Sepsis

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  • Sepsis

    1. 1. Sepsis Jayesh Patel UTFP-Resident Jan 21, 2009
    2. 2. Sepsis: ACCP/SCCM Definitions <ul><li>I nfection - Inflammatory response to microorganisms or invasion of normally sterile tissues. </li></ul><ul><ul><li>Bacteremia   — Bacteremia is defined as the presence of viable bacteria in the blood. </li></ul></ul><ul><li>SIRS(Systemic Inflammatory Response Syndrome)- Systemic inflammatory response to a variety of severe clinical insults. Manifested by two or more of the following: </li></ul><ul><ul><li>Temperature > 38 o C or < 36 o C </li></ul></ul><ul><ul><li>Heart rate > 90 beats/min </li></ul></ul><ul><ul><li>Respiratory rate > 20 breaths/min or PaCO 2 < 32 mm Hg </li></ul></ul><ul><ul><li>WBC > 12,000/mm 3 , < 4000/mm 3 , or > 10% immature (band) forms </li></ul></ul>
    3. 3. Sepsis: ACCP/SCCM Definitions <ul><li>The clinical signs that define SIRS are present and are due to either a culture-proven infection or an infection identified by visual inspection .The severity of sepsis is graded according to the associated organ dysfunction and hemodynamic compromise. </li></ul><ul><li>Severe sepsis  — Severe sepsis exists if there is sepsis plus at least one of the following signs of organ hypoperfusion or dysfunction. </li></ul><ul><li>Systolic blood pressure<90mmHg </li></ul><ul><li>Areas of mottled skin </li></ul><ul><li>Capillary refilling requires three seconds or longer </li></ul><ul><li>Urine output <0.5 mL/kg for at least one hour, or renal replacement therapy </li></ul><ul><li>Lactate >2 mmol/L </li></ul><ul><li>Abrupt change in mental status </li></ul><ul><li>Abnormal electroencephalographic (EEG) findings </li></ul><ul><li>Platelet count <100,000 platelets/mL </li></ul><ul><li>Disseminated intravascular coagulation </li></ul><ul><li>Acute lung injury or acute respiratory distress syndrome (ARDS) (PaO 2 /FiO 2 < 300) </li></ul><ul><li>Cardiac dysfunction, as defined by echocardiography or direct measurement of the cardiac index </li></ul>
    4. 4. Sepsis: ACCP/SCCM Definitions <ul><li>Septic shock  — Septic shock exists if there is severe sepsis plus one or both of the following, </li></ul><ul><li>Systemic mean blood pressure is <60 mmHg (or <80 mmHg if the patient has baseline hypertension) despite adequate fluid resuscitation. </li></ul><ul><li>Maintaining the systemic mean blood pressure >60 mmHg (or >80 mmHg if the patient has baseline hypertension) requires dopamine >5 mcg/kg per min, norepinephrine <0.25 mcg/kg per min, or epinephrine <0.25 mcg/kg per min despite adequate fluid resuscitation . </li></ul><ul><li>Refractory septic shock  — Refractory septic shock exists if maintaining the systemic mean blood pressure >60 mmHg (or >80 mmHg if the patient has baseline hypertension) requires dopamine >15 mcg/kg per min, norepinephrine >0.25 mcg/kg per min, or epinephrine >0.25 mcg/kg per min despite adequate fluid resuscitation. </li></ul>
    5. 5. <ul><li>Multiple Organ Dysfunction Syndrome(MODS)  — Multiple organ failure refers to the presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. There are no universally applicable criteria for the definition of individual organ dysfunction in MODS. Following major six organ-specific parameters to correlate MODS, </li></ul><ul><li>PO2/FiO2 ratio </li></ul><ul><li>Serum creatinine </li></ul><ul><li>Platelet count </li></ul><ul><li>Glasgow coma score </li></ul><ul><li>Serum bilirubin </li></ul><ul><li>Pressure-adjusted heart rate, defined by heart rate multiplied by the ratio of central venous pressure and mean arterial pressure. </li></ul><ul><li>Sequential Organ Failure Assessment (SOFA) score: created by European Society of Intensive Care to describe and quantities the degree of organ dysfunction in six organ systems. </li></ul>
    6. 8. Relationship of Sepsis, Severe Sepsis, and Septic Shock Sepsis Severe Sepsis Septic shock MODS Death Sepsis and organ dysfunction, hypoperfusion, or hypotension Sepsis-induced hypotension
    7. 9. Question?
    8. 10. Question? A 70 YO man presents to ER with 2 day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient’s family noted that he was more lethargic and dizzy. VS: Temp 101.5, HR 120, RR 30, B.P 70/35, O2 sat 80% @RA, CXR shows RLL infiltrate. This patient’s condition can be best defined as 1.Systemic inflammatory response syndrom(SIRS) 2. Multi-organ dysfunction syndrom(MODS) 3.Septic shock 4.Sepsis 5. Sever Sepsis
    9. 11. Answer: 5-Severe Sepsis
    10. 12. Incidence of Severe Sepsis/Septic Shock Approximate Cases/Year 800,000 600,000 400,000 200,000 0 Severe sepsis 800,000 Septic shock 400,000 Deaths from septic shock 200,000 Sepsis and sequelae are a leading cause of death in ICU Mortality in septic shock remains at 35 - 50%
    11. 13. Severe Sepsis: Comparative Incidence and Mortality Angus DC, et al. Crit Care Med. 2001; ACS. Incidence Cases/100,000 Mortality Deaths/Year
    12. 14. Mortality of Severe Sepsis by Age in the United States Angus DC, et al. Crit Care Med. 2001. <ul><li>0% </li></ul><ul><li>5% </li></ul><ul><li>10% </li></ul><ul><li>15% </li></ul><ul><li>20% </li></ul><ul><li>25% </li></ul><ul><li>30% </li></ul><ul><li>35% </li></ul><ul><li>40% </li></ul><ul><li>45% </li></ul><ul><li>0 </li></ul><ul><li>1 </li></ul><ul><li>5 </li></ul><ul><li>10 </li></ul><ul><li>15 </li></ul><ul><li>20 </li></ul><ul><li>25 </li></ul><ul><li>30 </li></ul><ul><li>35 </li></ul><ul><li>40 </li></ul><ul><li>45 </li></ul><ul><li>50 </li></ul><ul><li>55 </li></ul><ul><li>60 </li></ul><ul><li>65 </li></ul><ul><li>70 </li></ul><ul><li>75 </li></ul><ul><li>80 </li></ul><ul><li>85 </li></ul>Age Mortality <ul><li>Without Co-morbidity </li></ul><ul><li>With Co-morbidity </li></ul><ul><li>Overall </li></ul>
    13. 15. Projected Incidence of Severe Sepsis in the US: 2001 - 2050 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000 1,600,000 1,800,000 2001 2025 2050 Year 100,000 200,000 300,000 400,000 500,000 600,000 Severe Sepsis Cases US Population Sepsis Cases Total U.S. Population/1,000 Angus DC, et al. Crit Care Med. 2001.
    14. 16. Overall in-hospital mortality rate among patients hospitalized for sepsis, 1979-2000
    15. 17. Pathogenesis of Septic Shock
    16. 18. Figure B, page 948, reproduced with permission from Dellinger RP. Cardiovascular management of septic shock. Crit Care Med 2003;31:946-955 . Pathogenesis of Septic Shock
    17. 19. Screening Evaluation for Severe Sepsis <ul><li>1. Is the patient’s history suggestive of a new infection? </li></ul><ul><li>____Yes ____No </li></ul>Pneumonia, Empyema Bone/joint infection Implantable device infection Urinary tract infection Wound infection Skin/soft tissue infection Acute abdominal infection Bloodstream catheter infection Meningitis Endocarditis Other:_________
    18. 20. <ul><li>2. Are any two of following signs & symptoms of infection both present and new to the patient? </li></ul><ul><li>____Yes ____No </li></ul>Hyperthermia > 38.3 ⁰C (101 ⁰F) Tachypnea > 20 bpm Leukopenia (WBC< 4000) Hypothermia < 36 ⁰C (96.8⁰F) Acutely altered mental status Hyperglycemia (>120 mg/dL) in the absence of diabetes Tachycardia > 90 bpm Leukocytosis (WBC > 12,000) If the answer is yes to both question 1 and 2, suspicion of infection if present: <ul><li>Obtain: lactic acid, blood cultures (2 sites), CBC with differential, basic chemistry lab, bilirubin, CRP, Cortisol, BNP, Troponin, UA. Gram stains processed STAT. </li></ul><ul><li>At the physician’s discretion obtain: chest x-ray, amylase, lipase, ABG, and CT scan. </li></ul>
    19. 21. <ul><li>3. Are any of the following organ dysfunction criteria present at a site remote from the site of the infection that are not considered to be chronic conditions? </li></ul><ul><li>SBP < 90 mmHg or MAP < 65 mmHg </li></ul><ul><li>SBP decrease > 40 mmHg from baseline [note:hypertensive patients require higher MAP] </li></ul><ul><li>Bilateral pulmonary infiltrates with a new (or increased) oxygen requirement to maintain SpO2 > 90% </li></ul><ul><li>Bilateral pulmonary infiltrates with PaO2/FiO2 ratio < 300 </li></ul><ul><li>Creatinine > 2.0 mg/dl (176.8 mmol/L) or urine output < 0.5 ml/kg/hour for > 2 hours </li></ul><ul><li>Bilirubin > 2 mg/dl (34.2 mmol/L) </li></ul><ul><li>Platelet count < 100,000 </li></ul><ul><li>Coagulopathy (INR > 1.5 or aPTT > 60 Secs </li></ul><ul><li>Lactate > 2 mmol/L (18.0 mg/dl) </li></ul>____Yes ____No
    20. 22. <ul><li>If suspicion of infection is present AND organ dysfunction is present, the patient meets the criteria for SEVERE SEPSIS and should be managed in agreement with the Surviving Sepsis Campaign (SSC) Guidelines and Early Goal Directed Therapy . </li></ul>
    21. 23. General Principles <ul><li>Massive systemic vasodilation (drop in diastolic blood pressure) </li></ul><ul><li>Vascular leak (most administered crystalloid fluid is third spaced in less than one hour) </li></ul><ul><li>Vascular damage with clotting and impaired microcirculation (leading to organ dysfunction) </li></ul>
    22. 24. <ul><li>Patient survival is significantly improved with: </li></ul><ul><li>1- a) Early accurate diagnosis of infection and source control (if applicable)(1C)* </li></ul><ul><li> b) Institution (< 1 hour) of appropriate broad-spectrum antibiotic treatment(1B), </li></ul><ul><li>2- Aggressive Early Goal Directed Therapy targeting adequate hemodynamic support to optimize(1C): </li></ul><ul><li>a) Preload (CVP) 8-12mmHg </li></ul><ul><li>b) Mean arterial pressure 65 mmHg </li></ul><ul><li>c) Urinary Output 0.5 ml/kg/hr </li></ul><ul><li>d) Oxygen delivery (ScvO2) 70% </li></ul><ul><li>Grade1(strong), Grade 2(weak) level of recommendation. </li></ul><ul><li>GradeA(high), GradeB(moderate), GradeC(low), GradeD(very low) quality of evidence </li></ul>
    23. 25. Early Goal Directed Therapy
    24. 26. SEVERE SEPSIS PROTOCOL First 4 hours Primary Objectives Control of Infection ASAP Hemodynamic stabilization History CVP = 8-12 mmHg Physical exam ScvO2 sat ≥ 70% Laboratory and radiologic studies Mean Arterial Pressure (MAP) ≥ 65 mmHg Pan cultures – STAT Gram stain results Urinary Output ≥ 0.5 cc/kg/hr Broad spectrum ATB < 1 hour Arterial O2 saturation ≥ 95%
    25. 27. To be started as soon as possible and accomplished in 1 hour 1.Laboratory 2.Antibiotics 3.Monitoring 4.Fluid
    26. 28. To be started as soon as possible and accomplished in 1 hour: <ul><li>1.Laboratory </li></ul><ul><ul><li>CMP, CBC with maual differential, ABG, PT, PTT, lactate, CRP, cortisol, </li></ul></ul><ul><ul><li>Blood cultures (2 different sites)(1C) </li></ul></ul><ul><ul><li>Urine culture – STAT Gram stain </li></ul></ul><ul><ul><li>Sputum culture (intubated: ETA vs. BAL) – STAT Gram Stain </li></ul></ul>
    27. 29. <ul><li>2.Antibiotics </li></ul><ul><ul><li>Divide infections in community-acquired vs health-care related </li></ul></ul><ul><ul><li>Obtain history of recent antibiotic use – avoid using similar antibiotic class </li></ul></ul><ul><ul><li>Start antibiotics within 1 hour(1B) </li></ul></ul><ul><li>3.Monitoring </li></ul><ul><ul><li>Continuous MAP monitoring </li></ul></ul><ul><ul><li>Insert Foley catheter, strict I&O, √hourly urine output – GOAL: 0.5 cc/kg/h </li></ul></ul>
    28. 30. <ul><li>4.Fluid </li></ul><ul><ul><li>Place 2 18G peripheral lines, or a CVP if needed </li></ul></ul><ul><ul><li>Deliver 2 liter normal saline (0.9% NaCl) as fast as possible (30 minutes)(1B), </li></ul></ul><ul><ul><li>Continue to bolus (500-1,000 cc every 15 minutes)- GOAL: MAP≥65 mmHg(1C). </li></ul></ul><ul><ul><li>Caution in patients with low albumin, hyponatremia, or history of congestive heart failure (chest auscultation in between boluses) – if known LV dysfunction (EF <40%), consider PAC </li></ul></ul>
    29. 31. To be accomplished within 2 hours: <ul><li>1.If hypotension persist (MAP <65 mmHg and/or lactate > 4 mmol/L and/or urinary output < 0.5 cc/kg/hr) </li></ul><ul><ul><li>Insert a central line [follow strict aseptic measures ](1C) </li></ul></ul><ul><ul><ul><li>US-guided procedures. </li></ul></ul></ul><ul><ul><ul><li>Coagulopathy: femoral lines are acceptable. </li></ul></ul></ul><ul><ul><li>Measure central venous pressure (CVP) </li></ul></ul>
    30. 32. <ul><li>Achieve CVP > 10 with 0.9% Nacl 1 liter every 15 minutes(1C) </li></ul><ul><li>For persistent hypotension after 2-4 liters of 0.9% Nacl start Norepinephrine(levophed) IV @ 5 mcg/min(1C) </li></ul><ul><li>Norepinephrine: increase or decrease dose by 2mcg/min to maintain MAP > 65 mmHg. </li></ul><ul><li>Check CVP every 15 min – fluid challenge (500-1,000 cc every 15 minutes) for CVP < 10 mmHg. </li></ul><ul><li>Attention – After 4 liters of 0.9% Nacl change to Lactated Ringers (LR) to avoid hyperchloremic metabolic acidosis – EXCEPT IN SEVERE LIVER FAILURE – Attention RL contains citrate-> check Calcium level </li></ul><ul><li>Measure central venous oxygen saturation (venous ABG)(1C) </li></ul>
    31. 33. 2.Achieve central venous oxygen saturation (ScvO2) of 70% (>65% if measured via PAC) <ul><li>If ScvO2 less than 70% AND HCT less than 30% after initial fluid resuscitation, give 1 unit of PRBC. Repeat HCT 1 hour after transfusion(1B) </li></ul><ul><li>If ScvO2 less than 70% AND HCT more than 30% AND CVP 8-12 mmHg (12-15 in intubated patient on PEEP) after initial fluid resuscitation, begin Dobutamine @ 2.5 mcg/kg/min, increase by 2.5 mcg/kg/min every 5-10 minutes in pts with continuous ScvO2 (max 20 mcg/kg/min)(1C) </li></ul>
    32. 34. To be accomplished within 4 hours: <ul><li>1.If patient is on vasopressors for > 1 hour despite adequate preload(CVP:8-12) </li></ul><ul><li>Hydrocortisone 200 mg in 25 cc NS over 30 min(2C) – followed by: </li></ul><ul><li>Hydrocortisone 250 mg in 250 cc NS at 10 cc/hr OR Hydrocortisone 50mg IV every 6 hours. </li></ul><ul><li>Wean from steroid therapy when Vasopressors are no longer required(2D) </li></ul><ul><li>Do not use steroid to treat sepsis in absence of shock(1D) </li></ul>
    33. 35. Hydrocortisone Treatment of Refractory Septic Shock Timing Hydrocortisone Daily dose Loading dose over 30 min 200-mg IV bolus Day 0 until Day 8 IV infusion at 10ml/hr 240 mg Day 8 – Day 10 IV infusion at 5ml/hr 120 mg Day 10 – Day 12 IV infusion at 2.5 ml/hr 60 mg At ICU discharge, the infusion is changed to equivalent daily dosage divided in two IV doses. Day 0 until Day 8 120 mg (2.4 ml) Q 12 h 240 mg Day 8 – Day 10 60 mg (1.2 ml) Q 12 h 120 mg Day 10 – Day 12 30 mg (0.6 ml) Q 12 h 60 mg At hospital discharge or for any condition that might limit IV intake: equivalent oral dose to complete the 11 full days treatment is initiated in two divided doses.
    34. 36. <ul><li>2.Monitor urinary output and renal function </li></ul><ul><li>If urinary output is 0.5 cc/kg/hr and CVP < 12 mmHg – fluid challenge (500-1,000 cc) </li></ul><ul><li>BMP every 4-6 hours – GOAL: reduction in serum Creatinine and Anion Gap </li></ul><ul><li>3.Intense insulin treatment </li></ul><ul><li>GOAL: maintain blood glucose between 110 and 150 mg/dl with insulin infusion [see protocol](1B) </li></ul><ul><li>4.Bedside echocardiography </li></ul><ul><li>Assess LV contractility, for unstable patient and fluid overload patient. </li></ul>
    35. 37. To be accomplished within 8-12 hours: <ul><li>If patient requires high dose norepinephrine after 6 hours of hydrocortisone infusion </li></ul><ul><li>Vasopressin 0.04 units/minute.Do not titrate </li></ul><ul><li>Not a replacement for norepinephrine or dopamine as a first-line agent </li></ul><ul><li>Consider in refractory shock despite high-dose conventional vasopressors . </li></ul>
    36. 38. Early Goal Directed Therapy
    37. 39. Crystalloids VS. Colloids <ul><li>In critically ill ICU patient, there is no evidence to support the use of Albumin. </li></ul><ul><li>Albumin is more expensive and may be associated with higher mortality when compared to crystalloids. </li></ul><ul><li>A recently published meta-analysis concluded that in critical ill patient with hypovolemia, burns or hypoalbuminemia, albumin increase mortality. </li></ul><ul><li>There is a data that shows a survival benefit from albumin in cirrhotic patient with spontaneous bacterial peritonitis(SBP). </li></ul><ul><li>Albumin may be useful in preventing progression of renal failure in certain patient (i.e Cirrhosis). However, its use in this setting has not been validated. </li></ul>
    38. 40. Empiric antibiotics <ul><li>If Pseudomonas is an unlikely pathogen , it is recommeded combination vancomycin with one of the following: </li></ul><ul><li>Cephalosporin, 3rd or 4th generation (eg, ceftriaxone or cefotaxime ), or </li></ul><ul><li>Beta-lactam/beta-lactamase inhibitor (eg, piperacillin-tazobactam , ticarcillin-clavulanate , or ampicillin-sulbactam ), or </li></ul><ul><li>Carbapenem (eg, imipenem or meropenem ). </li></ul><ul><li>If Pseudomonas is a possible pathogen , it is recommended vancomycin with two of the following(2D) </li></ul><ul><li>Antipseudomonal cephalosporin (eg, ceftazidime or cefoperazone), or </li></ul><ul><li>Antipseudomonal carbapenem (eg, imipenem, meropenem ), or </li></ul><ul><li>Antipseudomonal beta-lactam/beta-lactamase inhibitor (eg, piperacillin-tazobactam , ticarcillin-clavulanate ), or </li></ul><ul><li>Fluoroquinolone with good anti-pseudomonal activity (eg, ciprofloxacin ), or </li></ul><ul><li>Aminoglycoside (eg, gentamicin , amikacin ), or </li></ul><ul><li>Monobactam (eg, aztreonam ) </li></ul>
    39. 41. APPENDIX I General Rule 1 Avoid re-exposure to B lactam and fluoroquinolones if received within 3 months. Attention: fluoroquinolones also cause resistance to B lactam (AVOID fluroquinolones in first ICU infection if possible) General Rule 2 Do not combine two B lactam antibiotics: Pencillin, Cephalosporin, Monobactam, and Carbapenem. General Rule 3 For Enterobacteriaceae (Klebsiella, E.coli) – use Carbapenem (AVOID Piperacillin/tazobactam) General Rule 4 Antibiotics that prolong QT-Torsade de pointes: Moxifloxacin, Levaquin, TMT-SMT, Erythromycin, Itraconazole, Ketoconazole, Pentamidine General Rule 5 For S. aureus bacteremia: Antibiotic treatment for at least two weeks – stop after 2 weeks if the following are met :1) removal of the intravascular catheter or drainage of the abcess that was presumed to be the source of the bacteremia, 2) the bacteremia is demonstrated to promptly resolve with the removal or drainage 3) there is prompt clinical response, including resolution of fever 4) heart valve are demonstrated to be normal. (Pt. with DM may need 4 weeks treatment) General Rule 6 Fluconazole sensitive Candida: Tropicalis, Albicans, Parapsilosis (TAP), Lusitaniae
    40. 42. Drotrecogin alfa activated(Xigris) OR Recombinant Human Activated Protein C (rhAPC)
    41. 43. Drotrecogin alfa activated(Xigris) OR Recombinant Human Activated Protein C (rhAPC) <ul><li>Reduced absolute mortality of patients with severe sepsis by approximately 6%. Long term (2-3 years) survival benefit is persistent. </li></ul><ul><li>Shorter time of using vasopressor and ventilator. </li></ul><ul><li>“ High-risk-of-death” group (APACHE II score >25), reduce mortality 13%. </li></ul><ul><li>“ Low-risk-of-death” group (APACHE II score <25), reduce mortality 1-2%. </li></ul><ul><li>Increased the risk of ICH of 0.1-0.3% in APACHE II <25 patient) </li></ul>
    42. 44. Drotrecogin alfa activated(Xigris) OR Recombinant Human Activated Protein C (rhAPC) <ul><li>Adult patients with severe sepsis should receive rhAPC </li></ul><ul><li>High risk of death </li></ul><ul><li>APACHE II score ≥ 25 (2B) </li></ul><ul><li>Multiple organ failure </li></ul><ul><li>should not receive rhAPC </li></ul><ul><ul><li>Low risk of death </li></ul></ul><ul><ul><li>APACHE II < 25 (1A) </li></ul></ul><ul><ul><li>One organ failure </li></ul></ul>
    43. 45. Sepsis and ARF Patients in sepsis and ARF are hypercatabolic states. Patient placed on renal replacement therapy have been shown to have mortality benefit.(2B)
    44. 46. Bicarbonate Therapy Bicarbonate therapy not recommended to improve hemodynamics in patients with lactate induced pH > 7.15
    45. 47. Platelet transfusion <ul><li>Transfusion required </li></ul><ul><li>< 5000/mm3 </li></ul><ul><li>May be considered when counts are </li></ul><ul><ul><li>5000-30,000/mm3 </li></ul></ul><ul><ul><li>significant risk of bleeding </li></ul></ul><ul><li>≥  50,000/mm3 is required </li></ul><ul><ul><ul><li>surgery </li></ul></ul></ul><ul><ul><ul><li>invasive procedures </li></ul></ul></ul>
    46. 48. FAST HUG F eeding(1B) A nalgesia(1B) S edation(1B) T hromboembolic prophylaxis(1A) H ead of bed elevation(1B) U lcer prophylaxis(1A) G lucose control(1B)
    47. 49. Consideration for limitation of support <ul><li>Advance care planning, including the communication of likely outcomes and realistic goal of treatment, be discussed with patient and families.(1D) </li></ul><ul><li>Decision for less aggressive support or withdrawal of support may be in patient’s best interest. </li></ul><ul><li>Family-physician communication </li></ul><ul><li>Anxiety, depression, frustration in family members and health care worker. </li></ul>
    48. 50. Questions?
    49. 51. <ul><li>A 70 YO man presents to ER with 2 day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient’s family noted that he was more lethargic and dizzy. VS: Temp 101.5, HR 120, RR 30, B.P 70/35, O2 sat 80% @RA, CXR shows RLL infiltrate. </li></ul><ul><li>What is the first step in the initial management of this patient? </li></ul><ul><li>Antibiotic therapy </li></ul><ul><li>B-Blocker therapy to control heart rate </li></ul><ul><li>IV Fluid resuscitation </li></ul><ul><li>Supplimental oxygen and airway management </li></ul><ul><li>Vasopressor with Norepinephrin(Levophed) </li></ul>
    50. 52. Answer:D-Supplimental oxygen and airway management First-Follow ABCD
    51. 53. Which of these options is a goal of initial resuscitation that has been demonstrated to decrease mortality in sepsis-induced tissue hypoperfusion? <ul><li>Heart rate < 90/min </li></ul><ul><li>Mean arterial pressure > 65 mm Hg </li></ul><ul><li>Normalization of lactate </li></ul><ul><li>Central venous o2 saturation  70% </li></ul>
    52. 54. Answer:4-Central venous saturation  70%
    53. 55. A 62-year-old man comes to the emergency department with altered mental status, tachycardia, tachypnea, and hypotension (BP 64/38 mm Hg). He has fever with leukocytosis, platelet count 75,000, and INR 2.0. A fluid bolus is being administered. Which adrenergic agents are most appropriate to maintain blood pressure during fluid bolus and following fluid bolus if hypotension persists?? <ul><li>Dopamine or epinephrine </li></ul><ul><li>Epinephrine or vasopressin </li></ul><ul><li>Vasopressin or norepinephrine </li></ul><ul><li>Norepinephrine or dopamine </li></ul>
    54. 56. Answer:D-Norepinephrine or Dopamine simple guide Low cardiac output Normal to high Cardiac output Low SVR Norepinephrine Phenylephrine High SVR Dobutamine Dopamine
    55. 57. A central line is inserted in the right neck in sepsis patient. CVP is 12 mm Hg. MAP is 70 mm Hg with vasopressor support. Lab results reveal elevated BUN and creatinine. Arterial gases reveal pH 7.22, PaCO2 28, and PaO2 65. Hematocrit is 32% and saturation is 94% with supplement oxygen. The central venous O2 saturation is 60%. Which one of the following is most appropriate at this time? <ul><li>Packed red blood cells </li></ul><ul><li>Intravenous bicarbonate </li></ul><ul><li>Dobutamine </li></ul><ul><li>Diuresis </li></ul>
    56. 58. Answer:C-Dobutamine
    57. 59. References Surviving Sepsis Campaign. The New England Journal of Medicine. Uptodate.com. Society of critical care Medicine. European Society of Intensive Care. American College of Chest Physicians. Society of Critical Care Medicine Journal
    58. 60. Thank you

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