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SHOCK INSHOCK IN
CRITICAL ILLNESSCRITICAL ILLNESS
Vikas Kesarwani MD FCCPVikas Kesarwani MD FCCP
Consultant, Pulmonary & C...
Dictionary definition of ShockDictionary definition of Shock
► 1. a sudden and violent1. a sudden and violent blow or impa...
DefinitionDefinition
►Kumar and Parrillo (1995)Kumar and Parrillo (1995)
- “The state in which- “The state in which profou...
Case ScenarioCase Scenario
► 45 yr old male. Teetotaller45 yr old male. Teetotaller
► BG: T2DM, HTN for 10 yrs. On OHA and...
Case ScenarioCase Scenario
► 45 yr old male.45 yr old male.
► BG: T2DM, HTN for 10 yrs. On OHA and antihypertensive medica...
DefinitionDefinition
►Kumar and Parrillo (1995)Kumar and Parrillo (1995)
- “The state in which profound and- “The state in...
Tissue PerfusionTissue Perfusion
3 components3 components
PumpPump
ContainerContainer
FluidFluid
► Cardiogenic shock –Cardiogenic shock –
due todue to cardiac pump failurecardiac pump failure ;loss of myocardial contrac...
Distributive ShockDistributive Shock
►Results from a severe decrease in SVRResults from a severe decrease in SVR
 Vasodil...
The Sepsis ContinuumThe Sepsis Continuum
SIRS = systemic inflammatory
response syndrome
Severe
SepsisSIRS
Septic
Shock
Ref...
What is SIRS?What is SIRS?
Systemic level ofSystemic level of acute inflammationacute inflammation,,
that may or may not b...
DefinitionsDefinitions (ACCP/SCCM)(ACCP/SCCM)
SepsisSepsis
• >>22 SIRSSIRS Criteria.Criteria.
• Either a culture-Either a ...
Sepsis: Grade ISepsis: Grade I
•Severe Sepsis:Severe Sepsis:
SSepsisepsis ++ at least one of the following signsat least o...
• Septic ShockSeptic Shock:: severe sepsissevere sepsis ++ one orone or
both of the following:both of the following:
1. Me...
• Refractory Septic ShockRefractory Septic Shock ::
To maintainTo maintain MMean BP >60ean BP >60 mmHgmmHg (or >80 mmHg(or...
The Sepsis ContinuumThe Sepsis Continuum
SIRS = systemic inflammatory
response syndrome
Severe
Sepsis
SIRS
Septic
Shock
Re...
SEPSIS
Relationship Between Sepsis andRelationship Between Sepsis and
SIRSSIRS
TRAUMA
BURNS
PANCREATITIS
SIRSINFECTION
BAC...
PrognosisPrognosis
Overall mortalityOverall mortality from SIRS/sepsis in the U.S.from SIRS/sepsis in the U.S.
isis approx...
Sepsis: PathophysiologySepsis: Pathophysiology
Pro-inflammatoryPro-inflammatory
MediatorsMediators
• Bacterial EndotoxinBacterial Endotoxin
• TNF-TNF-αα
• Interleukin-1I...
Cohen, Nature: 2002 420:885
Management: Septic ShockManagement: Septic Shock
Starting from common ground…Starting from common ground…
►Appropriate supportive careAppropriate supportive care
 ABCsABC...
CVP:
central
venous
pressure
MAP:
mean
arterial
pressure
ScvO2:
central
venous
oxygen
saturation
Early Goal-DirectedEarly ...
What to do if you don’t have facilityWhat to do if you don’t have facility
for CVP measurement ?for CVP measurement ?
-20m...
What to do if you don’t have facilityWhat to do if you don’t have facility
for CVP measurement ?for CVP measurement ?
Poor...
Treatment:Treatment: (Vasopressors)(Vasopressors)
►Noradrenaline, Adrenaline, Vasopressin.Noradrenaline, Adrenaline, Vasop...
TreatmentTreatment
AntibioticsAntibiotics
► ConsiderConsider possiblepossible organismsorganisms at suspected/confirmedat ...
Give your patientsGive your patients ONE FAST HUGONE FAST HUG
everyday in HDU & ICUeveryday in HDU & ICU
► OO: Oral care.:...
Evidence-Based SepsisEvidence-Based Sepsis
GuidelinesGuidelines
Components:Components:
• Early Goal-Directed TherapyEarly ...
Evidence based Summary of SepsisEvidence based Summary of Sepsis
GuidelinesGuidelines
InitiativeInitiative GradeGrade
DVT ...
InitiativeInitiative GradeGrade
Do not useDo not use low doselow dose dopaminedopamine for renalfor renal
protectionprotec...
InitiativeInitiative GradeGrade
Sedation protocolsSedation protocols with goal and assessmentwith goal and assessment
scal...
►Fluid resuscitation, goal-directedFluid resuscitation, goal-directed
►Appropriate cultures prior to antibioticAppropriate...
►Stress ulcer and DVT prophylaxisStress ulcer and DVT prophylaxis
►De-escalate antibiotic.De-escalate antibiotic.
►Prevent...
"First Do No Harm"
Shock in critically ill
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Shock in critically ill

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  • BACK-UP SLIDE: This slide shows specifically how the monitored parameters in EGDT were maintained. “ The protocol was as follows: A 500-ml bolus of crystalloid was given every 30 minutes to achieve a central venous pressure of 8 to 12 mm Hg. If the mean arterial pressure was less than 65 mm Hg, vasopressors were given to maintain a mean arterial pressure of at least 65 mm Hg. If the mean arterial pressure was greater than 90 mm Hg, vasodilators were given until it was 90 mm Hg or below. If the central venous oxygen saturation was less than 70 percent, red cells were transfused to achieve a hematocrit of at least 30 percent. After the central venous pressure, mean arterial pressure, and hematocrit were thus optimized, if the central venous oxygen saturation was less than 70 percent, dobutamine administration was started at a dose of 2.5 µg per kilogram of body weight per minute, a dose that was increased by 2.5 µg per kilogram per minute every 30 minutes until the central venous oxygen saturation was 70 percent or higher or until a maximal dose of 20 µg per kilogram per minute was given. Dobutamine was decreased in dose or discontinued if the mean arterial pressure was less than 65 mm Hg or if the heart rate was above 120 beats per minute. To decrease oxygen consumption, patients in whom hemodynamic optimization could not be achieved received mechanical ventilation and sedatives. ” (p. 1370) Purpose of study : to adjust cardiac preload, afterload and contractility to balance oxygen delivery with oxygen demand Entry criteria : patients in the emergency dept with severe sepsis & shock Plan : randomise to 6h of EGDT before transfer to ICU
  • Transcript of "Shock in critically ill"

    1. 1. SHOCK INSHOCK IN CRITICAL ILLNESSCRITICAL ILLNESS Vikas Kesarwani MD FCCPVikas Kesarwani MD FCCP Consultant, Pulmonary & Critical Care,Consultant, Pulmonary & Critical Care, Himalayan Institute of Medical Sciences,Himalayan Institute of Medical Sciences, HIHT University,HIHT University, Dehradun.Dehradun. 2626thth Feb 2011Feb 2011
    2. 2. Dictionary definition of ShockDictionary definition of Shock ► 1. a sudden and violent1. a sudden and violent blow or impact; collision, disturbanceblow or impact; collision, disturbance oror commotioncommotion of the mind, emotions, or sensibilitiesof the mind, emotions, or sensibilities ► 2. the physiological effect produced by the passage of an electric2. the physiological effect produced by the passage of an electric current through the body.current through the body. 3. shocks, Informal3. shocks, Informal .. shock absorbersshock absorbers, especially in the suspension, especially in the suspension of an automobile.of an automobile. 4.4. PathologyPathology . a collapse of circulatory function,. a collapse of circulatory function, caused by severe injury, blood loss, or disease, andcaused by severe injury, blood loss, or disease, and characterized by pallor, sweating, weak pulse, andcharacterized by pallor, sweating, weak pulse, and very low blood pressure.very low blood pressure. ––verb (used with object) 8. to strike or jar with intense surprise, horror,verb (used with object) 8. to strike or jar with intense surprise, horror, disgust, etc.: He enjoyed shocking people.disgust, etc.: He enjoyed shocking people. ► 9. to strike against violently.9. to strike against violently. ► 10. to give an10. to give an electric shockelectric shock to.to. Origin: 1555–65; French choc armed encounter, noun derivative of choquer to clash (in battle). Germanic; compare Dutch schokken to shake, jolt, jerk
    3. 3. DefinitionDefinition ►Kumar and Parrillo (1995)Kumar and Parrillo (1995) - “The state in which- “The state in which profoundprofound andand widespreadwidespread reduction of effective tissuereduction of effective tissue perfusionperfusion leadsleads first to reversiblefirst to reversible, and, and thenthen if prolonged, to irreversible cellularif prolonged, to irreversible cellular injuryinjury.”.” ►Clinically manifested byClinically manifested by  Hemodynamic disturbances.Hemodynamic disturbances.  Tissue Hypoxia.Tissue Hypoxia.  Organ dysfunctionOrgan dysfunction..
    4. 4. Case ScenarioCase Scenario ► 45 yr old male. Teetotaller45 yr old male. Teetotaller ► BG: T2DM, HTN for 10 yrs. On OHA andBG: T2DM, HTN for 10 yrs. On OHA and antihypertensive medication.antihypertensive medication. ► H/oH/o Cough, Expectoration, Fever - 5 days.Cough, Expectoration, Fever - 5 days. Delirious & Not passed urine since last 24 hours.Delirious & Not passed urine since last 24 hours. ► HR 121/min, BP 90/50,HR 121/min, BP 90/50, RR 28/min, SpO2 85% on RA.RR 28/min, SpO2 85% on RA.
    5. 5. Case ScenarioCase Scenario ► 45 yr old male.45 yr old male. ► BG: T2DM, HTN for 10 yrs. On OHA and antihypertensive medication.BG: T2DM, HTN for 10 yrs. On OHA and antihypertensive medication. ► H/oH/o Cough,Expectoration, Fever 5 days.Cough,Expectoration, Fever 5 days. Dilirious, Not passed urine since last 24 hours.Dilirious, Not passed urine since last 24 hours. ►Hemodynamic disturbance:Hemodynamic disturbance: HR 121/min, BPHR 121/min, BP 90/50,90/50, Tissue Hypoxia:Tissue Hypoxia: SpO2 85% on RA. Dilirious.SpO2 85% on RA. Dilirious. Organ Dysfunction:Organ Dysfunction: Anuric, dilirious.Anuric, dilirious.
    6. 6. DefinitionDefinition ►Kumar and Parrillo (1995)Kumar and Parrillo (1995) - “The state in which profound and- “The state in which profound and widespreadwidespread reduction of effectivereduction of effective tissue perfusiontissue perfusion leads first to reversible,leads first to reversible, and then if prolonged, to irreversibleand then if prolonged, to irreversible cellular injury.”cellular injury.” ►Clinically manifested byClinically manifested by  Hemodynamic disturbances.Hemodynamic disturbances.  Tissue Hypoxia.Tissue Hypoxia.  Organ dysfunction.Organ dysfunction.
    7. 7. Tissue PerfusionTissue Perfusion 3 components3 components PumpPump ContainerContainer FluidFluid
    8. 8. ► Cardiogenic shock –Cardiogenic shock – due todue to cardiac pump failurecardiac pump failure ;loss of myocardial contractility;loss of myocardial contractility / functional myocardium or structural/mechanical/ functional myocardium or structural/mechanical failure of the cardiac anatomy and characterized byfailure of the cardiac anatomy and characterized by elevations of diastolic filling pressures and volumeselevations of diastolic filling pressures and volumes ► Hypovolemic shockHypovolemic shock –– ↓↓ circulating blood volumecirculating blood volume in relation to the totalin relation to the total vascular capacity and characterized byvascular capacity and characterized by aa reduction of diastolic filling pressures.reduction of diastolic filling pressures. ► Distributive shock –Distributive shock – caused bycaused by loss of vasomotor controlloss of vasomotor control resulting inresulting in arteriolar/venular dilatationarteriolar/venular dilatation and characterizedand characterized (after fluid resuscitation) by(after fluid resuscitation) by increasedincreased cardiac output andcardiac output and decreased SVR.decreased SVR. Extra-cardiac obstructive shock –Extra-cardiac obstructive shock – due todue to obstruction to flow in the cardiovascular circuitobstruction to flow in the cardiovascular circuit andand characterized by eithercharacterized by either impairment of diastolic filling or excessiveimpairment of diastolic filling or excessive afterloadafterload ClassificationClassification
    9. 9. Distributive ShockDistributive Shock ►Results from a severe decrease in SVRResults from a severe decrease in SVR  Vasodilation reduces both preload & afterloadVasodilation reduces both preload & afterload  May be associated with increased COMay be associated with increased CO ►Etiologic categoriesEtiologic categories -Septicemia-Septicemia  Neurogenic / spinalNeurogenic / spinal  Systemic inflammation(SIRS)Systemic inflammation(SIRS) – pancreatitis, burns.– pancreatitis, burns.  Anaphylaxis and anaphylactoid reactionsAnaphylaxis and anaphylactoid reactions Toxin reactions – drugs, transfusion.Toxin reactions – drugs, transfusion.
    10. 10. The Sepsis ContinuumThe Sepsis Continuum SIRS = systemic inflammatory response syndrome Severe SepsisSIRS Septic Shock Refractory Septic Shock SEPSI S ACCP: American college of chest physician. SCCM: Society of critical care medicine
    11. 11. What is SIRS?What is SIRS? Systemic level ofSystemic level of acute inflammationacute inflammation,, that may or may not be due to infection.that may or may not be due to infection. Requires 2 of the following 4 features to be present:Requires 2 of the following 4 features to be present: ►Temp >38.3° or <36.0° CTemp >38.3° or <36.0° C ►Tachypnea (RR>20 or PaCO2 <32 mmHg)Tachypnea (RR>20 or PaCO2 <32 mmHg) ►Tachycardia (HR>100,Tachycardia (HR>100, in the absence of intrinsic heart disease)in the absence of intrinsic heart disease) ►WBC > 10,000/mmWBC > 10,000/mm33 or <4,000/mmor <4,000/mm33 oror >10% band forms on differential>10% band forms on differential
    12. 12. DefinitionsDefinitions (ACCP/SCCM)(ACCP/SCCM) SepsisSepsis • >>22 SIRSSIRS Criteria.Criteria. • Either a culture-Either a culture- provenproven infectioninfection or anor an infection identified by visual inspectioninfection identified by visual inspection ACCP: American college of chest physician. SCCM: Society of critical care medicine
    13. 13. Sepsis: Grade ISepsis: Grade I •Severe Sepsis:Severe Sepsis: SSepsisepsis ++ at least one of the following signsat least one of the following signs ofof organ hypoperfusion or dysfunctionorgan hypoperfusion or dysfunction.. •• Mottled skin, Capillary refillingMottled skin, Capillary refilling>>3sec.3sec. •• Urine output <0.5 mL/kg/Hr. or requiring Dialysis.Urine output <0.5 mL/kg/Hr. or requiring Dialysis. •• Lactate >2 mmol/L.Lactate >2 mmol/L. •• Altered sensorium.Altered sensorium. •• Platelet count <100,000/mLPlatelet count <100,000/mL •• Disseminated intravascular coagulation(DIC)Disseminated intravascular coagulation(DIC) •• Acute lung injury or acute respiratory distressAcute lung injury or acute respiratory distress syndrome (ARDS)syndrome (ARDS) •• Cardiac dysfunction.Cardiac dysfunction. Send the patient to higher centre or to a friend Doctor who can manage any further deterioration.
    14. 14. • Septic ShockSeptic Shock:: severe sepsissevere sepsis ++ one orone or both of the following:both of the following: 1. Mean1. Mean BP<60mmHgBP<60mmHg.. (<80 in Hypertensive pt.)(<80 in Hypertensive pt.) afterafter Adequate fluid resuscitation.Adequate fluid resuscitation. 2. Requires2. Requires dopamine dopamine >5 mcg/kg/min, or>5 mcg/kg/min, or norepinephrinenorepinephrine <0.25 mcg/kg/min, or <0.25 mcg/kg/min, or epinephrineepinephrine <0.25 mcg/kg/min <0.25 mcg/kg/min despitedespite adequate fluid resuscitation.adequate fluid resuscitation. Sepsis: grade IISepsis: grade II Adequate fluid resuscitation : infusion of 20 to 30 mL/kg of starch, infusion of 40 to 60 mL/kg of saline solution, or a measured pulmonary capillary wedge pressure (PCWP) of 12 to 20 mmHg.
    15. 15. • Refractory Septic ShockRefractory Septic Shock :: To maintainTo maintain MMean BP >60ean BP >60 mmHgmmHg (or >80 mmHg(or >80 mmHg if the patient has baseline hypertension)if the patient has baseline hypertension) requiresrequires dopamine >15dopamine >15 mcg/kg/min,mcg/kg/min, norepinephrine >0.25norepinephrine >0.25 mcg/kg/min, ormcg/kg/min, or epinephrine >0.25epinephrine >0.25 mcg/kg/minmcg/kg/min despite adequate fluid resuscitation.despite adequate fluid resuscitation. Sepsis: grade IIISepsis: grade III Adequate fluid resuscitation : infusion of 20 to 30 mL/kg of starch, infusion of 40 to 60 mL/kg of saline solution, or a measured pulmonary capillary wedge pressure (PCWP) of 12 to 20 mmHg.
    16. 16. The Sepsis ContinuumThe Sepsis Continuum SIRS = systemic inflammatory response syndrome Severe Sepsis SIRS Septic Shock Refractory Septic Shock SEPSI S ACCP: American college of chest physician. SCCM: Society of critical care medicine  A clinical responseA clinical response arising from aarising from a nonspecific insult, withnonspecific insult, with ≥≥2 of the following:2 of the following:  T >38T >38oo C or <36C or <36oo CC  HR >100 beats/minHR >100 beats/min  RR >20/minRR >20/min  WBC >12,000/mmWBC >12,000/mm33 or <4,000/mmor <4,000/mm33 oror >10% bands>10% bands Sepsis + organ hypo-perfusion or dysfunction SIRS + confirmed infection. Septic shock+ High Inotropes. Severe Sepsis + BP<60mmHg. after fluid resuscitation or Low Inotrope
    17. 17. SEPSIS Relationship Between Sepsis andRelationship Between Sepsis and SIRSSIRS TRAUMA BURNS PANCREATITIS SIRSINFECTION BACTEREMIA Fungemia Parasitemia viremia
    18. 18. PrognosisPrognosis Overall mortalityOverall mortality from SIRS/sepsis in the U.S.from SIRS/sepsis in the U.S. isis approximately 20%.approximately 20%. Mortality is roughly linearly related to theMortality is roughly linearly related to the number of organ failures.number of organ failures. Each additional organ failure raising theEach additional organ failure raising the mortality rate by 15%.mortality rate by 15%. HypothermiaHypothermia is one of the worstis one of the worst prognostic signs.prognostic signs. Patients presenting with SIRSPatients presenting with SIRS and hypothermia have an overalland hypothermia have an overall mortality of ~80%.mortality of ~80%.
    19. 19. Sepsis: PathophysiologySepsis: Pathophysiology
    20. 20. Pro-inflammatoryPro-inflammatory MediatorsMediators • Bacterial EndotoxinBacterial Endotoxin • TNF-TNF-αα • Interleukin-1Interleukin-1 • Interleukin-6Interleukin-6 • Interleukin-8Interleukin-8 • Platelet ActivatingPlatelet Activating Factor (PAF)Factor (PAF) • Interferon-GammaInterferon-Gamma • ProstaglandinsProstaglandins • LeukotrienesLeukotrienes • Nitric OxideNitric Oxide Mediators of SepticMediators of Septic ResponseResponse Anti-Anti- inflammatoryinflammatory MediatorsMediators • Interleukin-10Interleukin-10 • PGE2PGE2 • Protein CProtein C • Interleukin-6Interleukin-6 • Interleukin-4Interleukin-4 • Interleukin-12Interleukin-12 • LipoxinsLipoxins • GM-CSFGM-CSF • TGFTGF • IL-1RAIL-1RA
    21. 21. Cohen, Nature: 2002 420:885
    22. 22. Management: Septic ShockManagement: Septic Shock
    23. 23. Starting from common ground…Starting from common ground… ►Appropriate supportive careAppropriate supportive care  ABCsABCs (CAB if patient has arrested)(CAB if patient has arrested)  FluidsFluids  Vasopressors/inotropesVasopressors/inotropes  Organ support (ventilation, dialysis, etc.)Organ support (ventilation, dialysis, etc.) ►Appropriate empiric and adjustedAppropriate empiric and adjusted antibioticsantibiotics ►Source identification & control.Source identification & control. ►Steroids, Glycemic control, Nutrition,Steroids, Glycemic control, Nutrition, Activated protein C.Activated protein C.
    24. 24. CVP: central venous pressure MAP: mean arterial pressure ScvO2: central venous oxygen saturation Early Goal-DirectedEarly Goal-Directed TherapyTherapy NEJM 2001;345:1368-77.
    25. 25. What to do if you don’t have facilityWhat to do if you don’t have facility for CVP measurement ?for CVP measurement ? -20ml/Kg fluid bolus every 30--20ml/Kg fluid bolus every 30- 60minutes. (NS or Colloid)60minutes. (NS or Colloid) Poor Man’s CVP assessment & GuidedPoor Man’s CVP assessment & Guided fluid:fluid: Passive leg raising (PLR)Passive leg raising (PLR) increasingincreasing preload.preload. Watch HR trendWatch HR trend ↓HR= Give more.↓HR= Give more. ↑HR= Stop giving.↑HR= Stop giving. (other reasons for tachycardia/bradycardia ruled out)(other reasons for tachycardia/bradycardia ruled out)
    26. 26. What to do if you don’t have facilityWhat to do if you don’t have facility for CVP measurement ?for CVP measurement ? Poor Man’s CVP assessment & GuidedPoor Man’s CVP assessment & Guided fluid:fluid: Passive leg raising (PLR)Passive leg raising (PLR) Poor Man’s Cardiac output:Poor Man’s Cardiac output: U/OU/O>> 0.5ml/kg/hr.0.5ml/kg/hr. ►Spo2 ~95-97% (NOT 100%)Spo2 ~95-97% (NOT 100%) ►HRHR ►U/OU/O ►Neurological state.Neurological state.
    27. 27. Treatment:Treatment: (Vasopressors)(Vasopressors) ►Noradrenaline, Adrenaline, Vasopressin.Noradrenaline, Adrenaline, Vasopressin. (after volume resuscitation).(after volume resuscitation). ►? Dopamine & Dobutamine.? Dopamine & Dobutamine. ► A goal MAP =60-65mmHg,A goal MAP =60-65mmHg, ► Urine output, mental status, and skin perfusionUrine output, mental status, and skin perfusion areare better variables to use in monitoringbetter variables to use in monitoring adequateadequate perfusion then BP aloneperfusion then BP alone..
    28. 28. TreatmentTreatment AntibioticsAntibiotics ► ConsiderConsider possiblepossible organismsorganisms at suspected/confirmedat suspected/confirmed sitesite of the infection.of the infection. ► Obtain cultures, give empirical antibioticsObtain cultures, give empirical antibiotics quicklyquickly and atand at appropriate dose.appropriate dose. ► De-escalateDe-escalate ones organism identified.ones organism identified. Mechanical VentilationMechanical Ventilation ► Do not delayDo not delay mechanical ventilation if indicated.mechanical ventilation if indicated. Know your intubation criteria.Know your intubation criteria. ► Low tidal volume ventilation for ARDSLow tidal volume ventilation for ARDS ► Nearly all patientsNearly all patients with septic shock requirewith septic shock require oxygenoxygen, and, and 80%(80%(approx.) requireapprox.) require mechanical ventilation.mechanical ventilation.
    29. 29. Give your patientsGive your patients ONE FAST HUGONE FAST HUG everyday in HDU & ICUeveryday in HDU & ICU ► OO: Oral care.: Oral care. ► NN: Nose care.: Nose care. ► EE: Ear care.: Ear care. ► FF: Feeding: Feeding (adequate calories.)(adequate calories.) ► AA: Analgesia: Analgesia (Check)(Check) ► SS: sedation: sedation (Check)(Check) ► TT: Thromboprophylaxis: Thromboprophylaxis ► HH: Head raised: Head raised 4545degreedegree ► UU: Ulcer prophylaxis.: Ulcer prophylaxis. ► GG: Glucose control.: Glucose control. Crit Care Med 2005 Vol. 33, No. 6
    30. 30. Evidence-Based SepsisEvidence-Based Sepsis GuidelinesGuidelines Components:Components: • Early Goal-Directed TherapyEarly Goal-Directed Therapy • Steroid ReplacementSteroid Replacement • Recombinant Activated Protein CRecombinant Activated Protein C • Glycemic ControlGlycemic Control • Nutritional SupportNutritional Support • Adjuncts: Stress Ulcer Prophylaxis,Adjuncts: Stress Ulcer Prophylaxis, DVT Prophylaxis, Transfusion,DVT Prophylaxis, Transfusion, Sedation, Analgesia, OrganSedation, Analgesia, Organ ReplacementReplacement
    31. 31. Evidence based Summary of SepsisEvidence based Summary of Sepsis GuidelinesGuidelines InitiativeInitiative GradeGrade DVT prophylaxisDVT prophylaxis with low dose heparins orwith low dose heparins or mechanical devicesmechanical devices AA Stress ulcer prophylaxisStress ulcer prophylaxis, preferably with H, preferably with H22 blockersblockers AA Do not use > 300 mg/day hydrocortisoneDo not use > 300 mg/day hydrocortisone AA Weaning protocolWeaning protocol with spontaneouswith spontaneous breathing trialsbreathing trials AA Do not increase cardiac index to supranormalDo not increase cardiac index to supranormal AA Early initial resuscitation to goalsEarly initial resuscitation to goals BB Red blood cell transfusion/dobutamineRed blood cell transfusion/dobutamine toto goalsgoals BB
    32. 32. InitiativeInitiative GradeGrade Do not useDo not use low doselow dose dopaminedopamine for renalfor renal protectionprotection BB rh Activated Protein Crh Activated Protein C [drotrecogin alfa[drotrecogin alfa (activated)] in patients with high risk of death(activated)] in patients with high risk of death BB RBC transfusionRBC transfusion if hemoglobin <7 g/dLif hemoglobin <7 g/dL BB Do not use erythropoietinDo not use erythropoietin for sepsisfor sepsis causedcaused anemiaanemia BB Avoid high tidal volumesAvoid high tidal volumes and plateauand plateau pressures in ALI/ARDSpressures in ALI/ARDS BB Continuous vs. intermittentContinuous vs. intermittent renal replacementrenal replacement considered equivalentconsidered equivalent for acute renal failurefor acute renal failure BB Evidence based Summary of SepsisEvidence based Summary of Sepsis GuidelinesGuidelines
    33. 33. InitiativeInitiative GradeGrade Sedation protocolsSedation protocols with goal and assessmentwith goal and assessment scalescale BB Daily interruptionDaily interruption if continuous i.v. sedationif continuous i.v. sedation BB UseUse colloids or crystalloidscolloids or crystalloids CC CorticosteroidsCorticosteroids for 7 daysfor 7 days in septic shockin septic shock patients on vasopressorspatients on vasopressors CC Permissive hypercapniaPermissive hypercapnia to minimize plateauto minimize plateau pressures and tidal volumespressures and tidal volumes CC Do not use bicarbonate if pH ≥7.15Do not use bicarbonate if pH ≥7.15 inin hypoperfusion lactic acidemiahypoperfusion lactic acidemia CC Semirecumbent positioning to avoid VAPSemirecumbent positioning to avoid VAP (head of(head of bed at 45-degrees)bed at 45-degrees) CC Evidence based Summary of SepsisEvidence based Summary of Sepsis GuidelinesGuidelines
    34. 34. ►Fluid resuscitation, goal-directedFluid resuscitation, goal-directed ►Appropriate cultures prior to antibioticAppropriate cultures prior to antibiotic administration (but do not delay) andadministration (but do not delay) and source control ASAP.source control ASAP. ►Use of vasopressors/inotropes whenUse of vasopressors/inotropes when fluid resuscitation optimized.fluid resuscitation optimized. ►Low tidal volumes (6cc/kg) forLow tidal volumes (6cc/kg) for mechanical ventilation in ARDS.mechanical ventilation in ARDS. Take home messageTake home message
    35. 35. ►Stress ulcer and DVT prophylaxisStress ulcer and DVT prophylaxis ►De-escalate antibiotic.De-escalate antibiotic. ►Prevent VAP: 45 degree elevationPrevent VAP: 45 degree elevation ►Facilitate early discontinuation ofFacilitate early discontinuation of mechanical ventilation: sedationmechanical ventilation: sedation interruption, early SBTinterruption, early SBT Take home message (Cont’d)Take home message (Cont’d) Prevent ComplicationPrevent Complication
    36. 36. "First Do No Harm"
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