Severe sepsis management

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"sepsis" AND "management" AND "surviving sepsis"

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Surviving Sepsis Campaign 2024 2025 guidelines severe sepsis management

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https://www.sccm.org/clinical-resources/guidelines/guideline…

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I have comprehensive data. Now I'll compile a thorough, well-organized response.

Severe Sepsis Management

Note on terminology: Sepsis-3 (2016) removed "severe sepsis" as a standalone term. What was previously called "severe sepsis" is now simply called sepsis (infection + acute organ dysfunction). Septic shock is the subset with vasopressor requirement + lactate >2 mmol/L despite fluids. This guide covers both.

1. Definitions (Sepsis-3)

Term	Definition
Sepsis	Life-threatening organ dysfunction caused by a dysregulated host response to infection. Operationalized as suspected infection + SOFA score increase ≥2 points
Septic shock	Sepsis + vasopressor requirement to maintain MAP ≥65 mmHg + serum lactate >2 mmol/L (>18 mg/dL) despite adequate fluid resuscitation
qSOFA (screening)	RR ≥22/min + altered mentation (GCS <15) + SBP ≤100 mmHg - score ≥2 warrants full SOFA assessment

SOFA Score Components

System	Parameter	Score 0-4
Respiratory	PaO2/FiO2	≥400 → <100
Coagulation	Platelets (×10³/µL)	≥150 → <20
Liver	Bilirubin (mg/dL)	<1.2 → >12
Cardiovascular	MAP / vasopressors	MAP ≥70 → Dopa >15 or NE >0.1 µg/kg/min
CNS	Glasgow Coma Scale	15 → <6
Renal	Creatinine / urine output	<1.2 mg/dL → >5 mg/dL

Goldman-Cecil Medicine, screening table; Harrison's Principles 22E, Ch. 315

2. Initial Resuscitation - The "1-Hour Bundle"

A. Within the First Hour (Septic Shock or Lactate ≥4 mmol/L)

Measure lactate - repeat if initial >2 mmol/L to assess resuscitation
Blood cultures x2 before antibiotics (do not delay antibiotics >45 min to obtain cultures)
Broad-spectrum antibiotics - within 1 hour of recognition
IV crystalloid - 30 mL/kg within 3 hours (balanced crystalloids preferred)
Vasopressors if MAP <65 mmHg despite initial fluids

B. Fluid Resuscitation (SSC 2026 Updated Guidance)

Preferred fluid: Balanced crystalloids (Lactated Ringer's, Plasma-Lyte) over normal saline - reduces risk of hyperchloremic metabolic acidosis and AKI
Initial bolus: 30 mL/kg crystalloid in first 3 hours
Beyond 30 mL/kg: use dynamic hemodynamic parameters (pulse pressure variation, stroke volume variation, passive leg raise response) to guide further fluid
Albumin: consider when large volumes of crystalloid have been given and patient has persistent hypoperfusion
Avoid: hetastarch/HES formulations (increased AKI and mortality risk)
Post-resuscitation: SSC 2026 recommends active fluid removal (diuretics or ultrafiltration) once the acute resuscitation phase has passed - cumulative fluid overload worsens outcomes

SSC 2026 notes that either a liberal or restrictive fluid strategy post-30 mL/kg bolus may be used based on individual patient and health system factors.

3. Antibiotics

Timing

Septic shock or lactate ≥4 mmol/L: within 1 hour - each hour of delay adds ~7-8% mortality
Sepsis without shock: within 1-3 hours; if diagnosis uncertain and shock absent, time-limited clinical evaluation is reasonable before committing to empiric therapy
De-escalate based on culture/sensitivities as soon as possible (stewardship)
Procalcitonin: do NOT use to decide when to start antibiotics; may help guide when to stop

Empiric Selection by Suspected Source

Source	Empiric Regimen
Unknown / undifferentiated	Pip-tazo or cefepime ± vancomycin (if MRSA risk)
Gram-negative dominant (no Pseudomonas risk)	Ceftriaxone or cefotaxime
Pseudomonas risk	Cefepime, pip-tazo, or carbapenem (imipenem/meropenem)
High-resistance gram-negative risk	Two anti-gram-negative agents empirically
MRSA risk (healthcare exposure, nosocomial onset)	Add vancomycin or linezolid
Abdominal source	Pip-tazo, cefepime + metronidazole, or carbapenem
Fungal risk (abdominal surgery, TPN, Candida colonization, liver failure, diabetes)	Add empiric echinocandin
Influenza	Add oseltamivir
SARS-CoV-2	Consider remdesivir

Harrison's Principles 22E, Ch. 315; Barash Clinical Anesthesia 9e, Table 57-4

Antibiotic Optimization

Administer beta-lactams before vancomycin when both are indicated
Consider prolonged/extended infusion of beta-lactams to optimize time-above-MIC
Consult pharmacy/infectious disease for PK/PD optimization

4. Source Control

Mandatory and urgent - identify and eliminate the anatomic infection source as quickly as possible
Examples: drainage of abscesses (intraabdominal, soft tissue), debridement of necrotizing fasciitis, cholecystectomy/biliary drainage for cholangitis, nephrectomy/stenting for obstructive uropathy
Remove any infected indwelling catheters
If source control requires invasive procedure, it should not delay initiation of antibiotics

5. Vasopressors

Agent	Role	Notes
Norepinephrine	First-line	Target MAP ≥65 mmHg
Vasopressin	Second-line adjunct	Add at 0.03 U/min (fixed dose) when NE reaches 0.25-0.5 µg/kg/min; do not use as monotherapy
Epinephrine	Third-line	Add when hypotension persists despite NE + vasopressin
Dopamine	Avoid (mostly)	Only in highly selected circumstances (bradycardia + low CO)
Dobutamine	Adjunct for low CO	Add to NE (or use epi alone) if low cardiac output persists despite adequate fluids

Key Updates (SSC 2026)

Peripheral vasopressors are acceptable while obtaining central access - do not delay NE initiation
MAP target 65 mmHg (not higher targets - moderate evidence)
Levosimendan and terlipressin are not recommended

6. Corticosteroids

Indication: Septic shock that remains on vasopressors
Dose: Hydrocortisone 50 mg IV q6h (200 mg/day) - either bolus or continuous infusion
Evidence: Two meta-analyses show shorter duration of shock with corticosteroids, though mortality benefit is modest
SSC 2026: conditional recommendation, low certainty of evidence
Not recommended in sepsis without shock

7. Respiratory Support

Oxygen

Target SpO2 92-96% with supplemental O2
Low-flow O2 → high-flow nasal cannula → non-invasive ventilation before intubation (if appropriate)

Mechanical Ventilation (if ARDS develops)

Tidal volume: 6 mL/kg predicted body weight (lung-protective)
Plateau pressure: ≤30 cmH2O
PEEP: Higher PEEP strategies for moderate-severe ARDS
Do NOT use incremental PEEP titration strategy
Prone positioning: ≥12 hours/day for moderate-severe ARDS (PaO2/FiO2 <150)
Neuromuscular blockade: for prone positioning - intermittent boluses preferred over continuous infusion
VV-ECMO: consider for severe ARDS failing mechanical ventilation at experienced centers
Elevate head of bed 30-45° (semi-recumbent) unless contraindicated
Avoid routine pulmonary artery catheters
Use weaning protocols + daily sedation interruption (if continuous infusion sedation)

8. Glycemic Control

Target blood glucose 140-180 mg/dL (7.8-10 mmol/L)
Avoid tight control <110 mg/dL (hypoglycemia risk)
Use validated insulin infusion protocols
Monitor glucose q1-2h when on insulin infusion

9. Adjunctive and Supportive Care

Intervention	Recommendation
RBC transfusion	Only if Hgb <7 g/dL (absent active hemorrhage, ACS, tissue hypoperfusion)
DVT/VTE prophylaxis	Pharmacologic prophylaxis (LMWH preferred over UFH) unless contraindicated
Stress ulcer prophylaxis	For patients with bleeding risk factors
Renal replacement therapy	For AKI with refractory fluid overload, acidosis, uremia
Sodium bicarbonate	Only if pH ≤7.2 + AKI (AKIN stage 2-3) - conditional recommendation
Nutrition	Early enteral nutrition preferred over parenteral; avoid overfeeding
Sedation	Minimize depth; use analgesia-first (analgosedation); daily SATs if on drips
ICU admission	Within 6 hours of diagnosis for critically ill patients

10. Monitoring Adequacy of Resuscitation

Lactate clearance: target ≥10-20% reduction every 2 hours; normalization (<2 mmol/L) is the goal
MAP ≥65 mmHg
Urine output ≥0.5 mL/kg/hr
Mental status normalization
Dynamic parameters (PPV, SVV, passive leg raise) to guide ongoing fluid decisions

11. Common Organisms by Source (Quick Reference)

Primary Site	Common Pathogens
Urinary tract (48.9% of cases)	E. coli, Klebsiella, Enterococcus
Respiratory tract (32.9%)	S. pneumoniae, S. aureus/MRSA, Pseudomonas, Klebsiella
Intraabdominal (13.6%)	E. coli, Bacteroides, Enterococcus, Candida
Skin/soft tissue (10.3%)	S. aureus/MRSA, Group A Strep, Clostridium

Harrison's Principles 22E, Ch. 315

12. What's New - SSC 2026 Key Updates

Fluid resuscitation: more individualized approach - no mandated volume after initial 30 mL/kg; dynamic assessment guides further fluid
Earlier vasopressors: can be started peripherally; concurrent with fluids in unstable shock
Active fluid removal recommended post-resuscitation phase (diuretics/ultrafiltration)
Intermittent NMBA boluses preferred over continuous infusion for ARDS
VV-ECMO for refractory severe ARDS (conditional)
Children managed under separate 2026 pediatric SSC guidelines (PMID: 41869844)

Sources:

Harrison's Principles of Internal Medicine 22E (2025), Ch. 315 - Sepsis and Septic Shock
Barash Clinical Anesthesia 9e, Table 57-4 - Management of Sepsis and Septic Shock
Goldman-Cecil Medicine, Table 94-1 - Screening for Sepsis and Septic Shock
Surviving Sepsis Campaign International Guidelines 2026 - SCCM/ESICM
S3 Guideline Update 2025 (PMID: 40824313) - German adaptation of SSC 2021
Sepsis Alert Systems meta-analysis, JAMA Network Open 2024 (PMID: 39037814)

Create a management protocol poster for your ED/ICU

Reading File

Running Command

ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or not found"

Running Command

mkdir -p /home/daytona/workspace/sepsis-poster

Writing File

~/sepsis-poster/create_poster.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5" — poster-friendly
pres.title = "Severe Sepsis & Septic Shock Management Protocol";
pres.author = "ED/ICU Protocol";

// ─── COLOR PALETTE ───────────────────────────────────────────
const C = {
  bgDark:    "0D1B2A",   // deep navy - background
  red:       "C0392B",   // alert red - septic shock header
  orange:    "E67E22",   // warning orange - 1hr bundle
  teal:      "1A7A8C",   // teal - antibiotics
  green:     "1E8449",   // green - fluids
  purple:    "6C3483",   // purple - vasopressors
  slate:     "1B3A52",   // dark slate - section panels
  cardBg:    "112233",   // card background
  accentBg:  "0A2540",   // slightly lighter panel
  white:     "FFFFFF",
  offwhite:  "E8F0F5",
  yellow:    "F4D03F",
  lightBlue: "85C1E9",
  divider:   "1E4D70",
};

const slide = pres.addSlide();

// ── FULL BACKGROUND ──────────────────────────────────────────
slide.addShape(pres.ShapeType.rect, {
  x: 0, y: 0, w: 13.3, h: 7.5,
  fill: { color: C.bgDark },
  line: { color: C.bgDark },
});

// ── TOP HEADER BAR ───────────────────────────────────────────
slide.addShape(pres.ShapeType.rect, {
  x: 0, y: 0, w: 13.3, h: 0.72,
  fill: { color: C.red },
  line: { color: C.red },
});

slide.addText("⚠  SEVERE SEPSIS & SEPTIC SHOCK  —  MANAGEMENT PROTOCOL", {
  x: 0.15, y: 0, w: 9.5, h: 0.72,
  fontSize: 17, bold: true, color: C.white,
  fontFace: "Arial", valign: "middle", align: "left",
  charSpacing: 1, margin: 0,
});

slide.addText("SSC 2026 | Harrison's 22E", {
  x: 10.8, y: 0, w: 2.4, h: 0.72,
  fontSize: 9, color: "FFD1CC", fontFace: "Arial",
  valign: "middle", align: "right", italic: true, margin: 0,
});

// ── COLUMN LAYOUT: 5 columns, y from 0.82 ─────────────────────
// Col widths: 2.5 | 2.5 | 2.7 | 2.7 | 2.6  (gaps 0.1)
// x positions: 0.08 | 2.68 | 5.28 | 8.08 | 10.88

const colX = [0.08, 2.68, 5.28, 8.08, 10.88];
const colW = [2.52, 2.52, 2.72, 2.72, 2.35];
const topY  = 0.82;
const cardH = 6.55;
const hdrH  = 0.42;
const r     = 0.08;

function addCard(x, w, color, label) {
  // Card background
  slide.addShape(pres.ShapeType.roundRect, {
    x, y: topY, w, h: cardH,
    fill: { color: C.cardBg },
    line: { color: color, w: 1.5 },
    rectRadius: r,
  });
  // Header strip
  slide.addShape(pres.ShapeType.roundRect, {
    x, y: topY, w, h: hdrH,
    fill: { color: color },
    line: { color: color },
    rectRadius: r,
  });
  // Square off bottom corners of header strip
  slide.addShape(pres.ShapeType.rect, {
    x, y: topY + hdrH * 0.5, w, h: hdrH * 0.5,
    fill: { color: color },
    line: { color: color },
  });
  // Label
  slide.addText(label, {
    x: x + 0.08, y: topY, w: w - 0.16, h: hdrH,
    fontSize: 10.5, bold: true, color: C.white,
    fontFace: "Arial", valign: "middle", align: "center",
    charSpacing: 0.5, margin: 0,
  });
}

// ─── COL 1: RECOGNITION & DIAGNOSIS ────────────────────────
addCard(colX[0], colW[0], C.red, "RECOGNITION & DIAGNOSIS");

const diagContentY = topY + hdrH + 0.08;

slide.addText("DEFINITIONS (Sepsis-3)", {
  x: colX[0]+0.1, y: diagContentY, w: colW[0]-0.2, h: 0.22,
  fontSize: 7.5, bold: true, color: C.yellow, fontFace: "Arial",
  margin: 0,
});

slide.addText([
  { text: "SEPSIS: ", options: { bold: true, color: C.lightBlue } },
  { text: "Suspected infection\n+ SOFA ≥2 points", options: { color: C.offwhite } },
], {
  x: colX[0]+0.1, y: diagContentY+0.24, w: colW[0]-0.2, h: 0.52,
  fontSize: 8.2, fontFace: "Arial", margin: 0,
});

slide.addText([
  { text: "SEPTIC SHOCK: ", options: { bold: true, color: "FF8C7A" } },
  { text: "Sepsis + vasopressor\nto maintain MAP ≥65 mmHg\n+ Lactate >2 mmol/L\ndespite fluids", options: { color: C.offwhite } },
], {
  x: colX[0]+0.1, y: diagContentY+0.80, w: colW[0]-0.2, h: 0.9,
  fontSize: 8.2, fontFace: "Arial", margin: 0,
});

// qSOFA box
slide.addShape(pres.ShapeType.roundRect, {
  x: colX[0]+0.08, y: diagContentY+1.78, w: colW[0]-0.16, h: 0.85,
  fill: { color: "1A0505" }, line: { color: C.red, w: 1 }, rectRadius: 0.05,
});
slide.addText("qSOFA  (screen — score ≥2 = high risk)", {
  x: colX[0]+0.12, y: diagContentY+1.80, w: colW[0]-0.24, h: 0.22,
  fontSize: 7.5, bold: true, color: C.yellow, fontFace: "Arial", margin: 0,
});
slide.addText([
  { text: "• RR ≥22/min\n• Altered mentation (GCS <15)\n• SBP ≤100 mmHg", options: { color: C.offwhite } },
], {
  x: colX[0]+0.14, y: diagContentY+2.03, w: colW[0]-0.28, h: 0.56,
  fontSize: 8, fontFace: "Arial", margin: 0,
});

// SOFA table header
slide.addText("SOFA SCORE — organ dysfunction", {
  x: colX[0]+0.1, y: diagContentY+2.72, w: colW[0]-0.2, h: 0.2,
  fontSize: 7.5, bold: true, color: C.yellow, fontFace: "Arial", margin: 0,
});

const sofaRows = [
  ["System", "Key Parameter"],
  ["Respiratory", "PaO₂/FiO₂"],
  ["Coagulation", "Platelets"],
  ["Liver", "Bilirubin"],
  ["Cardiovascular", "MAP / vasopressors"],
  ["CNS", "GCS"],
  ["Renal", "Creatinine / UO"],
];
sofaRows.forEach((row, i) => {
  const ry = diagContentY + 2.96 + i * 0.29;
  slide.addShape(pres.ShapeType.rect, {
    x: colX[0]+0.08, y: ry, w: colW[0]-0.16, h: 0.27,
    fill: { color: i === 0 ? C.red : (i%2===0 ? "181F2B" : "111827") },
    line: { color: C.divider, w: 0.5 },
  });
  slide.addText(row[0], {
    x: colX[0]+0.1, y: ry+0.01, w: 1.3, h: 0.25,
    fontSize: 7.2, bold: i===0, color: i===0 ? C.white : C.offwhite,
    fontFace: "Arial", margin: 0, valign: "middle",
  });
  slide.addText(row[1], {
    x: colX[0]+0.1+1.3, y: ry+0.01, w: colW[0]-0.16-1.3, h: 0.25,
    fontSize: 7.2, bold: i===0, color: i===0 ? C.white : C.lightBlue,
    fontFace: "Arial", margin: 0, valign: "middle",
  });
});

// Mortality note
slide.addText("⚡  7–8% ↑ mortality per 1-hr delay in ABx", {
  x: colX[0]+0.08, y: topY + cardH - 0.32, w: colW[0]-0.16, h: 0.26,
  fontSize: 7.8, bold: true, color: C.yellow, fontFace: "Arial",
  align: "center", margin: 0,
  fill: { color: "2A0000" },
  shape: pres.ShapeType.roundRect,
});

// ─── COL 2: 1-HOUR BUNDLE ───────────────────────────────────
addCard(colX[1], colW[1], C.orange, "1-HOUR BUNDLE");

const bY = topY + hdrH + 0.1;

const bundleItems = [
  { num: "1", title: "Measure LACTATE", body: "Repeat if >2 mmol/L\nTarget: clearance ≥10–20%\nevery 2 hrs → normalize <2" },
  { num: "2", title: "Blood Cultures ×2", body: "BEFORE antibiotics\n(don't delay ABx >45 min\nto obtain cultures)" },
  { num: "3", title: "Broad-Spectrum ABx", body: "Within 1 hr of\nshock recognition\n(see Antibiotics column →)" },
  { num: "4", title: "IV Crystalloid Bolus", body: "30 mL/kg in 3 hrs\nBalanced crystalloids\n(LR or Plasma-Lyte)" },
  { num: "5", title: "Vasopressors if MAP <65", body: "Start norepinephrine\nCan initiate peripherally\nTarget MAP ≥65 mmHg" },
];

bundleItems.forEach((item, i) => {
  const iy = bY + i * 1.22;
  // Number circle
  slide.addShape(pres.ShapeType.ellipse, {
    x: colX[1]+0.1, y: iy+0.02, w: 0.3, h: 0.3,
    fill: { color: C.orange }, line: { color: C.orange },
  });
  slide.addText(item.num, {
    x: colX[1]+0.1, y: iy+0.02, w: 0.3, h: 0.3,
    fontSize: 9, bold: true, color: C.white,
    fontFace: "Arial", align: "center", valign: "middle", margin: 0,
  });
  // Title
  slide.addText(item.title, {
    x: colX[1]+0.48, y: iy+0.02, w: colW[1]-0.56, h: 0.26,
    fontSize: 9, bold: true, color: C.yellow,
    fontFace: "Arial", margin: 0, valign: "middle",
  });
  // Body
  slide.addText(item.body, {
    x: colX[1]+0.48, y: iy+0.30, w: colW[1]-0.56, h: 0.56,
    fontSize: 8, color: C.offwhite,
    fontFace: "Arial", margin: 0,
  });
  // Divider (except last)
  if (i < bundleItems.length - 1) {
    slide.addShape(pres.ShapeType.line, {
      x: colX[1]+0.1, y: iy+1.18, w: colW[1]-0.2, h: 0,
      line: { color: C.divider, w: 0.5, dashType: "dash" },
    });
  }
});

// ICU admission note
slide.addText("ICU admission within 6 hrs of diagnosis", {
  x: colX[1]+0.08, y: topY + cardH - 0.32, w: colW[1]-0.16, h: 0.26,
  fontSize: 8, bold: true, color: C.orange, fontFace: "Arial",
  align: "center", margin: 0,
});

// ─── COL 3: ANTIBIOTICS & SOURCE CONTROL ────────────────────
addCard(colX[2], colW[2], C.teal, "ANTIBIOTICS & SOURCE CONTROL");

const aY = topY + hdrH + 0.1;

slide.addText("EMPIRIC SELECTION", {
  x: colX[2]+0.1, y: aY, w: colW[2]-0.2, h: 0.2,
  fontSize: 7.5, bold: true, color: C.yellow, fontFace: "Arial", margin: 0,
});

const abxTable = [
  ["Suspected Source", "Empiric Agent(s)", true],
  ["Unknown (undiff.)", "Pip-tazo or cefepime", false],
  ["+ MRSA risk", "Add vancomycin or linezolid", false],
  ["No Pseudomonas risk", "Ceftriaxone / cefotaxime", false],
  ["Pseudomonas risk", "Cefepime, pip-tazo\nor carbapenem", false],
  ["Abdominal", "Pip-tazo, cefepime +\nmetronidazole, or carbapenem", false],
  ["High-resistance GN", "TWO anti-GN agents", false],
  ["Fungal risk*", "Add echinocandin", false],
  ["Influenza", "Add oseltamivir", false],
  ["COVID-19", "Consider remdesivir", false],
];

abxTable.forEach((row, i) => {
  const ry = aY + 0.24 + i * 0.38;
  slide.addShape(pres.ShapeType.rect, {
    x: colX[2]+0.08, y: ry, w: colW[2]-0.16, h: 0.36,
    fill: { color: row[2] ? C.teal : (i%2===0 ? "0E2233" : "091A27") },
    line: { color: C.divider, w: 0.5 },
  });
  slide.addText(row[0], {
    x: colX[2]+0.1, y: ry+0.01, w: 1.22, h: 0.34,
    fontSize: 7.2, bold: row[2], color: row[2] ? C.white : C.lightBlue,
    fontFace: "Arial", margin: 0, valign: "middle",
  });
  slide.addText(row[1], {
    x: colX[2]+0.1+1.22, y: ry+0.01, w: colW[2]-0.16-1.22, h: 0.34,
    fontSize: 7.2, bold: row[2], color: row[2] ? C.white : C.offwhite,
    fontFace: "Arial", margin: 0, valign: "middle",
  });
});

// Footnote
slide.addText("*Fungal risk: recent abdominal surgery, TPN, Candida colonization, liver failure, diabetes", {
  x: colX[2]+0.08, y: aY + 0.24 + abxTable.length * 0.38 + 0.05, w: colW[2]-0.16, h: 0.28,
  fontSize: 6.8, color: "7FBCD2", fontFace: "Arial", margin: 0, italic: true,
});

// Source Control box
const scY = aY + 0.24 + abxTable.length * 0.38 + 0.36;
slide.addShape(pres.ShapeType.roundRect, {
  x: colX[2]+0.08, y: scY, w: colW[2]-0.16, h: 0.92,
  fill: { color: "071520" }, line: { color: C.teal, w: 1 }, rectRadius: 0.05,
});
slide.addText("SOURCE CONTROL", {
  x: colX[2]+0.12, y: scY+0.04, w: colW[2]-0.24, h: 0.2,
  fontSize: 7.5, bold: true, color: C.yellow, fontFace: "Arial", margin: 0,
});
slide.addText([
  { text: "• Drain abscesses, debride necrotizing fasciitis\n", options: { color: C.offwhite } },
  { text: "• Biliary drainage (cholangitis), relieve obstruction\n", options: { color: C.offwhite } },
  { text: "• Remove infected catheters / hardware\n", options: { color: C.offwhite } },
  { text: "• Urgently — do NOT delay for resuscitation", options: { bold: true, color: "FF8C7A" } },
], {
  x: colX[2]+0.12, y: scY+0.26, w: colW[2]-0.24, h: 0.62,
  fontSize: 7.5, fontFace: "Arial", margin: 0,
});

// De-escalation reminder
slide.addText("De-escalate ABx based on cultures. Use PCT to guide stopping.", {
  x: colX[2]+0.08, y: topY + cardH - 0.32, w: colW[2]-0.16, h: 0.26,
  fontSize: 7.8, bold: false, italic: true, color: C.lightBlue, fontFace: "Arial",
  align: "center", margin: 0,
});

// ─── COL 4: FLUIDS & VASOPRESSORS ───────────────────────────
addCard(colX[3], colW[3], C.green, "FLUIDS & VASOPRESSORS");

const fY = topY + hdrH + 0.1;

// FLUIDS
slide.addText("FLUID RESUSCITATION", {
  x: colX[3]+0.1, y: fY, w: colW[3]-0.2, h: 0.22,
  fontSize: 7.5, bold: true, color: C.yellow, fontFace: "Arial", margin: 0,
});

const fluidItems = [
  ["30 mL/kg crystalloid", "in first 3 hours — initial bolus"],
  ["Balanced crystalloids", "LR or Plasma-Lyte over normal saline"],
  ["Dynamic monitoring", "PPV, SVV, PLR to guide further fluid"],
  ["Liberal vs restrictive", "after 30 mL/kg — individualize to patient"],
  ["Consider albumin", "when large volumes of crystalloid given"],
  ["Avoid HES/hetastarch", "↑ AKI and mortality risk"],
  ["Active fluid removal", "post-resuscitation phase (diuretics/UF)"],
];

fluidItems.forEach((item, i) => {
  const fy2 = fY + 0.26 + i * 0.3;
  slide.addShape(pres.ShapeType.rect, {
    x: colX[3]+0.08, y: fy2, w: colW[3]-0.16, h: 0.28,
    fill: { color: i%2===0 ? "0A1F10" : "0D2416" },
    line: { color: C.divider, w: 0.4 },
  });
  slide.addText(item[0], {
    x: colX[3]+0.12, y: fy2+0.01, w: 1.4, h: 0.26,
    fontSize: 7.5, bold: true, color: C.green === "1E8449" ? "4ECB8C" : C.green,
    fontFace: "Arial", margin: 0, valign: "middle",
    color: "4ECB8C",
  });
  slide.addText(item[1], {
    x: colX[3]+0.12+1.4, y: fy2+0.01, w: colW[3]-0.16-1.4, h: 0.26,
    fontSize: 7.2, color: C.offwhite, fontFace: "Arial", margin: 0, valign: "middle",
  });
});

// Monitoring targets box
const mtY = fY + 0.26 + fluidItems.length * 0.3 + 0.05;
slide.addShape(pres.ShapeType.roundRect, {
  x: colX[3]+0.08, y: mtY, w: colW[3]-0.16, h: 0.46,
  fill: { color: "071510" }, line: { color: "4ECB8C", w: 1 }, rectRadius: 0.05,
});
slide.addText("Resuscitation targets: MAP ≥65 | UO ≥0.5 mL/kg/hr | Lactate clearance ≥10–20%/2h | Mental status improvement", {
  x: colX[3]+0.12, y: mtY+0.02, w: colW[3]-0.24, h: 0.42,
  fontSize: 7.5, bold: false, color: "4ECB8C", fontFace: "Arial", margin: 0,
});

// Divider line
slide.addShape(pres.ShapeType.line, {
  x: colX[3]+0.1, y: mtY + 0.52, w: colW[3]-0.2, h: 0,
  line: { color: C.green, w: 1, dashType: "dash" },
});

// VASOPRESSORS
const vpY = mtY + 0.6;
slide.addText("VASOPRESSORS", {
  x: colX[3]+0.1, y: vpY, w: colW[3]-0.2, h: 0.22,
  fontSize: 7.5, bold: true, color: C.yellow, fontFace: "Arial", margin: 0,
});

const vpItems = [
  { agent: "Norepinephrine", role: "1st LINE", dose: "Start peripherally; titrate to MAP ≥65", color: "E74C3C" },
  { agent: "Vasopressin", role: "2nd LINE", dose: "0.03 U/min (fixed); add when NE ≥0.25–0.5 µg/kg/min", color: "E67E22" },
  { agent: "Epinephrine", role: "3rd LINE", dose: "Add if persistent hypotension on NE+VP", color: "F4D03F" },
  { agent: "Dobutamine", role: "Low CO", dose: "Add to NE if low cardiac output persists", color: "85C1E9" },
  { agent: "Dopamine", role: "AVOID", dose: "Only selected cases (brady + low CO)", color: "666666" },
];

vpItems.forEach((vp, i) => {
  const vy = vpY + 0.26 + i * 0.32;
  slide.addShape(pres.ShapeType.rect, {
    x: colX[3]+0.08, y: vy, w: 0.65, h: 0.30,
    fill: { color: vp.color }, line: { color: vp.color },
  });
  slide.addText(vp.role, {
    x: colX[3]+0.08, y: vy, w: 0.65, h: 0.30,
    fontSize: 6.5, bold: true, color: C.white, fontFace: "Arial",
    align: "center", valign: "middle", margin: 0,
  });
  slide.addText([
    { text: vp.agent + ": ", options: { bold: true, color: C.offwhite } },
    { text: vp.dose, options: { color: "AABFCC" } },
  ], {
    x: colX[3]+0.78, y: vy, w: colW[3]-0.86, h: 0.30,
    fontSize: 7.2, fontFace: "Arial", margin: 0, valign: "middle",
  });
});

// ─── COL 5: SUPPORTIVE CARE ─────────────────────────────────
addCard(colX[4], colW[4], C.purple, "SUPPORTIVE CARE");

const sY = topY + hdrH + 0.1;

const supportSections = [
  {
    heading: "CORTICOSTEROIDS",
    color: "B07FDB",
    items: [
      "Indication: septic shock ON vasopressors",
      "Hydrocortisone 200 mg/day (50 mg q6h IV or infusion)",
      "Not recommended without shock",
    ],
  },
  {
    heading: "MECHANICAL VENTILATION (ARDS)",
    color: "85C1E9",
    items: [
      "Tidal volume 6 mL/kg predicted BW",
      "Plateau pressure ≤30 cmH₂O",
      "Higher PEEP for moderate-severe ARDS",
      "Prone ≥12 hrs/day for mod-severe ARDS",
      "Intermittent NMB boluses (not infusion)",
      "VV-ECMO if refractory — experienced centers",
    ],
  },
  {
    heading: "BLOOD GLUCOSE",
    color: "F0B27A",
    items: [
      "Target 140–180 mg/dL (7.8–10 mmol/L)",
      "Avoid tight control <110 mg/dL",
    ],
  },
  {
    heading: "TRANSFUSION",
    color: "EC7063",
    items: [
      "Transfuse RBC if Hgb <7 g/dL",
      "(unless active bleed, ACS, hypoperfusion)",
    ],
  },
  {
    heading: "SUPPORTIVE BUNDLE",
    color: "52BE80",
    items: [
      "LMWH VTE prophylaxis (preferred over UFH)",
      "Stress ulcer prophylaxis (if risk factors)",
      "Early enteral nutrition (over parenteral)",
      "Head of bed 30–45° semi-recumbent",
      "Daily sedation interruption (SAT + SBT)",
      "Glucose monitoring q1–2h on insulin infusion",
    ],
  },
];

let curY = sY;
supportSections.forEach((sec) => {
  slide.addText(sec.heading, {
    x: colX[4]+0.1, y: curY, w: colW[4]-0.2, h: 0.22,
    fontSize: 7.2, bold: true, color: sec.color,
    fontFace: "Arial", margin: 0,
  });
  curY += 0.24;
  sec.items.forEach((item) => {
    slide.addText("• " + item, {
      x: colX[4]+0.14, y: curY, w: colW[4]-0.24, h: 0.235,
      fontSize: 7.2, color: C.offwhite, fontFace: "Arial", margin: 0,
    });
    curY += 0.22;
  });
  curY += 0.1;
});

// ─── BOTTOM FOOTER BAR ──────────────────────────────────────
slide.addShape(pres.ShapeType.rect, {
  x: 0, y: 7.3, w: 13.3, h: 0.2,
  fill: { color: "1A0A00" }, line: { color: "1A0A00" },
});
slide.addText(
  "Based on: Surviving Sepsis Campaign International Guidelines 2026  |  Harrison's Principles of Internal Medicine 22E  |  Goldman-Cecil Medicine  |  Barash Clinical Anesthesia 9e",
  {
    x: 0.2, y: 7.3, w: 12.9, h: 0.2,
    fontSize: 5.8, color: "556677", fontFace: "Arial",
    align: "center", valign: "middle", margin: 0, italic: true,
  }
);

// ─── WRITE FILE ─────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/sepsis-poster/Severe_Sepsis_Management_Protocol.pptx" })
  .then(() => console.log("SUCCESS: Poster created."))
  .catch(err => console.error("ERROR:", err));

Running Command

cd /home/daytona/workspace/sepsis-poster && node create_poster.js 2>&1

Running Command

ls -lh /home/daytona/workspace/sepsis-poster/

Your ED/ICU poster is ready:

Severe Sepsis Management Protocol

Presentation · PPTX

What's on the poster - a single wide-format slide (13.3" × 7.5", printable as A0/A1 landscape) with a dark navy clinical theme and 5 color-coded columns:

Column	Color	Content
Recognition & Diagnosis	Red	Sepsis-3 definitions, qSOFA screening tool, full SOFA score table
1-Hour Bundle	Orange	The 5 mandatory steps with timing, targets, and lactate clearance goals
Antibiotics & Source Control	Teal	Empiric regimens by suspected source (including MRSA, Pseudomonas, fungal, viral), de-escalation reminder
Fluids & Vasopressors	Green	30 mL/kg initial bolus, balanced crystalloids, dynamic monitoring, vasopressor ladder (NE→vasopressin→epi), MAP targets
Supportive Care	Purple	Corticosteroids, lung-protective ventilation + ARDS protocol, glucose control, transfusion threshold, VTE/SUP prophylaxis

Sources cited in the footer: SSC 2026, Harrison's 22E, Goldman-Cecil, Barash Clinical Anesthesia 9e.

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