis ?
該做什麼 ? ( 項目 ? 優先順序 ?)
監測什麼 ?
有没有漏掉什麼 ?
 救回可救回的病人

3. 回答下列問題 ?
 Sepsis 是什麼 ? 那些病人有 sepsis ?
 何時啓動 Sepsis bundle ?
 輸液什麼時候給 ? 給多少 ? 給多快 ? 什麼
停 ( 減 ) ?
 抗生素什麼時候給 ? 用那類 ? 合併那類 ?
 升壓劑什麼時候給 ? 用那類 ?

12. SIRS (Systemic Inflammatory
Response Syndrome)
 Temp < 36 ° C or > 38.3 ° C
 HR > 90
 RR > 20 or PCO2 < 32
 WBC < 4K or > 12K or bands > 10%
 以上符合兩項 ( 含 ) 以上

13. Sepsis 敗血症的定義

SIRS +Infection

14. Septic Shock 敗血性休克
 Hypotension that does NOT respond to fluid
(500 cc bolus)

15. Severe Sepsis 嚴重敗血症
 Sepsis + Organ Dysfunction
 Elevated Creatinine (>2)
 Elevated INR (DIC)
 Altered Mental Status (GCS <12)
 Elevated Lactate (>4 mmol/L)
 Hypotension that responds to fluid

16. 敗血症 EGDT 流程啟動時機
 SIRS ：符合兩項以上
 疑似感染或有陽性培養
 經靜脈罐注後 SBP ＜ 90mmHg 或 MAP <
65mmHg 或 lactate 36 mg/dl≧ 或一種以上器
官急性機能失調

17. STOP Bundle Strategies 執行目標
 2 小時內啟用血流動力監測 (CVP/ScvO2)
 1 小時內投予廣效抗生素
 EGDT 流程啟動６小時內達成下列目標：
CVP 8 mmHg, MAP 65 mmHg, ≧ ≧
ScvO2 70%≧
 監測乳酸是否下降；如使用升壓劑，考慮使用
steroid

18. Fluid Therapy of Severe Sepsis
1. Crystalloids as the initial fluid of choice in the
resuscitation of severe sepsis and septic shock
(grade 1B).
2. Against the use of hydroxyethyl starches for
fluid resuscitation of severe sepsis and septic
shock (grade 1B).
3. Albumin in the fluid resuscitation of severe
sepsis and septic shock when patients require
substantial amounts of crystalloids (grade 2C).

19. 4. Initial fluid challenge : > 30 mL/kg of
crystalloids (a portion of this may be albumin
equivalent). (grade 1C).
5. Fluid challenge technique is continued as
long as there is hemodynamic improvement
( dynamic, eg, change in pulse pressure, stroke
volume variation, or static, eg, arterial pressure,
heart rate) .
Fluid Therapy of Severe Sepsis

20. Vasopressors
1. Vasopressor therapy initially to target a mean
arterial pressure (MAP) of 65 mm Hg (grade 1C).
2. Norepinephrine as the first choice vasopressor
(grade 1B).
3. Epinephrine (added to and potentially
substituted for norepinephrine) when an addition-
al agent is needed to maintain adequate blood
pressure (grade 2B).

21. Vasopressors
4. Vasopressin 0.03 units/minute can be added
to norepinephrine (NE) with intent of either
raising MAP or decreasing NE dosage.
5. Low dose vasopressin is not recommended
as the single initial vasopressor for treatment of
sepsis-induced hypotension and vaso-pressin
doses higher than 0.03-0.04 units/minute
should be reserved for salvage therapy (failure
to achieve adequate MAP with other
vasopressor agents)

22. 6. Dopamine, only in highly selected patients
(eg, patients with low risk of tachyarrhythmias
and absolute or relative bradycardia) (grade
2C).
7. Low-dose dopamine should not be used for
renal protection (grade 1A).
Vasopressors

23. Thank for your attention !