Topic ReviewSeptic Shock Management    Piti Niyomsirivanich, MD.                                10 Jan 2013
Take home message• Adequate preload• Appropriate Antibiotic within 1 hr• Proper dose of vasopressors• Consult
Outline•   Definition•   Pathophysiology•   Early Goal Directed Therapy•   Fluid Resuscitation•   Vasopressors•   Steroids...
Definition• Bacteremia : Bacteria in blood• Septicemia : Bacteria + toxin in blood• SIRS : 2/4 of following conditions   –...
Pathophysiology
Guideline    Surviving Sepsis Campaign: International guidelines for    management of severe sepsis and septic shock:2008
Since 2001 10+ years ago!!!
Result of EGDT           N Engl J Med 2001; 345:1368-           1377 November 8, 2001
Early goal directed therapy                                          SIRS                                             +   ...
Fluid Resusitation• Fluid therapy   – crystalloids or colloids (1B)   – Target a CVP of 8-12 mmHg (1C)   – Give fluid chal...
Frank-Starling Law
Shock• BP = CO X TVR• CO = HR X SV• SV = EDV – ESV• BP = ( EDV- ESV ) X HR X TVR   X EDV              EDV• BP = EF X HR X ...
Volume         N Engl J Med 2001; 345:1368-         1377November 8, 2001
Fluid• Crystalloids  – NSS  – Ringer Lactate Solution• Colloids  – albumin  – Dextrans  – Gelatins e.g. Haemaccel  – Hydro...
Fluid• Crystalloids  – NSS                                            Low cost  – Ringer Lactate Solution                 ...
Fluid• Crystalloids  – NSS                                   Low cost  – Ringer Lactate Solution            Lactate  live...
Fluid• Crystalloids  – NSS                                                          SAFE Study *  – Ringer Lactate Solutio...
Fluid• Crystalloids                                Coagulopathy (inh. F VIII/ vWF)  – NSS                                 ...
Fluid• Crystalloids                           Gelofundol                                         Haemaccel  – NSS  – Ringe...
Fluid• Crystalloids                    • MW 450-480 kDa                                     Hetastarch Hespan  – NSS      ...
Cochrane Database Syst. Rev. CD 001319,2003
Volume Assessment• Static VS dynamic• Non-invasive   – U/S IVC   – Passive leg raising test   – Pulse oximetry plethysmogr...
Volume Assessment•            Require Endotracheal tube•            No Endotracheal tube• W/WO Endotracheal tube
CVP measurement         a= Atrial contraction         c= Ventricular Contraction         x= Atrial relaXation         v= V...
CVP• CVP : poor predictor of fluid volume                               CHEST. July 2008;134(1):172-178.
Fluid Challenge Test for CVP              Load IV fluid 200-250 ml in 10 min       CVP +                       CVP +      ...
Ultrasound IVCCaval Index = 100 x (diam expiration - diam inspiration)/diam expirationCaval Index > 50%  suggest low CVP ...
Passive leg raising testEsophageal doppler :   in cardiac output >   8% predict fluid responsiveness                     ...
Pulse oximetry plethysmographic waveform amplitude variation
CASE A          CASE BCVP =15 cmH2O   CVP =5 cmH2O
Pulse oximetry plethysmographic waveform amplitude variation%POP variation          POP max – POP min X 100               ...
Arterial Line
Pulse Pressure Variation
Vasopressor therapy• Dopamine VS Norepinephrine                                        Kaplan–Meier Curves for            ...
Vasopressure therapyDopamine    Low dose    Moderate dose (beta adrenergic receptor )         5-10 ug/kg/min    High dose ...
Vasopressor therapyExampleผู้หญิง 64 ปี หนัก 70 kg มาด้วย ไข้ หนาวสั่น ปัสสาวะแสบขัดCBC : WBC 25000/ul N% 85 Band 2% Hb 12...
Vasopressor therapyExampleผู้หญิง 64 ปี หนัก 70 kg มาด้วย ไข้ หนาวสัน ปัสสาวะแสบขัด                                       ...
Vasopressor therapyExampleผู้หญิง 64 ปี หนัก 70 kg มาด้วย ไข้ หนาวสัน ปัสสาวะแสบขัด                                       ...
Early goal directed therapy                                          SIRS                                             +   ...
ScvO2ให้เงินไปโรงเรียน        ขากลับ       เหลือ 50         บาท            แปลว่าให้เงินไปโรงเรียนพอใช้
ScvO2O2 content     O2 content     เหลือ 70%         แปลว่าให้ออกซิเจนไปเนือเยือพอใช้                               ้ ่
ScvO2
O2 delivery• DO2 = [1.39 x Hb x SaO2 + (0.003 x PaO2)] x CO• Depend on                                    < 70%           ...
Alternative for ScvO2• Lactate clearance  – lactate clearance >10% or higher     • 6% lower in-hospital mortality than tho...
Antimicrobial Therapy• administration of broad-spectrum antibiotic therapy within 1  hr of diagnosis of septic shock (1B) ...
Empirical Antibiotic• Host  –   Immunocompetent  –   Neutropenia  –   IVDU  –   Post Splenectomy  –   AIDS• Risk factors &...
Tips• every 10 min, survival is decreased by 1%.*• First dose  Full dose   – Then renal adjustment                       ...
De-escalate Therapy• De-escalate  Empirical antimicrobial therapy  in life-threatening situations  – Start with Broad Spe...
De-escalate Therapy : Life Threatening• "สันๆ แต่ aggressive" แล้วปรับลงมา     ้   – Recurrent infections were more common...
Antibiotic therapy in patients with septic shockEuropean Journal of Anaesthesiology (EJA). 28(5):318-324, May 2011
Steroids in CIRCI(critical illness related corticosteroid insufficiency)          •stress-dose steroid therapy given only ...
Steroids in CIRCISurge in cortisol (> 9 ug/dl) response to ACTH250 ug stimulationBenefit from steroids  JAMA. 2002 Aug 21;...
CIRCIBaseline cortisol level < or = 35 microg/dl is a useful diagnostic threshold fordiagnosis of steroid responsiveness i...
CIRCI• Hydrocortisone 100 mg bolus then 200 mg V  drip in 24 hr• OR• Hydrocortisone bolus q 4-6 hr NOT q 8 hr  – e.g. Hydr...
Blood Sugar control
Blood Sugar control• NICE-SUGAR study  – 3050 patients  – Medicine & Surgery Ward  – Multicenter randomized open label stu...
NICE-SUGAR Study        The NICE-SUGAR Study Investigators        N Engl J Med 2009; 360:1283-1297March 26, 2009
Sliding Scale Insulin
Basal Insulin with Scheduled Insulin (prandial insulin) with                     Correctional dose
• CBG (ก่อนอาหาร) เช้า   กลางวัน   เย็น    ก่อนนอน
Somchai Pathanaangkul ,Royal Thai Army MedicaVol 57 No.4 Oct.-Dec. 2004
Blood Transfusion● Give red blood cells when hemoglobin decreases to 7.0 g/dL (70 g/L) to   target a hemoglobin of 7.0–9.0...
Blood Transfusion• TRICC Study  – Study design: Multicenter RCT  – Setting: 25 ICUs across Canada  – Hb     • 7-9 g/dl (Re...
TRICC Study                 Hb 7-9 g/dl              Hb 10-12 g/dl
Bicarbonate Therapy• We recommend against the use of sodium  bicarbonate therapy for the purpost of  improving hemodynamic...
Hb O2 Dissociation curve
Stress Ulcer Prophylaxis• We recommend that stress ulcer prophylaxis  using H2 blocker (1A)• Or PPI (1B) be given to patie...
Other• Sucralfate*  – Not associated with an increase in stress    ulceration.  – Less impact gastric colonization  Less ...
Take home message• Adequate preload• Antibiotic within 1 hr• Proper dose of vasopressors.• Consult
Thank you
Septic shock
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Lecture องค์กรแพทย์ เรื่องติดเชื้อในกระแสเลือด Septic Shock

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  1. 1. Topic ReviewSeptic Shock Management Piti Niyomsirivanich, MD. 10 Jan 2013
  2. 2. Take home message• Adequate preload• Appropriate Antibiotic within 1 hr• Proper dose of vasopressors• Consult
  3. 3. Outline• Definition• Pathophysiology• Early Goal Directed Therapy• Fluid Resuscitation• Vasopressors• Steroids• Antibiotics• Glucose control• Blood product administration• Bicarbonate therapy• Stress ulcer prophylaxis
  4. 4. Definition• Bacteremia : Bacteria in blood• Septicemia : Bacteria + toxin in blood• SIRS : 2/4 of following conditions – 1)Temp > 38 C or < 36 C – 2) Pulse rate > 90 /min – 3) RR > 20 /min or PaCO2 < 32 mmHg – 4) WBC > 12,000/ul or < 4000 /ul and/or Band form > 10%• Sepsis = SIRS from infection• Severe sepsis = Sepsis+ end organ damage – CVS , Renal , pulmonary , Hematologic ,Metabolic acidosis• Septic Shock = Sepsis + hypotension
  5. 5. Pathophysiology
  6. 6. Guideline Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008
  7. 7. Since 2001 10+ years ago!!!
  8. 8. Result of EGDT N Engl J Med 2001; 345:1368- 1377 November 8, 2001
  9. 9. Early goal directed therapy SIRS + SBP < 90 mmHg or MAP < 65 mmHg ONE -Or- Lactate > 4 mmol/L Hour After 20-30 ml/kg crystalloid IVF Culture Supplement oxygen Antibiotic within 1 hour Critical care consultationor ET tube (if necessary) Volume accessment < 8-12 mmHg CVP ? IVF 8-12 mmHg < 65 mmHg Five MAP ? Vasopressor (NE/dopamine) Hours >/= 65 mmHg < 70% Blood transfusion to Hct > 30% ScvO2 ? > 70% Inotropic agent Goals achieved Sedatives & muscle relaxants Resuscitation complete N Engl J Med 2001; 345:1368-1377November 8, 2001
  10. 10. Fluid Resusitation• Fluid therapy – crystalloids or colloids (1B) – Target a CVP of 8-12 mmHg (1C) – Give fluid challenges of 1000 mL of crystalloids • or 300–500 mL of colloids over 30 mins. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008
  11. 11. Frank-Starling Law
  12. 12. Shock• BP = CO X TVR• CO = HR X SV• SV = EDV – ESV• BP = ( EDV- ESV ) X HR X TVR X EDV EDV• BP = EF X HR X TVR X EDV
  13. 13. Volume N Engl J Med 2001; 345:1368- 1377November 8, 2001
  14. 14. Fluid• Crystalloids – NSS – Ringer Lactate Solution• Colloids – albumin – Dextrans – Gelatins e.g. Haemaccel – Hydroxyethylstarch e.g. Voluven
  15. 15. Fluid• Crystalloids – NSS Low cost – Ringer Lactate Solution edema• Colloids Hemodilution Hyperchloremic metabolic acidosis – albumin – Dextrans – Gelatins e.g. Haemaccel – Hydroxyethylstarch e.g. Voluven
  16. 16. Fluid• Crystalloids – NSS Low cost – Ringer Lactate Solution Lactate  liver Acetate  peripheral tissue• Colloids Potassium – albumin edema – Dextrans – Gelatins e.g. Haemaccel – Hydroxyethylstarch e.g. Voluven
  17. 17. Fluid• Crystalloids – NSS SAFE Study * – Ringer Lactate Solution not differrent VS NSS• Colloids hypocalcemia – albumin expensive – Dextrans – Gelatins e.g. Haemaccel – Hydroxyethylstarch e.g. Voluven *A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit N ENGL J MED 2004; 350:2247-2256 May 27, 2004
  18. 18. Fluid• Crystalloids Coagulopathy (inh. F VIII/ vWF) – NSS Renal damage – Ringer Lactate Solution Cross matching problem• Colloids Osmotic diuresis – albumin Anaphylaxis 0.27% – Dextrans – Gelatins e.g. Haemaccel – Hydroxyethylstarch e.g. Voluven
  19. 19. Fluid• Crystalloids Gelofundol Haemaccel – NSS – Ringer Lactate Solution 30,000-35,000 kDa• Colloids Renal Excretion – albumin Short half life – Dextrans Anaphylaxis 0.34% – Gelatins e.g. Haemaccel – Hydroxyethylstarch e.g. Voluven
  20. 20. Fluid• Crystalloids • MW 450-480 kDa Hetastarch Hespan – NSS •MW 200 kDa – Ringer Lactate Solution •HAES-Steril 6%,10%• Colloids •MW 70 kDa •HES 70/0.5 – albumin •Voluven – Dextrans Anaphylaxis 0.058% – Gelatins e.g. Haemaccel – Hydroxyethylstarch e.g. Voluven
  21. 21. Cochrane Database Syst. Rev. CD 001319,2003
  22. 22. Volume Assessment• Static VS dynamic• Non-invasive – U/S IVC – Passive leg raising test – Pulse oximetry plethysmographic waveform amplitude variation• Invasive – CVP – Fluid challenge test – CVP variation – Pulse pressure variation
  23. 23. Volume Assessment• Require Endotracheal tube• No Endotracheal tube• W/WO Endotracheal tube
  24. 24. CVP measurement a= Atrial contraction c= Ventricular Contraction x= Atrial relaXation v= Venous filling y = Tr”Y”cuspids opening
  25. 25. CVP• CVP : poor predictor of fluid volume CHEST. July 2008;134(1):172-178.
  26. 26. Fluid Challenge Test for CVP Load IV fluid 200-250 ml in 10 min CVP + CVP + CVP + </=2 2-5 >/=5Continue fluid therapy Wait Decrease rate of fluid therapy
  27. 27. Ultrasound IVCCaval Index = 100 x (diam expiration - diam inspiration)/diam expirationCaval Index > 50%  suggest low CVP Ann Emerg Med 2010; 55:290-295.
  28. 28. Passive leg raising testEsophageal doppler : in cardiac output > 8% predict fluid responsiveness Critical Care 2006, 10:170
  29. 29. Pulse oximetry plethysmographic waveform amplitude variation
  30. 30. CASE A CASE BCVP =15 cmH2O CVP =5 cmH2O
  31. 31. Pulse oximetry plethysmographic waveform amplitude variation%POP variation POP max – POP min X 100 > 13% POP mean
  32. 32. Arterial Line
  33. 33. Pulse Pressure Variation
  34. 34. Vasopressor therapy• Dopamine VS Norepinephrine Kaplan–Meier Curves for 28-Day Survival in the Intention-to-Treat Population. N Engl J Med 2010; 362:779-789
  35. 35. Vasopressure therapyDopamine Low dose Moderate dose (beta adrenergic receptor ) 5-10 ug/kg/min High dose (alpha adrenergic receptor) >10 ug/kg/min Maximum dose 50 ug/kg/minNorepinephrine start 0.5 mcg/min Harrison Int. Med edition 18 th
  36. 36. Vasopressor therapyExampleผู้หญิง 64 ปี หนัก 70 kg มาด้วย ไข้ หนาวสั่น ปัสสาวะแสบขัดCBC : WBC 25000/ul N% 85 Band 2% Hb 12 g/dl Plt 200,000/ulUA WBC 50-100BP 80/40 mmHg PR 95/min Temp 37.8 C RR 18/minจงคำานวณ dose ของ Dopamine ให้ start 5 ug/kg/min
  37. 37. Vasopressor therapyExampleผู้หญิง 64 ปี หนัก 70 kg มาด้วย ไข้ หนาวสัน ปัสสาวะแสบขัด ่CBC : WBC 25000/ul N% 85 Band 2% Hb 12 g/dl Plt 200,000/ulUA WBC 50-100BP 80/40 mmHg PR 65/min Temp 37.8 C RR 18/minจงคำานวณ dose ของ Dopamine ให้ start 5 ug/kg/min 60 X W (kg) X D (ug/kg/min) Rate (ml/min) C Solute C= 1,000 Volume
  38. 38. Vasopressor therapyExampleผู้หญิง 64 ปี หนัก 70 kg มาด้วย ไข้ หนาวสัน ปัสสาวะแสบขัด ่CBC : WBC 25000/ul N% 85 Band 2% Hb 12 g/dl Plt 200,000/ulUA WBC 50-100BP 80/40 mmHg PR 65/min Temp 37.8 C RR 18/minจงคำานวณ dose ของ Dopamine ให้ start 5 ug/kg/min 60 X 70 X 5 Rate (ml/min) = 10.5 ml/hr 2000 1000 C= 1,000 = 2000 500 (Dopamine 1000 mg ผสม 5%D/W 500 ml)
  39. 39. Early goal directed therapy SIRS + SBP < 90 mmHg or MAP < 65 mmHg ONE -Or- Lactate > 4 mmol/L Hour After 20-30 ml/kg crystalloid IVF Culture Supplement oxygen Antibiotic within 1 hour Critical care consultationor ET tube (if necessary) Volume accessment < 8-12 mmHg CVP ? IVF 8-12 mmHg < 65 mmHg Five MAP Vasopressor (NE/dopamine) Hours >/= 65 mmHg < 70% Blood transfusion to Hct > 30% ScvO2 > 70% Inotropic agent Goals achieved Sedatives & muscle relaxants Resuscitation complete N Engl J Med 2001; 345:1368-1377November 8, 2001
  40. 40. ScvO2ให้เงินไปโรงเรียน ขากลับ เหลือ 50 บาท แปลว่าให้เงินไปโรงเรียนพอใช้
  41. 41. ScvO2O2 content O2 content เหลือ 70% แปลว่าให้ออกซิเจนไปเนือเยือพอใช้ ้ ่
  42. 42. ScvO2
  43. 43. O2 delivery• DO2 = [1.39 x Hb x SaO2 + (0.003 x PaO2)] x CO• Depend on < 70% Blood transfusion to Hct > 30 ScvO2 – Hemoglobin > 70% Inotropic agent – O2 saturation Goals achieved – Cardiac output – ScvO2 < 70% • target Hct > 30 • Inotropic drug  increase cardiac output Contin Educ Anaesth Crit Care Pain (2004) 4 (4) 123-126
  44. 44. Alternative for ScvO2• Lactate clearance – lactate clearance >10% or higher • 6% lower in-hospital mortality than those resuscitated to an ScvO2 of at least 70% – (95% CI, −3% to 15%) – noninferiority trial. JAMA. 2010 Feb 24;303(8):739-46.
  45. 45. Antimicrobial Therapy• administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D);• reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C);• a usual 7–10 days of antibiotic therapy guided by clinical response (1D);• source control with attention to the balance of risks and benefits of the chosen method (1C); Survival Sepsis Guideline .Crit Care Med 2008
  46. 46. Empirical Antibiotic• Host – Immunocompetent – Neutropenia – IVDU – Post Splenectomy – AIDS• Risk factors & exposures• Site of infection• Antibiotics of choice ?? Antibiotic therapy in patients with septic shock European Journal of Anaesthesiology (EJA). 28(5):318-324, May 2011
  47. 47. Tips• every 10 min, survival is decreased by 1%.*• First dose  Full dose – Then renal adjustment * Antibiotic therapy in patients with septic shock European Journal of Anaesthesiology (EJA). 28(5):318-324, May 2011
  48. 48. De-escalate Therapy• De-escalate  Empirical antimicrobial therapy in life-threatening situations – Start with Broad Spectrum • ‘Broad-spectrum antibiotics’ refers to antibiotics with activity against Pseudomonas aeruginosa, including imipenem-cilastatin, piperacillin-tazobactam, ceftazidime or ciprofloxacin. • Limited-spectrum antibiotics will only refer to β-lactam antibiotics without activity against P. aeruginosa (essentially, ceftriaxone and amoxicillin-clavulanate). Antibiotic therapy in patients with septic shock European Journal of Anaesthesiology (EJA). 28(5):318-324, May 2011
  49. 49. De-escalate Therapy : Life Threatening• "สันๆ แต่ aggressive" แล้วปรับลงมา ้ – Recurrent infections were more common in Group No De-escalate (19% versus 5%, P = 0.01) – An inadequate empiric antibiotic therapy was more frequent in Group No De-escalate (27.5% versus 7.7% P = 0.02) – Mortality between the two groups 18.3% (D) vs 24.6% (ND) Critical Care 2010, 14:R225
  50. 50. Antibiotic therapy in patients with septic shockEuropean Journal of Anaesthesiology (EJA). 28(5):318-324, May 2011
  51. 51. Steroids in CIRCI(critical illness related corticosteroid insufficiency) •stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C) •Survival Sepsis Guideline 2008 Serum cortisol •< 15 ug/dl  definite adrenal insufficiency •13-35 ug/dl  Suspected •>35 ug/dl  no benefit •สมาคมเวชบำาบัดวิกฤติแห่งประเทศไทย
  52. 52. Steroids in CIRCISurge in cortisol (> 9 ug/dl) response to ACTH250 ug stimulationBenefit from steroids JAMA. 2002 Aug 21;288(7):862-71
  53. 53. CIRCIBaseline cortisol level < or = 35 microg/dl is a useful diagnostic threshold fordiagnosis of steroid responsiveness in Thai patients with septic shockACTH stimulation test should not be usedsensitivity was 85%, the specificity was 62% J Med Assoc Thai 2010 Jan;93 Suppl 1:S187-95
  54. 54. CIRCI• Hydrocortisone 100 mg bolus then 200 mg V drip in 24 hr• OR• Hydrocortisone bolus q 4-6 hr NOT q 8 hr – e.g. Hydrocortisone 50 mg V q 6 hr • Then taper off
  55. 55. Blood Sugar control
  56. 56. Blood Sugar control• NICE-SUGAR study – 3050 patients – Medicine & Surgery Ward – Multicenter randomized open label study – ICU & non ICU – Intensive control 81-108 mg% – Conventional control 144-180 mg% The NICE-SUGAR Study Investigators N Engl J Med 2009; 360:1283-1297March 26, 2009
  57. 57. NICE-SUGAR Study The NICE-SUGAR Study Investigators N Engl J Med 2009; 360:1283-1297March 26, 2009
  58. 58. Sliding Scale Insulin
  59. 59. Basal Insulin with Scheduled Insulin (prandial insulin) with Correctional dose
  60. 60. • CBG (ก่อนอาหาร) เช้า กลางวัน เย็น ก่อนนอน
  61. 61. Somchai Pathanaangkul ,Royal Thai Army MedicaVol 57 No.4 Oct.-Dec. 2004
  62. 62. Blood Transfusion● Give red blood cells when hemoglobin decreases to 7.0 g/dL (70 g/L) to target a hemoglobin of 7.0–9.0 g/dL in adults (1B). A higher hemoglobin lev el may be required in special circumstances (e.g., myocardial ischaemia, se vere hypoxemia, acute hemorrhage, cyanotic heart disease, or lactic acidosi s)● Do not use erythropoietin to treat sepsis-related anemia. Erythropoietin may be used for other accepted reasons (1B) Do not use fresh frozen plasma to correct laboratory clotting abnormalities unless there is bleeding or planned i nvasive procedures (2D)● Do not use antithrombin therapy (1B) Administer platelets when (2D) Counts are 5000/mm3 (5 109/L) regardless of bleeding Counts are 5000–30,000/mm3 (5–30 109/L) and there is significant bleeding risk Higher platelet counts (50,000/mm3 [50 109/L]) are required for surgery or invasive procedures
  63. 63. Blood Transfusion• TRICC Study – Study design: Multicenter RCT – Setting: 25 ICUs across Canada – Hb • 7-9 g/dl (Restrictive Strategy) • 10-12 g/dl (Liberal Strategy) – Primary Outcome : mortality rate 30 days – Results • Hb 7-9 g/dl group mortality rate 22.2% • Hb 10-12 g/dl mortality rate 28.1% • (P=0.05)
  64. 64. TRICC Study Hb 7-9 g/dl Hb 10-12 g/dl
  65. 65. Bicarbonate Therapy• We recommend against the use of sodium bicarbonate therapy for the purpost of improving hemodynamics or reducing vasopressure requirement with hypoperfusion-induced lactic acidemia with pH > 7.15 (1B) Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008
  66. 66. Hb O2 Dissociation curve
  67. 67. Stress Ulcer Prophylaxis• We recommend that stress ulcer prophylaxis using H2 blocker (1A)• Or PPI (1B) be given to patients with severe sepsis to prevent upper GI bleed.• Weighted aginst the potential effect of an increased stomach pH on development of VAP Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008
  68. 68. Other• Sucralfate* – Not associated with an increase in stress ulceration. – Less impact gastric colonization  Less VAP – Increase aspiration• Enteral Feeding *EAST Practice Management Guidelines Committee
  69. 69. Take home message• Adequate preload• Antibiotic within 1 hr• Proper dose of vasopressors.• Consult
  70. 70. Thank you
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