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  <head>
    <title>038-02 Dynamic sepsis care, diagnostic stewardship, and interruption of transmission</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Dynamic sepsis care and transmission">
      <outline text="Recognition as a parallel process">
        <outline text="Neither suspicion nor dysfunction is specific">
          <outline text="Pneumonia can cause hypoxaemia alone"/>
          <outline text="Mimics: pancreatitis, bleeding, embolism, adrenal crisis"/>
        </outline>
        <outline text="Treat reversible threats while building evidence"/>
        <outline text="Response to intervention changes probability"/>
      </outline>
      <outline text="Heterogeneous circulation and organ failure">
        <outline text="Mediators lower tone and raise permeability">
          <outline text="Effective arterial volume falls despite excess water"/>
        </outline>
        <outline text="Heart strain, arrhythmia, ventilation limit output"/>
        <outline text="Regional oxygen failure with acceptable pressure"/>
        <outline text="Same pressure, different response by perfusion"/>
        <outline text="ARDS raises permeability, reduces aerated lung"/>
        <outline text="Kidney injury is more than low flow"/>
        <outline text="One failing organ burdens others">
          <outline text="Trajectory and reserve over a single score"/>
        </outline>
      </outline>
      <outline text="Lactate interpretation">
        <outline text="Adrenergic glycolysis raises lactate with oxygen"/>
        <outline text="Liver clearance, seizures, beta agonists, thiamine"/>
        <outline text="Forcing normalisation with fluid causes congestion"/>
        <outline text="Read with refill, skin, mentation, urine, ultrasound"/>
      </outline>
      <outline text="Fluid as a therapeutic trial">
        <outline text="Balanced isotonic crystalloid by severity"/>
        <outline text="Ask: stroke volume, perfusion, congestion"/>
        <outline text="Passive leg raise as reversible challenge"/>
        <outline text="Variation indices need suitable rhythm and ventilation"/>
        <outline text="Static venous pressure predicts poorly"/>
        <outline text="Responsive does not mean fluid is needed"/>
        <outline text="Reassess congestion after each bolus">
          <outline text="No perfusion gain with congestion: stop repeating"/>
        </outline>
      </outline>
      <outline text="Vasopressors and inotropes">
        <outline text="Norepinephrine early for profound hypotension">
          <outline text="Peripheral vein avoids harmful delay"/>
          <outline text="Watch site and act on extravasation"/>
        </outline>
        <outline text="Vasopressin can spare norepinephrine"/>
        <outline text="Epinephrine can raise lactate and arrhythmia"/>
        <outline text="Inotropes only for low output with hypoperfusion"/>
        <outline text="Rising requirement is not simple underdosing">
          <outline text="Reassess bleeding, tamponade, source, acidaemia"/>
        </outline>
      </outline>
      <outline text="Antibiotics and diagnostic stewardship">
        <outline text="Urgency proportional to likelihood and consequence">
          <outline text="Shock, meningitis, neutropenia: immediate therapy"/>
          <outline text="Stable weak evidence: focused diagnostic interval"/>
        </outline>
        <outline text="Adequate first dose, loading often preserved"/>
        <outline text="Separate sites with sufficient culture volume">
          <outline text="Underfilling lowers sensitivity"/>
          <outline text="Contamination drives unnecessary therapy"/>
        </outline>
        <outline text="Urine culture only when infection is plausible"/>
        <outline text="Panels miss off-panel organisms, find carriage"/>
        <outline text="Right specimen first, not blanket withholding"/>
      </outline>
      <outline text="Source control">
        <outline text="Turns an antimicrobial problem into an anatomical one"/>
        <outline text="Delay sustains growth, toxin, and inflammation"/>
        <outline text="Unstable necrotising cases may need exploration first"/>
        <outline text="Deep samples, since swabs misdirect therapy"/>
        <outline text="Plan: what, who, when, prepared physiology"/>
        <outline text="High risk: drainage, staging, device exchange"/>
        <outline text="Check residual collections and re-obstruction"/>
      </outline>
      <outline text="Reassessment and stewardship">
        <outline text="Reassess within hours, not at course end"/>
        <outline text="Narrow when organism and susceptibility reliable"/>
        <outline text="Culture-negative sepsis has several causes"/>
        <outline text="Persistent fever does not prove narrow cover"/>
        <outline text="Stewardship protects the treated patient first">
          <outline text="Less toxicity, C. difficile, microbiota disruption"/>
        </outline>
        <outline text="Asymptomatic bacteriuria shows diagnostic harm">
          <outline text="Pyuria and cloudy urine are nonspecific"/>
          <outline text="Culture must explain new invasion first"/>
        </outline>
      </outline>
      <outline text="Interrupting transmission">
        <outline text="Hierarchy: eliminate, engineer, systems, protection"/>
        <outline text="Hand hygiene fails with poor access or staffing"/>
        <outline text="Unchanged gloves become a vehicle"/>
        <outline text="Standard precautions because carriage is unknown"/>
        <outline text="Ventilation controls airborne risk at population level"/>
        <outline text="Surgical masks for source control and droplets"/>
        <outline text="Respirators reduce inhalation when fit-tested"/>
        <outline text="Devices need indication, bundle, removal trigger"/>
        <outline text="Checklists work only if staff can stop practice"/>
        <outline text="Sterilise critical, high-level for semicritical"/>
        <outline text="Clean first: organic matter shields organisms"/>
        <outline text="Outbreak: confirm excess and case definition">
          <outline text="Genomic match cannot replace epidemiology"/>
        </outline>
      </outline>
      <outline text="Recovery and the final record">
        <outline text="Recovery is an active phase of care"/>
        <outline text="Muscle loss, neuropathy, cognition, sleep"/>
        <outline text="Document source, cultures, resistance, true allergy"/>
        <outline text="Record source confidence and unexcluded mimics"/>
        <outline text="Stop acute-only drugs continued by inertia"/>
        <outline text="Readmission as incomplete recovery"/>
      </outline>
    </outline>
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