Major Case Presentation Septic Shock

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  • Once the bacteria invades the host, inflammatory mediators are produced which causes damage to the host tissue and activation of leukocytes. The balance to control the inflammatory mediators are lost and therefore a systemic inflammatory response develops which in turn converts the infection into sepsis, severe sepsis or septic shock. The key proinflammatory mediator is the tumor necrosis factor-α (TNF-α),interleukin-1 (IL-1), and interleukin-6 (IL-6) . The TNF-áa) is considered the primary mediator of sepsis. Once the TNFáa) is activated, it leads to the activation of IL-1 and IL-6. The TNFá also contributes to the production of Thrombaxane A2, and prostaglandins, which causes vascular endothelial damage, capillary leak, vasodilation, microvascular thrombi formation. Which in turn lead to disseminated intravascular coagulation and acute kidney injury.
  • Major Case Presentation Septic Shock

    1. 1. Pharmacotherapy of Septic Shock<br />Munzur Morshed, Pharm D. candidate 2011Arnold & Marie Schwartz College of Pharmacy and Health SciencesNorth Shore- Long Island Jewish Health SystemInfectious Diseases-Advanced Pharmacy Practice<br />
    2. 2. Case Presentation<br />IMA is a 59 Y/O female, who recently had a left urethral stent placed in her left ureter two weeks ago, came to the <br />emergency room complaining of left-sided flank pain for 1-2 days. Patient was noted to have vomiting for one<br />day, with symptoms of headache, and anxiety. Patient had no hx. of URI, possible kidney stone is suspected. <br />Patient was admitted to the ICU with septic shock secondary to left pyelonephritis, hypoxia and HOTN. Her BP<br />did not respond to the fluids given in the ER. Patient is currently intubated and is monitored on the ventilator.<br /> <br />Past Medical/Surgical history: Patient had a left urethral stent placed a few weeks<br /> <br />Family Hx: Patient has a family history of DM and CAD.<br />Allg: NKA<br />Meds on admission:IV Norepinephrine 2MG/250mL;Normal Saline 1000 ML; Lovenox 40MG SQ QD; Primaxin 500MG IVPB Q6H, Flagyl 1500 mg IVPB q6H STAT, Merrem 500mg IVPB Q8H, Regular Insulin Sliding Scale, Sodium Bicarb 7.5% 44.6MEQ, Gentamicin 100 MG IVPB one/time STAT, Protonix IVPB 40 mg PO q6h; Tylenol with Codeine #3 -1T PO Q4H PRN <br />PE: Temp 102.6, Pulse 114, RR 18, BP 79/50,<br />Laboratory Findings: WBC 20.6, Hg 8.5, Na 131, K 2.6, Cl 2.6, CO2 24, BUN 17, Scr 1.5, Glucose 217, Ca 6.5, <br />Lactate 5.2, AST/ALT 61/91, MAP 59.67, PH 7.19, HCO3 17<br />Urinalysis: Protein 150, Blood Urine- Large, Leuko Ester- Moderate, Nitrites (+), WBC 10-25, Bacteria-many<br />Microbiology Blood Culture: Gram (-) Rods in aerobic Bottle. <br />Urine Culture: Greater than 100,000 CFU/ML Pseudomona Less than 10,000 CFU/ML of other organism<br />Diagnosis: Septic Shock and Pyelonephritis secondary to Stent placement<br />
    3. 3. Introduction<br /><ul><li>What is shock?
    4. 4. Life threatening state, decrease in tissue perfusion of blood supply
    5. 5. Characterized by lack of nutrient and O2 rich blood to the organs resulting in inadequate perfusion
    6. 6. Vital Signs
    7. 7. HR < 20 or > 150 bpm
    8. 8. SBP < 80 mmHg, decrease by at least 40mmHg
    9. 9. MAP < 60 mmHg
    10. 10. DBP > 120 mmHg
    11. 11. RR > 35 breaths/min
    12. 12. pH < 7.1 or >7.7
    13. 13. low urine output (<0.5ml/kg/hr ) and confusion or loss of consciousness</li></li></ul><li>Types of Shock<br /><ul><li>Hypovolemic Shock
    14. 14. Loss of blood volume (plasma + RBCs)
    15. 15. External-surgery or trauma
    16. 16. Internal-GI bleeding
    17. 17. Cardiogenic Shock
    18. 18. Hearts inability to pump appropriate amount of blood
    19. 19. Decreased Cardiac Output
    20. 20. Septic Shock- Discussed in detail
    21. 21. Obstructive Shock
    22. 22. Subtype of Hypovolemic Shock
    23. 23. Increase pressure of the jugular vein distended jugular vein
    24. 24. Neurogenic Shock
    25. 25. Injury of the spine
    26. 26. Loss of cardiac nerve fibers from the sympathetic nerve fibers at T1-T4 resulting in profound bradycardia
    27. 27. Diaphoretic Skin
    28. 28. Anaphylactic Shock
    29. 29. Angioedema like reaction
    30. 30. Large Eruptions or bumpy skin
    31. 31. Edema, Massive Swelling
    32. 32. Constricted Airways; Swollen throat; Breathlessness and cough
    33. 33. Weak or rapid pulse</li></li></ul><li>What is Septic Shock?<br /><ul><li>Massive Systemic infection associated with arterial hypotension that is refractory to fluid resuscitation
    34. 34. It is a systemic inflammatory Response syndrome
    35. 35. Criteria must include the following (2 out of 4)
    36. 36. WBC >12K or <4K or >10% bands
    37. 37. Temperature > 38C or < 36C
    38. 38. Heart rate > 90bpm
    39. 39. Respiratory Rate > 22 breaths/min
    40. 40. PaCO2 < 32mmHg
    41. 41. Systemic Infection- Any etiology
    42. 42. Bacterial- Presence of Bacteria in the bloodstream
    43. 43. Fungemia- Presence of Fungus in the Bloodstream</li></li></ul><li>Epidemiology<br />Defined by site of infection<br />Respiratory Tract (21%-68%)<br />Intraabdominal Space (14%-22%)<br />Urinary Tract (14%-18%)<br />Pathogens<br />Gram-Positive bacteria (40% of patients)<br />Gram-Negative bacteria (38% of patients)<br />Fungi (17%)<br />
    44. 44. Pathogens<br />Gram-Positive Bacterial Sepsis<br />Gram-Negative Bacterial Sepsis<br />Most predominant in Septic Shock<br />Staph. Aureus <br />Strep. Pneumoniae <br />Coagulase-Negative Staphylococci<br />Enterococcus <br />Strep. Pneumoniae- Mortality rate of more than 25%<br />Staph. Epidermidis- related to infected intravascular device<br />Severity depends on underlying comorbidites<br />Fatal Prognosis<br />Acute Leukemia<br />Aplastic Anemia<br />Burn Injury- >70& BSA<br />Non-fatal prognosis<br />Diabetes Mellitus<br />Chronic Renal Insufficiencies<br />Most predominant<br />Escherichia coli<br />Pseudomonas aeruginosis<br />
    45. 45. Pathogens Cont…<br />Anaerobes and miscellaneous bacterial Sepsis <br />Fungal Sepsis<br />Low risk organism but can occur<br />Usually seen with other common pathogens in sepsis<br />Meningococci, gonococci, rickettsiae, chlamydiae, spirochetes<br /><ul><li>Rate of the infection doubled since the 2000
    46. 46. Most Common pathogens
    47. 47. Candida Albicans ( Most Dominant)
    48. 48. Candida Glabrata
    49. 49. Candida Tarapsilosis
    50. 50. Candida Tropicalis
    51. 51. Candida Krusei
    52. 52. Risk factors of fungal-sepsis
    53. 53. Abdominal Surgery
    54. 54. Poorly controlled Diabetes Mellitus
    55. 55. Broad-spectrum Antimicrobials
    56. 56. Corticosteroids
    57. 57. Foley
    58. 58. Central Venous Catheter</li></li></ul><li>Pathophysiology<br />
    59. 59. Clinical Presentation<br />
    60. 60. Prognosis<br /><ul><li>Increase mortality rate in a step-wise approach
    61. 61. SIRSSepsisSevere Sepsis Septic Shock
    62. 62. Higher mortality rates with co-morbidities
    63. 63. Advanced age
    64. 64. COPD
    65. 65. HIV
    66. 66. Pseudomonas Infection
    67. 67. Failing Organs
    68. 68. Ex. From 2 to 4 organs Increase mortality from 54% to 100%.
    69. 69. Elevated serum Lactate->4 mmol/L- Increase mortality as high as 89%</li></li></ul><li>Goals of therapy<br />Identify the source of infection.<br />Control the source of infection<br />Eradicate the infection<br />Provide adequate hemodynamic support and tissue perfusion<br />Prevent continued organ failure, complications, and/or mortality<br />Provide supportive care during the length of stay in the ICU<br />
    70. 70. Therapeutic Alternatives<br />Interventions/therapies-Must be accomplished within the first 6 hours<br />Cultures<br />Antibiotics within 1 hour<br />Measure a serum lactate<br />Achieve a CVP = 8-12 mmHg<br />MAP > 65 mmHg<br />Maintain urine output ≥0.5 mL/kg/hr<br />Achieve a ScvO2 ≥70%<br />
    71. 71. Diagnosis and Identification of Pathogens<br /><ul><li>Determine the source of the infection
    72. 72. Systemic Complication
    73. 73. Recent Travel history
    74. 74. Animal Exposure
    75. 75. Use of antimicrobials
    76. 76. Two sets of Blood samples
    77. 77. Peripheral Vein- Culture in an aerobic and an-aerobic environment
    78. 78. Cather-related suspecting
    79. 79. Two sets of blood culture
    80. 80. Catheter Hub
    81. 81. Peripheral Vein
    82. 82. Abdominal infections- Fluid Collections by imaging studies
    83. 83. Lumbar Puncture- in cases of mental alteration, severe headache, or a seizure</li></li></ul><li>Hemodynamic Monitoring<br /><ul><li>Mean Arterial Pressure(MAP)- Systemic Vascular Resistance x Cardiac Output
    84. 84. MAP greater than 50mmHG-Goal
    85. 85. MAP less than 50 decrease coronary and cerebral blood flow
    86. 86. Monitor Continuously- Arterial Catheter in the Radial Artery
    87. 87. Central Venous Catheter
    88. 88. Placed in 3 veins-Triple Lumen
    89. 89. Internal Jugular Vein-Neck
    90. 90. Subclavian Vein- Chest
    91. 91. Femoral Vein- Groin
    92. 92. Measures the central venous oxygen saturation- ScvO2, Central Venous Pressure (CVP)
    93. 93. Goal CVP = 8-12 mmHg during fluid resuscitation
    94. 94. Goal CVP = 12-15mmHg-in presence of mechanical ventilation</li></li></ul><li>Hemodynamic Monitoring cont…<br /><ul><li>Central Venous Catheters
    95. 95. Depends on CO, Oxygen demand, SaO2 and Hemoglobin
    96. 96. Goal SaO2 = >70% in shock
    97. 97. Lower Value Inadequate O2 oxygen delivery to tissue and high extraction by tissue
    98. 98. Lactate
    99. 99. Metabolic product of Pyruvate increase production in anaerobic conditions
    100. 100. Goal= 0.5 – 2.2 mmol/L
    101. 101. Better correlation with outcomes</li></li></ul><li>Treatment Recommendations<br />
    102. 102. Antimicrobial Therapy <br /><ul><li> Empiric parenteral aggressive antimicrobial therapy is a MUST
    103. 103. Selection of the antimicrobial depends on
    104. 104. Suspected site of infection
    105. 105. The most likely pathogens
    106. 106. Community acquired or Hospital Acquired
    107. 107. Immune status of the patient
    108. 108. Institution susceptibility profile of the ABX
    109. 109. Re-asses the regimen 48-72 hours laterSwitch to narrow spectrum based on culture and susceptibility
    110. 110. Cases of Pseudomonas, Neutropenia, severe sepsis - Combination therapy is imminent</li></li></ul><li>Empiric Antimicrobial Therapy <br />
    111. 111. Empiric Antimicrobial Therapy <br />
    112. 112. Antifungal Therapy<br /><ul><li>Choice of therapy depends upon
    113. 113. Fungal Species
    114. 114. Presence of Liver and Kidney dysfunction-Elimination
    115. 115. Prior Exposure to anti-fungal agents
    116. 116. Treatment of Choice-
    117. 117. Amphotericin B based preparations
    118. 118. Fluconazole, Itraconazole
    119. 119. Fluconazole plus Amphotericin B
    120. 120. Voriconazole- Fluconazole resistant isolates
    121. 121. Caspofungin- Potent against all Candida Species
    122. 122. Initial Empiric Therapy-
    123. 123. parenteral amphotericin B or caspofungin
    124. 124. Better activity against Resistant fungal speicies, non-albicans; neutropenic and critically-ill patients</li></li></ul><li>Duration of Therapy<br />Variable- Site of infection<br />Neutropenic- continue therapy until afebrile for 72 hours and no longer neutropenic<br />Normal host with sepsis- 7 to 10 days<br />Host with Fungal infection- 10 to 14 days<br />Step-Down from parenteral to oral therapy<br />Hemodynamically Stable<br />Afebrile for 48 to 72 hours<br />Normal WBC count<br />Able to take PO medications<br />
    125. 125. Fluids<br />Significant Fluid Requirements due to<br />Peripheral Vasodilation<br />Capillary Leakage<br />Mechanism of action<br />Increasing left ventricular preload  maximize cardiac output restore tissue perfusion decrease in serum lactate level<br />Titrate over time based on mental status,HR, BP, UOP<br />Choice of Agents Crystalloids vs. Colloids<br />
    126. 126. Fluids cont…<br />Intravenous Fluids<br />Dextrose- Not a crystalloid, used for uncomplicated dehydration caused by water deficit<br />Crystalloids<br />Freely cross the semi-permeable membrane and form crystals<br />Colloids<br />Increased molecular weight= Increased retention time<br />Cannot pass through the semi-permeable membrane<br />Eventually will leak through the membrane (e.g. 60% of albumin shifts to interstitium by day 3-5)<br />
    127. 127. Crystalloids vs. Colloids<br />
    128. 128. Crystalloids vs. Colloids Cont…<br />
    129. 129. Inotropes<br />Improves Cardiac Output<br />Must be on board if failed therapy with fluids<br />Increase risk of atrial, ventricular arrhythmias<br />Increases demand of Myocardial O2 in pt.s with CAD-Caution.<br />Dobutamine<br />Milrinone, Nesiritide- Not used in Septic Shock<br />
    130. 130. Inotropes cont…<br />Dobutamine<br />b-adrenergic inotropic agent<br />b1 > b2 ≥ a1<br />Vasodilatation due to stimulation of the Beta receptor<br />Can be an add on to nor-epinephrine in sepsis<br />2.5-5 mcg/kg/min<br />
    131. 131. Vasopressors<br />Must be on board if failed therapy with fluids<br />Considered when Systolic BP < 90mmHg, MAP <60-65mmHg <br />Titrate slowly to achieve MAP w/o impairing SV<br />Norepinephrine, Dopamine, Epinephrine, Phenylephrine <br />
    132. 132. Vasopressors cont…<br />Norepinephrine(Levophed)<br />First line agent for septic shock<br />Stimulates a1,2 > b1<br />Increases MAP by vasoconstriction on peripheral vascular beds<br />
    133. 133. Vasopressors cont…<br />Dopamine<br />Activity against D1,2,a1 and b2 activity-Dose related<br />1-3 mcg/kg/min-D1,2<br />For treatment or prevention of AKI<br />3-10 mcg/kg/min- D1, b1<br />>10-20 mcg/kg/min- a1, b1<br />Vasoconstriction AND increase MAP<br />May depress ventilation, worsen hypoxemia, inhibit GH secretion and T-Cell proliferation<br />
    134. 134. Vasopressors cont…<br /><ul><li>Epinephrine (Adrenaline)
    135. 135. nonspecific a and b-adrenergic agonist
    136. 136. significant peripheral vasoconstriction- Last line therapy for refractory shock
    137. 137. 1-10 mcg/min
    138. 138. Phenylephrine (Neosynephrine)
    139. 139. selective a1-agonist
    140. 140. Rapid onset, short duration, and primary vascular effects, and it is least likely to produce tachycardia
    141. 141. Limitted use- preferred in tachyarrhythmia </li></li></ul><li>Tight Glucose Control<br />Intensive Insulin Therapy<br />Hyperglycemia causes phagocyte dysfunction, worsens ischemia, increases platelet activation, increases production of pro-inflammatory cytokines (Il-6, TNF-a)<br />Target Goal- <140-180mg/dL (NICE SUGAR study)<br />Desired Goal- < 150 mg/dL<br />Regular Insulin 100 units in 100ml NS, start at 3 units/hr, check FSBS q1hr<br />
    142. 142. Corticosteroids<br />Indications<br />Diagnosis of Critical Illness related corticosterioid insufficiency <br />Random Cortisol < 10mcg/dL<br />D Total serum Cortisol <9mcg/dL<br />Refractory Septic Shock<br />SBP <90mmHg for >1 hour despite fluid resuscitation, inotropes, vasopressors<br />Hydrocortisone 200-300 mg/day IV divided q6-q8h ± fludrocortisones 50mcg PO daily x 7 days<br />
    143. 143. Drotrecogin<br /><ul><li>Recombinant Human Activated Protein C (rhAPC)
    144. 144. Inhibits Coagulation, reduces inflammation
    145. 145. Clinical Trial- Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS)
    146. 146. Reduced Mortality by 24.7% in those who received rhAPC
    147. 147. Current recommendations
    148. 148. APACHE II score ≥25, sepsis-induced multiple organ failure, septic shock, or
    149. 149. Sepsis-induced ARDS and with no absolute contraindication related to bleeding risk
    150. 150. Recommend avoid rhAPC if APACHE II < 20 or one organ failure </li></li></ul><li>DVT Prophylaxis<br />Pharmacologic Approach<br />Unfractionated Heparin<br />Low Molecular Weight Heparin<br />Fondaparinux<br />Avoid if kidney function is impaired<br />Non-Pharmacologic Approach if high risk for bleeding<br />Graduated Compression Stockings (GCS)<br />Intermittent Pneumatic Compression (IPC)<br />
    151. 151. DVT Prophylaxis<br />Patient Considerations<br />UFH or LMWH preferred first-line<br />Consider LMWH for highest risk<br />E.g. Spinal Cord Injury, Trauma, Surgery<br />Consider GCS or IPCs if C/I to pharmacologic prophylaxis<br />Severe Risk- E.g.- Shock, Septic<br />UFH or LMWH + GCS or IPC<br />
    152. 152. Stress-Ulcer Prophylaxis<br /><ul><li>Pharmacologic Approach
    153. 153. Proton Pump Inhibitors (PPIs)
    154. 154. Greater acid-suppression (less evidence)
    155. 155. First line for patients with upper GI bleed
    156. 156. Histamine-2 receptor antagonists (H2RAs)
    157. 157. Most Evidence
    158. 158. Sucralfate-Sucrose octasulfate, Aluminum Hydroxide
    159. 159. Patient Considerations
    160. 160. Thrombocytopenia- Consider PPI
    161. 161. More gastric acid suppression may lead to Clostridium Difficile- associated diarrhea, pneumonia
    162. 162. PPIs are the most common cause of interstitial nephritis
    163. 163. Sucralfate may clog feeding tubes </li></li></ul><li>Management<br /><ul><li>Early goal directed therapy
    164. 164. Reach the following endpoints w/in 6 hours of onset
    165. 165. CVP=8-12mmHg, (or 12-15 if mechanically ventilated)
    166. 166. MAP ≥65mmHg, UOP ≥0.5mL/kg/hr
    167. 167. ScvO2 >70%
    168. 168. Fluid challenges with crystalloids 1000mL or colloids 300-500mL over 30 min
    169. 169. Target CVP= 8-12mmHg or (12-15 if mechanically ventilated)
    170. 170. Begin Broad-Spectrum ABX w/in 1 hour
    171. 171. Consider most likely pathogens and fungal infections based on suspected source of infection
    172. 172. Skin and Soft tissue
    173. 173. Intra-Abdominal
    174. 174. Respiratory
    175. 175. Urinary Tract</li></li></ul><li>Management cont…<br /><ul><li>Vasopressors to maintain MAP ≥ 65mmHg
    176. 176. Administer centrally
    177. 177. NE or DA are first line
    178. 178. NE-1st line
    179. 179. Phenylephrine, Epinephrine, Vasopressin- Last line
    180. 180. Use epinephrine if blood pressure unresponsive to first line
    181. 181. Do not use low dose DA for renal protection
    182. 182. If ScvO2 target not reached with fluids, transfuse packed RBCs to hematocrit ≥ 30% and/or dobutamine infusion
    183. 183. Corticosteroids
    184. 184. Refractory Septic Shock
    185. 185. SBP <90mmHg for >1 hour despite fluid resuscitation, vasopressors</li></li></ul><li>Management Cont…<br />rhAPC <br />Use if APACHE II ≥ 25 or multiple sepsis-induced organ failure if no C/I<br />Avoid if APACHE II <20 or one organ failure<br />Analgesia, sedation protocols titrated to predetermined endpoints<br />DVT prophylaxis with UFH and LMWH<br />Head of the bed elevation >30-45 degree angle<br />SUP with PPI or H2RA<br />Glycemic control with intensive insulin therapy<br />
    186. 186. Conclusion<br /><ul><li>Septic Shock- Systemic Infection of any etiology
    187. 187. It is a goal directed therapy
    188. 188. Must Achieve the following parameters within the first 6 hours
    189. 189. Measured Serum Lactate
    190. 190. CVP= 8-12mmHg
    191. 191. MAP > 65mmHg
    192. 192. urine output ≥0.5 mL/kg/hr
    193. 193. ScvO2 ≥70%
    194. 194. Provide Supportive therapy
    195. 195. Treat the systemic infection
    196. 196. Monitor closely for efficacy and toxicity</li></li></ul><li>Case Presentation<br />IMA is a 59 Y/O female, who recently had a left urethral stent placed in her left ureter two weeks ago, came to the <br />emergency room complaining of left-sided flank pain for 1-2 days. Patient was noted to have vomiting for one<br />day, with symptoms of headache, and anxiety. Patient had no hx. of URI, possible kidney stone is suspected. <br />Patient was admitted to the ICU with septic shock secondary to left pyelonephritis, hypoxia and HOTN. Her BP<br />did not respond to the fluids given in the ER. Patient is currently intubated and is monitored on the ventilator.<br />Past Medical/Surgical history: Patient had a left urethral stent placed a few weeks<br /> <br />Family Hx: Patient has a family history of DM and CAD.<br />Allg: NKA<br />Meds on admission:IV Norepinephrine 2MG/250mL;Normal Saline 1000 ML; Lovenox 40MG SQ QD; Primaxin 500MG IVPB Q6H, Flagyl 1500 mg IVPB q6H STAT, Merrem 500mg IVPB Q8H, Regular Insulin Sliding Scale, Sodium Bicarb 7.5% 44.6MEQ, Gentamicin 100 MG IVPB one/time STAT, Protonix IVPB 40 mg PO q6h; Tylenol with Codeine #3 -1T PO Q4H PRN <br />PE: Temp 102.6, Pulse 114, RR 18, BP 79/50,<br />Laboratory Findings: WBC 20.6, Hg 8.5, Na 131, K 2.6, Cl 2.6, CO2 24, BUN 17, Scr 1.5, Glucose 217, Ca 6.5, <br />Lactate 5.2, AST/ALT 61/91, MAP 59.67, PH 7.19, HCO3 17<br />Urinalysis: Protein 150, Blood Urine- Large, Leak Ester- Moderate, Nitrites (+), WBC 10-25, Bacteria-many<br />Microbiology Blood Culture: Gram (-) Rods in aerobic Bottle. <br />Urine Culture: Greater than 100,000 CFU/ML Pseudomonas Less than 10,000 CFU/ML of other organism<br />Diagnosis: Septic Shock and Pyelonephritis secondary to Stent placement<br />
    197. 197. Problem List<br /><ul><li>Septic Shock
    198. 198. Objective
    199. 199. Heart Rate >90bmp
    200. 200. RR >22bpm
    201. 201. WBC >12,000
    202. 202. Severe HOTN
    203. 203. Elevated Lactate
    204. 204. Gram (-) rods on blood culture
    205. 205. Pyelonephritis
    206. 206. Subjective
    207. 207. Flank abdominal pain
    208. 208. Vomiting/headache/anxiety
    209. 209. Objective
    210. 210. Urinary Stent
    211. 211. Moderate Esterase
    212. 212. Pyuria
    213. 213. WBC 10-50K
    214. 214. Urine Culture: Pseudomonas and other organism
    215. 215. Metabolic Acidosis
    216. 216. Objective
    217. 217. pH less than 7.35
    218. 218. HCO3 less than 22 mEq/L</li></li></ul><li>Medication Critique <br /><ul><li>Pyelonephritis
    219. 219. Gentamicin- Good Choice
    220. 220. Primaxin and Merrem- Not the DOC; therapy duplication
    221. 221. Metabolic Acidosis
    222. 222. Sodium Bicarbonate 7.5%- Good Choice
    223. 223. Septic Shock
    224. 224. The patient is receiving the appropriate fluid therapy
    225. 225. Antibiotics
    226. 226. Gentamicin- Good Choice
    227. 227. Primaxin and Merrem- Therapy Duplication
    228. 228. Flagyl- No indication
    229. 229. Vasopressors
    230. 230. Norepinephrine-DOC
    231. 231. Supportive Care
    232. 232. Glucose Control
    233. 233. Regular Insulin- Good Choice
    234. 234. Stress Ulcer Prophylaxis
    235. 235. Protonix- Good Choice</li></li></ul><li>Recommendations<br /><ul><li>Septic Shock
    236. 236. Continue IV Normal Saline
    237. 237. Antibiotics
    238. 238. Tobramycin IV 500mg Q36H
    239. 239. Pseudomonal Coverage
    240. 240. Maximizes concentration-dependent killing activity
    241. 241. Ceftazadime 1 gram IV q12h
    242. 242. Excellent Gram (-) infection plus Pseudomonal Coverage
    243. 243. Vasopressors
    244. 244. Norepinephrine 1-4mcg/kg/min IV
    245. 245. Increase by 1-4 mcg/kg/min titration to the desired effect
    246. 246. Supportive Care
    247. 247. Head of the bed elevation 30-45 degree angle
    248. 248. Analgesia
    249. 249. Fentanyl 200 mcg/hr IV
    250. 250. Glucose Control
    251. 251. Regular Insulin- Good Choice
    252. 252. Stress Ulcer Prophylaxis
    253. 253. Protonix 40 mg IVPB q6h- Good Choice
    254. 254. Agitation
    255. 255. Precedex- 0.4mcg/kg/hr via IV
    256. 256. DVT Prophylaxis
    257. 257. Lovenox 40 mg SQ QD plus Compression Stockings
    258. 258. High Risk Patient</li></li></ul><li>Recommendations<br />Pyelonephritis<br />Antibiotics<br />Tobramycin IV 500mg Q36H<br />Pseudomonal Coverage <br />Maximizes concentration-dependent killing activity<br />Ceftazadime 1 gram IV q12h<br />Excellent Gram (-) infection plus Pseudomonal Coverage<br />Metabolic Acidosis<br />Sodium Bicarbonate 7.5%- Good Choice<br />
    259. 259. Monitoring Parameters<br />Efficacy<br />Serum Lactate- Goal less than 2.2mmol/L<br />Central Venous Pressure-8-12 mmHg<br />Mean Arterial Pressure- >65 mmHg<br />Maintain urine output ≥0.5 mL/kg/hr<br />a ScvO2 ≥70%<br />Tobramycin<br />Trough at 6-14 hours after the first dose<br />CBC, WBC, LFT’s, symptoms of bleeding- everyday<br />Urinalysis and Blood Culture<br />
    260. 260. Monitoring Parameters<br /><ul><li>Toxicity
    261. 261. Aminoglycoside
    262. 262. Nephrotoxicty
    263. 263. Ototoxicity
    264. 264. Neuromuscular Blockade
    265. 265. HOTN
    266. 266. Ceftazadime
    267. 267. Anaphylaxis Reaction
    268. 268. Norepinephrine
    269. 269. Chest Pain
    270. 270. Palpitations
    271. 271. Extravasations
    272. 272. Toxicity
    273. 273. Fentanyl
    274. 274. Respiratory Depression
    275. 275. Precedex
    276. 276. Hypotension
    277. 277. Bradycardia
    278. 278. Regular Insulin
    279. 279. Hypoglycemia
    280. 280. Lovenox
    281. 281. Bleeding
    282. 282. Decrease Hemoglobin level
    283. 283. Protonix
    284. 284. Diarrhea
    285. 285. Melena</li></li></ul><li>Thank You!<br />
    286. 286. References<br />Clinical Pharmacology-Gold Standard ( database online)2010.<br />MICROMEDEX® Healthcare Series: Micromedex, Greenwood Village, Colorado<br />DiPiro JT, Talbert RL, Hayes PE, Yee GC, Matzke GR, Posey Lm. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, N.Y.: Appleton & Lange Inc.2008. Chapter 123-Sepsis and Septic Shock<br />

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