1. Immediate recognition and activation (time zero)

• Suspect sepsis in any patient with infection plus organ dysfunction.
• Trigger sepsis pathway if any of:
  • Hypotension (MAP <65 mmHg or SBP <90 mmHg)
  • Lactate ≥2 mmol/L
  • New altered mental status, oliguria, hypoxemia, coagulopathy, bilirubin rise, thrombocytopenia.
• Call ICU sepsis response and assign roles (airway, lines, cultures, antibiotics, fluids, vasopressors).

1. First hour bundle

• Airway/breathing:
  • Give oxygen to keep SpO2 92 to 96% (88 to 92% if chronic hypercapnia risk).
  • Early intubation if severe work of breathing, hypoxemia, or encephalopathy.
• Circulation:
  • Obtain 2 large-bore IV lines or central access if needed.
  • Draw lactate now (repeat within 2 to 4 hours if elevated).
  • Send blood cultures x2 sets before antibiotics if this does not delay treatment.
  • Start broad-spectrum IV antibiotics within 1 hour.
  • Give balanced crystalloid 30 mL/kg rapidly for hypotension or lactate ≥4 mmol/L.
• If hypotension persists during/after fluids:
  • Start norepinephrine to target MAP ≥65 mmHg (do not wait for full fluid completion if shock persists).

1. Diagnostic workup (parallel to resuscitation)

• Labs:
  • CBC, CMP, coagulation panel, ABG/VBG, lactate, CRP/procalcitonin (if used locally), glucose.
• Microbiology:
  • Blood cultures, urine culture, respiratory sample, wound/drain cultures as indicated.
• Imaging/source localization:
  • Chest imaging, abdominal ultrasound/CT, echocardiography if cardiogenic component suspected.
• Organ dysfunction scoring:
  • SOFA/qSOFA for severity tracking.
• Hemodynamic reassessment:
  • Dynamic tests preferred (passive leg raise, stroke volume variation, bedside echo, capillary refill, urine output).

1. Antimicrobial strategy

• Empiric therapy:
  • Cover likely source, gram positive, gram negative, and resistant organisms as risk dictates.
  • Add antifungal only with clear risk factors.
• Dosing:
  • ICU dosing with renal/hepatic adjustment and PK/PD optimization (extended/continuous infusion for beta-lactams if possible).
• Review at 24 to 48 hours:
  • De-escalate per culture and clinical response.
  • Stop unnecessary combinations.
• Typical duration:
  • 7 to 10 days in most controlled infections, longer for deep foci/endocarditis/immunosuppression.

1. Hemodynamic management

• Fluid strategy:
  • Initial bolus as above, then conservative, response-guided fluids.
  • Avoid ongoing blind boluses after no fluid responsiveness.
• Vasopressors:
  • First line: norepinephrine.
  • Add vasopressin (0.03 U/min) if high norepinephrine need.
  • Add epinephrine if refractory.
• Inotrope:
  • Dobutamine if low cardiac output with tissue hypoperfusion despite MAP goal.
• Targets:
  • MAP ≥65 mmHg (individualize higher in chronic hypertension if needed),
  • Urine output ≥0.5 mL/kg/h,
  • Improving lactate/clinical perfusion signs.

1. Source control (as early as possible, ideally within 6 to 12 hours)

• Drain abscess, remove infected lines/devices, debride necrotic tissue, relieve obstruction, operate when indicated.
• Document source-control plan and deadline at ICU admission.

1. Adjunctive therapies

• Corticosteroids:
  • If septic shock remains on moderate/high vasopressor requirement despite fluids/vasopressors, use hydrocortisone 200 mg/day IV.
• Blood products:
  • RBC transfusion threshold usually Hb <7 g/dL unless special indications.
• Glycemic control:
  • Target 140 to 180 mg/dL with insulin protocol.
• Temperature:
  • Treat high fever for comfort/hemodynamic burden; avoid overcooling.
• DVT prophylaxis:
  • LMWH unless contraindicated.
• Stress ulcer prophylaxis:
  • For high GI bleed risk or mechanically ventilated/coagulopathic patients.

1. Organ support

• Ventilation (if ARDS/severe respiratory failure):
  • Lung protective strategy: tidal volume ~6 mL/kg predicted body weight, plateau pressure <30 cmH2O.
  • Prone positioning for severe ARDS.
• Renal:
  • Initiate RRT for standard indications (refractory acidosis, hyperkalemia, volume overload, uremic complications).
• Nutrition:
  • Early enteral nutrition within 24 to 48 hours if feasible.
• Sedation/delirium:
  • Light sedation targets, daily awakening trials when safe, delirium prevention bundle.

1. Monitoring and reassessment schedule

• Hourly: MAP, HR, SpO2, urine output, vasopressor dose.
• Every 4 to 6 hours early phase: lactate trend (until improving), perfusion exam, fluid responsiveness.
• Daily:
  • SOFA score, culture review, antibiotic review/de-escalation, device necessity check (line, catheter, ventilator), goals of care update.

1. Quality/safety checklist

• Antibiotics within 1 hour documented.
• Cultures before antibiotics documented (if feasible).
• Lactate initial and repeat documented.
• Fluid amount and response documented.
• Vasopressor initiation time and MAP goal documented.
• Source control completed or escalated.
• 48-hour antimicrobial timeout completed.

1. a one-page bedside checklist,
2. a full order set format,
3. a Belarus-adapted protocol template aligned to your local formulary and ICU capabilities.

RHEUMATOID ARTHRITIS (RA)

Early recognition. Early treatment. Better outcomes.

What is RA?

Who is at risk?

• Female sex (about 3:1)
• Age 40 to 60 years (can occur at any age)
• Family history/genetic susceptibility (HLA-DR4/DR1)
• Smoking
• Possible infectious and environmental triggers

Red flag symptoms

• Morning stiffness >60 minutes
• Symmetrical small-joint pain/swelling (MCP, PIP, wrists, MTP)
• Warm, tender, swollen joints
• Fatigue, low-grade fever, weight loss
• Reduced grip strength and hand function

Typical hand deformities in established disease

• Ulnar deviation
• Swan neck deformity
• Boutonniere deformity
• Z deformity of thumb

Extra-articular manifestations

• Rheumatoid nodules
• Eye: episcleritis/scleritis, dry eye
• Lung: pleuritis/interstitial disease
• Heart/pericardium involvement
• Vasculitis
• Neuropathy
• Renal amyloidosis (late/severe disease)

Diagnosis (ACR/EULAR approach)

• Clinical synovitis in at least 1 joint
• No better alternative diagnosis
• Score based on:
  1. Joint involvement
  2. Serology (RF, anti-CCP)
  3. Acute phase reactants (ESR/CRP)
  4. Symptom duration

Key investigations

• RF (Rheumatoid factor)
• Anti-CCP/ACPA (high specificity)
• ESR, CRP
• CBC, liver/renal profile
• X-ray hands/feet
• Ultrasound or MRI for early synovitis/erosions

Treatment principles

Treat to Target (T2T)

1. Start DMARD early
   • First-line: Methotrexate (+ folic acid)
2. If inadequate response:
   • Combination conventional DMARDs or
   • Biologic/targeted synthetic DMARDs
3. NSAIDs for symptom relief (short term)
4. Glucocorticoids as short bridging therapy
5. Physiotherapy, occupational therapy, smoking cessation, vaccination, cardiovascular risk management

Monitoring

• Disease activity (DAS28), function, pain
• ESR/CRP trends
• Drug safety labs (CBC, LFT, creatinine)
• Imaging for progression when indicated

Why early treatment matters

• Prevents erosions and deformity
• Preserves quality of life and work ability
• Reduces long-term disability and systemic complications

Refer urgently to Rheumatology if:

• Persistent inflammatory joint swelling >6 weeks
• Positive anti-CCP with inflammatory arthritis
• Rapid functional decline or suspected systemic involvement

1. a patient-friendly poster (simple language),
2. a hospital academic poster (with criteria tables), or
3. a designed printable poster image.