EBM: Sepsis Clinical Management

Ebook "Sepsis Management: A Quick Guide"

Finally, our ebook for sepsis management in our local setting was published! 31 July 2019

Confuse about how to identify sepsis?

Confuse about how and when to use qSOFA score?

But eager to know the cheapest and simplest ways to monitor and manage sepsis in a busy and limited resources setting?

"Sepsis Management: A Quick Guide", this ebook is customised to suit our local setting and other low-middle income countries to provide you with the answer.

The book contains side by side illustrations with texts to unfold the complexity of sepsis and easy to understand. It also contains important pitfalls and tips while managing sepsis. Furthermore, the book is also equiped with google translation tool to accommodate readers of different languages.

This book is suitable for:

1. Doctors who work in district, Emergency Departments, ICU and Critical care unit. It also suitable for Infection disease specialists, pharmacists and healthcare providers,  especially those from low-middle income countries.

2. Paramedics and Nursing personals.

3. Scientists who is currently doing or wishing to do clinical research in sepsis.

Get a copy at Google Play Book Store with offer price at this link. (support for both ios and android user)



27 Jun 2019

Sepsis Resuscitation and Monitoring Chart (SRMC) in Low-Middle Income Country Setting

Due to the limited resources, our society had come out a simplified sepsis resuscitation chart for a appropriate goal directed and guided sepsis resuscitation management in emergency department and critical care unit. It is guided using pulse oximetry plethysmographic waveform analysis, Modified SOFA score and Frank Stratling Curve. This make sepsis management more easy and organised in our setting.

Link to download
PDF: https://drive.google.com/file/d/1bkZR5UBRRXL5jlKqcAFpZF7QoLPD0v5e/view?usp=sharing

PNG : https://drive.google.com/file/d/1orZRtnWwmt5KZbgLOo61nnq9sudvEtbT/view?usp=sharing

8 Oct 2019

The Relevance of Drug Volume of Distribution in Antibiotic Dosing

Sepsis and the Systemic Inflammatory Response Syndrome (SIRS)
When a severe infection occurs, the physiologic response against the bacterial and fungal antigens activate a host response that induce dramatic changes in the vascular permeability that lead to hypotension and capillary leakage of fluids to the extravascular space [10]. If the clinical scenario worsens with hypotension and septic shock, the amount of fluid administered to the patients is also likely to have a significant impact in the Vd of hydrophilic drugs. In fact, it has
been reported that critically ill patients receive up to 12 L of fluid within the first two days of ICU admission [11]. Extensive research has highlighted the variable pharmacokinetics
of different antibiotic classes in critically ill patients with sepsis. For instance, the Vd of hydrophilic antibiotics such as aminoglycosides has been shown to increase in septic patients and correlates positively with severity of illness [12]. Glycopeptides and beta-lactams have been shown to have similar behaviour to aminoglycosides [13-18]. A similar effect appears to occur for linezolid [19]. 

Forty to fifty percent of critically ill patients have been reported to have albumin levels lower than 25 g/L [20], and data shows that this can considerably affect the Vd of highly protein-bound drugs including ceftriaxone, aztreonam, flucloxacillin, fusidic acid and ertapenem [14, 21-26]. Mechanistically, hypoalbuminemia reduces the number of binding sites available for antibiotics that bind to albumin. This leads to a larger amount of unbound drug molecules in
the plasma which are able to “escape” from the bloodstream and distribute into tissues to a larger extent than when there is “normal” protein binding. An increase in drug Vd results because the higher initial unbound drug concentration distributes into the larger extravascular compartment faster, resulting in lower concentrations in the intravascular compartment during the distribution phase. Therefore, the availability of more unbound molecules to distribute into the extravascular space is likely to further decrease the effective concentrations in plasma over time.

8 Oct 2019
Antibiotic dose optimization in critically ill patients

Abstract The judicious use of existing antibiotics is essential for preserving their activityagainst infections. In the era of multi-drug resistance, this is of particular importance in clin-ical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimizationin critically ill patients requires sound knowledge not only of the altered physiology in seri-ous infections --- including severe sepsis, septic shock and ventilator-associated pneumonia ---but also of the pathogen---drug exposure relationship (i.e. pharmacokinetic/pharmacodynamicindex). An important consideration is the fact that extreme shifts in organ function, such asthose seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, canhave an impact upon drug exposure, and constant vigilance is required when reviewing antibi-otic dosing regimens in the critically ill. The use of continuous renal replacement therapy andextracorporeal membrane oxygenation remain important interventions in these patients; how-ever, both of these treatments can have a profound effect on antibiotic exposure. We suggestplacing emphasis on the use of therapeutic drug monitoring and dose individualization whenoptimizing therapy in these settings.

Another common phenomenon soon after the ini-tial phase of severe sepsis and septic shock is thepronounced reduction in serum albumin concentrations(hypoalbuminemia).23Albumin constitutes nearly two-thirdsof all human serum proteins and is the primary proteinresponsible for drug-protein binding.24Previously defined asa serum albumin concentration less than 25 g/L,25hypoal-buminemia has a direct impact on the PK of antibiotics,particularly on those antibiotics that are highly proteinbound.26Firstly, it increases the unbound or ‘free’ frac-tion of drug. This is important given that it is only theunbound drug that can exert a pharmacodynamic effect.As hypoalbuminemic states can increase the amount ofdrug that distributes into tissues, this is likely to havea direct effect on the Vdof an antibiotic. Finally, asonly the unbound drug in the intravascular compartmentis available for metabolism and elimination, low serumalbumin concentrations may mean that there is higher pro-portion of unbound drug available for clearance leadingto low concentrations toward the end of the dosing inter-val.

17 Oct 2018

Vitamin C, Thiamin and Steriod improve organ failure 

The components of Marik’s life-saving sepsis cocktail are simply steroids and vitamins, a therapy, which many have said is harmless, but may improve sepsis survival dramatically. Steroids for sepsis have been around decades, and although there have been several trials evaluating its benefits in the septic patient; it is safe to say that the use of steroids remains controversial. The recently completed HYPRESS trial did not demonstrate a benefit for steroids in patients with sepsis.  How about the use of vitamin C and thiamine? This is not a new concept and there are studies demonstrating benefit so perhaps, combining all these “harmless” therapies would work on the deranged physiologic pathways that are present in the septic patient.

So the conjecture here is that Marik’s new cocktail has little patient harm because the individual components are individually benign and have been studied before. In fact, Marik himself has made the claim that withholding this therapy while waiting for a multicenter trial to be completed would be unethical. In support of his statement he has even invoked the infamous “parachute analogy” where some therapies are so obvious that it would be illogical to test them in a clinical trial.

Adapted from (Marik et al 2016)
Background: The global burden of sepsis is estimated as 15 to 19 million cases annually with a mortality rate approaching 60% in low income countries.

Methods: In this retrospective before-after clinical study, we compared the outcome and
clinical course of consecutive septic patients treated with intravenous vitamin C,
hydrocortisone and thiamine during a 7-month period (treatment group) compared to a
control group treated in our ICU during the preceding 7 months. The primary outcome was
hospital survival. A propensity score was generated to adjust the primary outcome.

Findings: There were 47 patients in both treatment and control groups with no significant
differences in baseline characteristics between the two groups. The hospital mortality was
8.5% (4 of 47) in the treatment group compared to 40.4% (19 of 47) in the control group (p
< 0.001). The propensity adjusted odds of mortality in the patients treated with the vitamin
C protocol was 0.13 (95% CI 0.04-0.48, p=002). The SOFA score decreased in all patients in
the treatment group with none developing progressive organ failure. Vasopressors were
weaned off all patients in the treatment group, a mean of 18.3 ± 9.8 hours after starting
treatment with vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4
hours in the control group (p<0.001).

Conclusion: Our results suggest that the early use of intravenous vitamin C, together with
corticosteroids and thiamine may prove to be effective in preventing progressive organ
dysfunction including acute kidney injury and reducing the mortality of patients with
severe sepsis and septic shock. Additional studies are required to confirm these
preliminary findings.

The clinical trial paper can be found at this link:


For those who want to get a quick glance on this topic, please kindly go to this link (credits to R.E.B.E.L EM group making the topic easy to understand):


MSOFA: An Important Step Forward, but Are We Spending Too Much Time on the SOFA?

SEPSIS 3 recommended the use of SOFA score to assess the organ failure status. However, the criteria are quite complex. We recommend the use of modified SOFA to adapt to the local minimum setting.

The mortality rate was 9% for patients with no organ failure on admission, increasing to 82.6% for patients with four or more failing organs.

When two organ systems were failing, as defined by a SOFA score of 3 or 4, the presence of respiratory failure as one of the two failing systems was associated with a lower mortality rate than any other combination. For combinations of other organs, there was a narrow range of mortality (65% to 74%), and no identifiable pattern of increased risk with any specific organ. 

SOFA Score
Mortality if initial score
Mortality if highest score
Mean SOFA Score

To download this file please follow this link :
powerpoint : https://drive.google.com/open?id=1j1bGoA7yAv4cshuLqR9_qcnM8VIAyx5H
png file       : https://drive.google.com/open?id=19UczWkza9U6udO-oBxUn8vVjjU1qRyxN


15 August 2018


•  Sepsis is a syndrome of life threatening infection with organ dysfunction, and most guidelines do not advise use of corticosteroids to treat it in the absence of refractory shock
•  Two new trials of corticosteroid treatment for sepsis came to differing conclusions
•  Corticosteroids may reduce the risk of death by a small amount and increase neuromuscular weakness by a small amount, but the evidence is not definitive
•  This guideline makes a weak recommendation for corticosteroids in patients with sepsis; both steroids and no steroids are reasonable management options
•  Fully informed patients who value avoiding death over quality of life and function would likely choose corticosteroids

For Further Reading, please go to the follow link


Acknowledgement to The BMJ for permission for non profit reused.


Clinical Sepsis Algorithm (local recommandation) 

Surviving Sepsis Campaign Hour-1 Bundle 2018