- This document summarizes guidelines from the Surviving Sepsis Campaign for the management of severe sepsis and septic shock.
- The guidelines recommend beginning resuscitation immediately for patients with hypotension or elevated lactate, obtaining cultures before antibiotics, administering broad-spectrum antibiotics within 1 hour, and controlling blood glucose with insulin.
- For patients requiring vasopressors, the guidelines suggest considering vasopressin, dobutamine, or hydrocortisone therapy and treating with recombinant human activated protein C for certain high-risk patients.
This document summarizes guidelines from the 4th Edition of the American Society of Regional Anesthesia and Pain Medicine on the anesthetic management of patients receiving various antithrombotic therapies. It outlines recommendations regarding neuraxial blocks and catheter management for patients taking medications such as thrombolytics, unfractionated heparin, low molecular weight heparin, and newer oral anticoagulants. The guidelines provide evidence-based recommendations on timing of blocks and catheter removal in relation to medication dosing and coagulation status monitoring. They emphasize the importance of interdisciplinary communication and individualized clinical decision making to minimize risks while providing optimal pain management.
This document provides guidelines for managing severe local anesthetic toxicity:
1. Signs of toxicity include sudden changes in mental status, seizures, and cardiovascular collapse. Immediate steps are to secure the airway, provide oxygen, treat seizures, and assess the cardiovascular system.
2. For circulatory arrest, start CPR and treat arrhythmias. Consider lipid emulsion and continue CPR during treatment. For stable patients, consider lipid emulsion and treat hypotension, bradycardia, or tachyarrhythmias.
3. Follow up includes monitoring for pancreatitis, reporting cases, and safe transfer until recovery is achieved.
Anticoagulants, antiplatelet drugs and anesthesiaRajesh Munigial
It is a presentation on anticoagulants and antiplatelets in anesthesia , starting from basis of coagulation , its tests and dugs and anesthetic implications
Based on latest ASRA (AMERICAN SOCIETY OF REGIONAL ANESTHESIA GUIDELINES)
The document discusses the risks and management of neuraxial anesthesia in patients receiving anticoagulant or antiplatelet medications. It states that while neuraxial techniques can reduce thromboembolic risks, anticoagulants are still often needed and precautions must be taken with neuraxial blocks. The timing of medication discontinuation, monitoring of coagulation parameters, and catheter management varies depending on the specific agent and dosing regimen. Neurological monitoring is important when combining these techniques due to the rare but serious risk of spinal hematoma.
This document discusses anticoagulation and neuraxial anesthesia/analgesia. It provides an overview of case reports of epidural hematomas occurring with the anticoagulant Lovenox. It then reviews indications for antithrombotic therapy and recommended prophylaxis for DVT/VTE. The properties and monitoring of various anticoagulants including heparin, warfarin, low molecular weight heparin, and antiplatelet medications are discussed. Guidelines for the use of neuraxial techniques in patients on different anticoagulation regimens are provided.
The document provides guidelines from the American Society of Regional Anesthesia (ASRA) on placing and removing epidural catheters in patients taking anticoagulant and antiplatelet drugs. It lists recommended minimum times to wait after the last dose of various medications before catheter placement and removal, as well as when to restart anticoagulation therapy after removal. The medications are grouped into heparins, low molecular weight heparins, factor Xa and direct thrombin inhibitors, antiplatelet agents, fibrinolytics, and glycoprotein IIb/IIIa inhibitors. For each group, it provides the drug names and recommended waiting times.
This document discusses regional anesthesia and antithrombotic drugs. It notes that vertebral canal hematoma is a rare but potentially devastating complication of central neuraxial blockade, especially for patients taking anticoagulant or antithrombotic drugs. It provides guidance on timing the administration of various antithrombotic drugs like aspirin, clopidogrel, enoxaparin and warfarin in relation to regional anesthesia to minimize bleeding risks. It also discusses risk factors and considerations for different types of regional techniques and antithrombotic drugs.
- Spinal hematoma is a rare but serious complication of central neuraxial blockade like spinal anesthesia and epidural anesthesia. It can cause neurological deficits if not treated urgently.
- Common risk factors include patient factors like coagulopathies, procedure factors like difficult blocks, and drug factors like anticoagulants and antiplatelets. Low molecular weight heparins are a common cause of drug-related spinal hematomas.
- Guidelines recommend minimum time intervals between neuraxial procedures or catheter manipulations and anticoagulant/antiplatelet doses to reduce risk. These intervals are based on drug half-lives and time for clot stabilization. Strict adherence to guidelines is important for patient safety.
This document summarizes guidelines from the 4th Edition of the American Society of Regional Anesthesia and Pain Medicine on the anesthetic management of patients receiving various antithrombotic therapies. It outlines recommendations regarding neuraxial blocks and catheter management for patients taking medications such as thrombolytics, unfractionated heparin, low molecular weight heparin, and newer oral anticoagulants. The guidelines provide evidence-based recommendations on timing of blocks and catheter removal in relation to medication dosing and coagulation status monitoring. They emphasize the importance of interdisciplinary communication and individualized clinical decision making to minimize risks while providing optimal pain management.
This document provides guidelines for managing severe local anesthetic toxicity:
1. Signs of toxicity include sudden changes in mental status, seizures, and cardiovascular collapse. Immediate steps are to secure the airway, provide oxygen, treat seizures, and assess the cardiovascular system.
2. For circulatory arrest, start CPR and treat arrhythmias. Consider lipid emulsion and continue CPR during treatment. For stable patients, consider lipid emulsion and treat hypotension, bradycardia, or tachyarrhythmias.
3. Follow up includes monitoring for pancreatitis, reporting cases, and safe transfer until recovery is achieved.
Anticoagulants, antiplatelet drugs and anesthesiaRajesh Munigial
It is a presentation on anticoagulants and antiplatelets in anesthesia , starting from basis of coagulation , its tests and dugs and anesthetic implications
Based on latest ASRA (AMERICAN SOCIETY OF REGIONAL ANESTHESIA GUIDELINES)
The document discusses the risks and management of neuraxial anesthesia in patients receiving anticoagulant or antiplatelet medications. It states that while neuraxial techniques can reduce thromboembolic risks, anticoagulants are still often needed and precautions must be taken with neuraxial blocks. The timing of medication discontinuation, monitoring of coagulation parameters, and catheter management varies depending on the specific agent and dosing regimen. Neurological monitoring is important when combining these techniques due to the rare but serious risk of spinal hematoma.
This document discusses anticoagulation and neuraxial anesthesia/analgesia. It provides an overview of case reports of epidural hematomas occurring with the anticoagulant Lovenox. It then reviews indications for antithrombotic therapy and recommended prophylaxis for DVT/VTE. The properties and monitoring of various anticoagulants including heparin, warfarin, low molecular weight heparin, and antiplatelet medications are discussed. Guidelines for the use of neuraxial techniques in patients on different anticoagulation regimens are provided.
The document provides guidelines from the American Society of Regional Anesthesia (ASRA) on placing and removing epidural catheters in patients taking anticoagulant and antiplatelet drugs. It lists recommended minimum times to wait after the last dose of various medications before catheter placement and removal, as well as when to restart anticoagulation therapy after removal. The medications are grouped into heparins, low molecular weight heparins, factor Xa and direct thrombin inhibitors, antiplatelet agents, fibrinolytics, and glycoprotein IIb/IIIa inhibitors. For each group, it provides the drug names and recommended waiting times.
This document discusses regional anesthesia and antithrombotic drugs. It notes that vertebral canal hematoma is a rare but potentially devastating complication of central neuraxial blockade, especially for patients taking anticoagulant or antithrombotic drugs. It provides guidance on timing the administration of various antithrombotic drugs like aspirin, clopidogrel, enoxaparin and warfarin in relation to regional anesthesia to minimize bleeding risks. It also discusses risk factors and considerations for different types of regional techniques and antithrombotic drugs.
- Spinal hematoma is a rare but serious complication of central neuraxial blockade like spinal anesthesia and epidural anesthesia. It can cause neurological deficits if not treated urgently.
- Common risk factors include patient factors like coagulopathies, procedure factors like difficult blocks, and drug factors like anticoagulants and antiplatelets. Low molecular weight heparins are a common cause of drug-related spinal hematomas.
- Guidelines recommend minimum time intervals between neuraxial procedures or catheter manipulations and anticoagulant/antiplatelet doses to reduce risk. These intervals are based on drug half-lives and time for clot stabilization. Strict adherence to guidelines is important for patient safety.
This document provides guidelines for holding and restarting various anticoagulant and antiplatelet medications before, during, and after procedures involving neuraxial catheters. It lists medications such as heparin, warfarin, low molecular weight heparins, direct thrombin inhibitors, and others along with recommended hold times and when to restart each medication. It also includes each medication's mechanism of action and half-life.
The document summarizes the 2010 recommendations of the European Society of Anesthesiology on neuraxial anesthesia and antithrombotic drugs. It provides time intervals that should elapse between taking different antithrombotic medications and performing neuraxial blocks or catheter removals based on the half-lives of the drugs. It also discusses preoperative versus postoperative thromboprophylaxis and considerations for various classes of antithrombotic agents including heparins, anti-Xa agents, direct thrombin inhibitors, vitamin K antagonists, and platelet aggregation inhibitors.
Anesthesia in patients on anti coagulantsNavin Jain
This document discusses anesthesia considerations for patients on various anticoagulant medications. It reviews the coagulation cascade and indications for anticoagulation therapy. Common anticoagulants are described including antiplatelet drugs, oral anticoagulants like warfarin, heparins, and newer agents. Guidelines are provided for managing patients on these medications in the perioperative period, including recommendations for stopping medications prior to procedures and resuming them postoperatively. Specific guidance is given for neuraxial anesthesia in anticoagulated patients.
This study compared ticagrelor pretreatment versus prasugrel at time of PCI in NSTE-ACS patients undergoing PCI. The primary outcome was rate of periprocedural myonecrosis within 24 hours of PCI. Results showed ticagrelor pretreatment significantly reduced myonecrosis compared to prasugrel at PCI (16.9% vs. 35.8%, p=0.003), due to faster onset of platelet inhibition. Secondary outcomes including MACE at 1 month were similar. This pilot study supports ticagrelor pretreatment to improve outcomes in intermediate-high risk NSTE-ACS undergoing PCI.
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis with profound circulatory and cellular abnormalities and increased mortality. The new definitions of sepsis and septic shock aim to improve early recognition and management. The one hour sepsis bundle outlines initial resuscitation goals including administering antibiotics and fluids, obtaining cultures, measuring lactate, and assessing for a source of infection within the first hour of recognition. Proper management of sepsis requires a multifaceted approach including source control, infection prevention strategies, organ support, and consideration of goals of care.
A crash cart or code cart contains medications, supplies, and equipment needed to respond to medical emergencies like cardiac arrest. It includes a defibrillator, ambu bags, oxygen, IV supplies and medications like epinephrine, atropine, lidocaine, sodium bicarbonate. The crash cart must be checked regularly, standardized, and placed in an easily accessible location. It is organized with equipment and medications grouped by function in drawers and sections for quick access during emergencies. Common arrhythmias include premature beats, supraventricular arrhythmias, ventricular arrhythmias, and bradyarrhythmias which can be harmless or potentially fatal depending on their type and underlying heart condition.
This document discusses guidelines for performing neuraxial blocks in patients who require anticoagulation or antiplatelet therapy. It provides an overview of various anticoagulant and antiplatelet medications, including their mechanisms of action, dosages, and monitoring parameters. For each medication, recommendations are given on appropriate timing of neuraxial blocks or catheter removal in relation to the medication. The risks of spinal hematoma are also discussed. Overall, the document provides expert consensus guidelines on safely managing regional anesthesia for patients on various coagulation-altering medications.
Perioperative management of antithrombotic therapyZaito Hjimae
This document discusses the perioperative management of antithrombotic therapy. The goals are to prevent thromboembolic events like strokes while reducing the risk of major hemorrhage during surgery. It assesses thrombotic risk based on the type of anticoagulation and bleeding risk scores. It provides guidance on bridging anticoagulation during surgery and reversing anticoagulants. It also discusses perioperative management of antiplatelet drugs like aspirin and clopidogrel based on surgery type and risk of cardiovascular events.
This document provides information on the indications, dosing, contraindications, drug interactions, and monitoring of rivaroxaban. It summarizes:
1. Rivaroxaban is indicated for non-valvular AF, DVT/PE, thromboprophylaxis, and superficial vein thrombosis. Dosing depends on the indication.
2. Contraindications include GFR <15, active bleeding, high bleeding risk, chronic liver disease, pregnancy/lactation, and certain interacting drugs.
3. Drug interactions can increase or decrease rivaroxaban levels. Dose adjustments may be needed based on risk factors like age, weight, renal function, and concurrent medications.
Anaesthesia for patient with anticoagulantAnaestHSNZ
This document discusses guidelines for managing patients on anticoagulant therapy who require surgery. It is important to balance the risk of thromboembolic events from stopping anticoagulants against the risk of bleeding from continued anticoagulation. Factors like the urgency and type of surgery, the indication for anticoagulation and the patient's risk profile are considered. Bridging with low molecular weight heparin may be used when anticoagulants need to be stopped temporarily to reduce thromboembolic risk. Regional anesthesia can be used cautiously in anticoagulated patients when benefits outweigh bleeding risks.
This document discusses anesthesia for patients on anticoagulant therapy. It provides an overview of hemostasis and the coagulation cascade involving platelets and clotting factors. Key laboratory tests for assessing coagulation are described, including prothrombin time (PT), international normalized ratio (INR), partial thromboplastin time (PTT), thrombin time, and thromboelastography. Common anticoagulants like heparin and warfarin are explained in terms of their mechanisms and monitoring. Warfarin inhibits vitamin K dependent clotting factors and its effect is monitored by PT/INR, while heparin acts by binding to antithrombin.
This document discusses the management of peri-operative anticoagulation. It addresses balancing the risks of bleeding and thromboembolism when discontinuing or continuing anticoagulants for surgery or procedures. It provides guidance on interrupting and resuming different classes of anticoagulants like warfarin, NOACs, anti-platelets, and bridging with low molecular weight heparin. It also reviews patient and procedure risks factors for bleeding or thrombosis and considerations for urgent anticoagulant reversal in emergency surgeries.
Tenecteplase X Alteplase no Acidente Vascular Cerebral - AVCJeferson Espindola
This randomized controlled trial compared the thrombolytic drugs tenecteplase and alteplase for the treatment of acute ischemic stroke. The trial assigned 75 patients in a 1:1:1 ratio to receive either alteplase (the standard treatment), tenecteplase at a dose of 0.1 mg/kg, or tenecteplase at a higher dose of 0.25 mg/kg. Patients were selected based on having a large perfusion lesion on CT imaging and an associated vessel occlusion. The primary outcomes were the extent of reperfusion on MRI and clinical improvement at 24 hours. The results showed that the tenecteplase groups had significantly greater reperfusion and clinical improvement compared to al
The document summarizes 90 critical care clinical trials covering important topics in intensive care. It focuses on the randomization method, excluded populations, and conclusions of each trial. The summaries are brief and not meant to replace reading the full text, but to provide a quick overview of the currently available evidence in critical care medicine.
This document discusses recommendations for bridging anticoagulation therapy for patients on warfarin undergoing medical procedures. It provides guidance on stratifying patients into high, moderate, and low risk and makes recommendations for whether bridging therapy is needed for different types of procedures for each risk group. For example, it states that bridging is generally recommended for high risk patients undergoing procedures, but may not be needed for moderate risk patients. It also discusses specific procedures like dental work, pacemaker implantation, and cardioversion and provides bridging recommendations for different risk levels.
GP IIb/IIIa inhibitors are a class of drugs that work by blocking the GP IIb/IIIa receptor on platelets, which prevents platelet aggregation and thrombus formation. They are frequently used during percutaneous coronary interventions and for acute coronary syndromes to reduce risks of heart attack, death, and the need for repeat procedures. Common GP IIb/IIIa inhibitors include abciximab, tirofiban, and eptifibatide, which are administered intravenously and have potential side effects like bleeding.
This document summarizes the BRIDGE study published in NEJM in 2015, which compared bridging anticoagulation versus no bridging in atrial fibrillation patients undergoing elective surgery requiring interruption of warfarin therapy. The study found discontinuing warfarin without bridging anticoagulation was noninferior to bridging in preventing arterial thromboembolism and resulted in less major and minor bleeding compared to bridging. Bridging anticoagulation tripled the risk of major bleeding but did not reduce thromboembolic risks. The findings suggest perioperative thromboembolism risk in AF may be overstated and not mitigated by bridging, which increases bleeding risks.
This document discusses NOACs (new oral anticoagulants) such as dabigatran and factor Xa inhibitors in the emergency department setting. It outlines how to test for their effects via thrombin time, dabigatran levels, and anti-factor Xa activity. Reversal strategies are discussed, including general measures and the specific antidote idarucizumab for dabigatran. Case examples demonstrate challenges in patients presenting with bleeding or traumatic injuries while on NOACs.
Natriuretic peptides like BNP and NT-proBNP are important biomarkers for the diagnosis and management of congestive heart failure (CHF). BNP is released from cardiac ventricles in response to increased wall stress and levels correlate with left ventricular dysfunction. While both BNP and NT-proBNP can help diagnose CHF, NT-proBNP is more stable and its levels better predict mortality and rehospitalization risk in patients with CHF. The diagnostic accuracy of BNP and NT-proBNP can be affected by factors like renal function, obesity, and atrial fibrillation.
This document summarizes the ROCKET-AF clinical trial which compared the efficacy of rivaroxaban versus warfarin in preventing thromboembolic events in patients with non-valvular atrial fibrillation. The trial had a large multi-center international design with over 1,100 sites across 45 countries. It enrolled patients at moderate to high risk of stroke and had rigorous exclusion criteria to reduce risk of bleeding and confounding variables. The primary objective was to demonstrate rivaroxaban was non-inferior to warfarin in preventing strokes and other thromboembolic events.
This document summarizes a study examining the cellular uptake of siRNA nanoparticles for drug delivery in whole blood and lymphocytes. The study introduces fluorescently tagged RNA nanoparticles to both whole blood samples and isolated lymphocytes from human donors. Flow cytometry is used to measure fluorescence changes indicating the relative uptake of nanoparticles by blood cells. Preliminary results show a marked difference in nanoparticle uptake depending on whether the samples are diluted or undiluted, which may affect apoptosis and cell morphology of lymphocytes and their interaction with nanoparticles. Further experimentation will examine which nanoparticles and cells have the most efficient uptake, the best lipid-like carrier, and mechanisms of cellular entry.
This document provides guidelines for holding and restarting various anticoagulant and antiplatelet medications before, during, and after procedures involving neuraxial catheters. It lists medications such as heparin, warfarin, low molecular weight heparins, direct thrombin inhibitors, and others along with recommended hold times and when to restart each medication. It also includes each medication's mechanism of action and half-life.
The document summarizes the 2010 recommendations of the European Society of Anesthesiology on neuraxial anesthesia and antithrombotic drugs. It provides time intervals that should elapse between taking different antithrombotic medications and performing neuraxial blocks or catheter removals based on the half-lives of the drugs. It also discusses preoperative versus postoperative thromboprophylaxis and considerations for various classes of antithrombotic agents including heparins, anti-Xa agents, direct thrombin inhibitors, vitamin K antagonists, and platelet aggregation inhibitors.
Anesthesia in patients on anti coagulantsNavin Jain
This document discusses anesthesia considerations for patients on various anticoagulant medications. It reviews the coagulation cascade and indications for anticoagulation therapy. Common anticoagulants are described including antiplatelet drugs, oral anticoagulants like warfarin, heparins, and newer agents. Guidelines are provided for managing patients on these medications in the perioperative period, including recommendations for stopping medications prior to procedures and resuming them postoperatively. Specific guidance is given for neuraxial anesthesia in anticoagulated patients.
This study compared ticagrelor pretreatment versus prasugrel at time of PCI in NSTE-ACS patients undergoing PCI. The primary outcome was rate of periprocedural myonecrosis within 24 hours of PCI. Results showed ticagrelor pretreatment significantly reduced myonecrosis compared to prasugrel at PCI (16.9% vs. 35.8%, p=0.003), due to faster onset of platelet inhibition. Secondary outcomes including MACE at 1 month were similar. This pilot study supports ticagrelor pretreatment to improve outcomes in intermediate-high risk NSTE-ACS undergoing PCI.
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis with profound circulatory and cellular abnormalities and increased mortality. The new definitions of sepsis and septic shock aim to improve early recognition and management. The one hour sepsis bundle outlines initial resuscitation goals including administering antibiotics and fluids, obtaining cultures, measuring lactate, and assessing for a source of infection within the first hour of recognition. Proper management of sepsis requires a multifaceted approach including source control, infection prevention strategies, organ support, and consideration of goals of care.
A crash cart or code cart contains medications, supplies, and equipment needed to respond to medical emergencies like cardiac arrest. It includes a defibrillator, ambu bags, oxygen, IV supplies and medications like epinephrine, atropine, lidocaine, sodium bicarbonate. The crash cart must be checked regularly, standardized, and placed in an easily accessible location. It is organized with equipment and medications grouped by function in drawers and sections for quick access during emergencies. Common arrhythmias include premature beats, supraventricular arrhythmias, ventricular arrhythmias, and bradyarrhythmias which can be harmless or potentially fatal depending on their type and underlying heart condition.
This document discusses guidelines for performing neuraxial blocks in patients who require anticoagulation or antiplatelet therapy. It provides an overview of various anticoagulant and antiplatelet medications, including their mechanisms of action, dosages, and monitoring parameters. For each medication, recommendations are given on appropriate timing of neuraxial blocks or catheter removal in relation to the medication. The risks of spinal hematoma are also discussed. Overall, the document provides expert consensus guidelines on safely managing regional anesthesia for patients on various coagulation-altering medications.
Perioperative management of antithrombotic therapyZaito Hjimae
This document discusses the perioperative management of antithrombotic therapy. The goals are to prevent thromboembolic events like strokes while reducing the risk of major hemorrhage during surgery. It assesses thrombotic risk based on the type of anticoagulation and bleeding risk scores. It provides guidance on bridging anticoagulation during surgery and reversing anticoagulants. It also discusses perioperative management of antiplatelet drugs like aspirin and clopidogrel based on surgery type and risk of cardiovascular events.
This document provides information on the indications, dosing, contraindications, drug interactions, and monitoring of rivaroxaban. It summarizes:
1. Rivaroxaban is indicated for non-valvular AF, DVT/PE, thromboprophylaxis, and superficial vein thrombosis. Dosing depends on the indication.
2. Contraindications include GFR <15, active bleeding, high bleeding risk, chronic liver disease, pregnancy/lactation, and certain interacting drugs.
3. Drug interactions can increase or decrease rivaroxaban levels. Dose adjustments may be needed based on risk factors like age, weight, renal function, and concurrent medications.
Anaesthesia for patient with anticoagulantAnaestHSNZ
This document discusses guidelines for managing patients on anticoagulant therapy who require surgery. It is important to balance the risk of thromboembolic events from stopping anticoagulants against the risk of bleeding from continued anticoagulation. Factors like the urgency and type of surgery, the indication for anticoagulation and the patient's risk profile are considered. Bridging with low molecular weight heparin may be used when anticoagulants need to be stopped temporarily to reduce thromboembolic risk. Regional anesthesia can be used cautiously in anticoagulated patients when benefits outweigh bleeding risks.
This document discusses anesthesia for patients on anticoagulant therapy. It provides an overview of hemostasis and the coagulation cascade involving platelets and clotting factors. Key laboratory tests for assessing coagulation are described, including prothrombin time (PT), international normalized ratio (INR), partial thromboplastin time (PTT), thrombin time, and thromboelastography. Common anticoagulants like heparin and warfarin are explained in terms of their mechanisms and monitoring. Warfarin inhibits vitamin K dependent clotting factors and its effect is monitored by PT/INR, while heparin acts by binding to antithrombin.
This document discusses the management of peri-operative anticoagulation. It addresses balancing the risks of bleeding and thromboembolism when discontinuing or continuing anticoagulants for surgery or procedures. It provides guidance on interrupting and resuming different classes of anticoagulants like warfarin, NOACs, anti-platelets, and bridging with low molecular weight heparin. It also reviews patient and procedure risks factors for bleeding or thrombosis and considerations for urgent anticoagulant reversal in emergency surgeries.
Tenecteplase X Alteplase no Acidente Vascular Cerebral - AVCJeferson Espindola
This randomized controlled trial compared the thrombolytic drugs tenecteplase and alteplase for the treatment of acute ischemic stroke. The trial assigned 75 patients in a 1:1:1 ratio to receive either alteplase (the standard treatment), tenecteplase at a dose of 0.1 mg/kg, or tenecteplase at a higher dose of 0.25 mg/kg. Patients were selected based on having a large perfusion lesion on CT imaging and an associated vessel occlusion. The primary outcomes were the extent of reperfusion on MRI and clinical improvement at 24 hours. The results showed that the tenecteplase groups had significantly greater reperfusion and clinical improvement compared to al
The document summarizes 90 critical care clinical trials covering important topics in intensive care. It focuses on the randomization method, excluded populations, and conclusions of each trial. The summaries are brief and not meant to replace reading the full text, but to provide a quick overview of the currently available evidence in critical care medicine.
This document discusses recommendations for bridging anticoagulation therapy for patients on warfarin undergoing medical procedures. It provides guidance on stratifying patients into high, moderate, and low risk and makes recommendations for whether bridging therapy is needed for different types of procedures for each risk group. For example, it states that bridging is generally recommended for high risk patients undergoing procedures, but may not be needed for moderate risk patients. It also discusses specific procedures like dental work, pacemaker implantation, and cardioversion and provides bridging recommendations for different risk levels.
GP IIb/IIIa inhibitors are a class of drugs that work by blocking the GP IIb/IIIa receptor on platelets, which prevents platelet aggregation and thrombus formation. They are frequently used during percutaneous coronary interventions and for acute coronary syndromes to reduce risks of heart attack, death, and the need for repeat procedures. Common GP IIb/IIIa inhibitors include abciximab, tirofiban, and eptifibatide, which are administered intravenously and have potential side effects like bleeding.
This document summarizes the BRIDGE study published in NEJM in 2015, which compared bridging anticoagulation versus no bridging in atrial fibrillation patients undergoing elective surgery requiring interruption of warfarin therapy. The study found discontinuing warfarin without bridging anticoagulation was noninferior to bridging in preventing arterial thromboembolism and resulted in less major and minor bleeding compared to bridging. Bridging anticoagulation tripled the risk of major bleeding but did not reduce thromboembolic risks. The findings suggest perioperative thromboembolism risk in AF may be overstated and not mitigated by bridging, which increases bleeding risks.
This document discusses NOACs (new oral anticoagulants) such as dabigatran and factor Xa inhibitors in the emergency department setting. It outlines how to test for their effects via thrombin time, dabigatran levels, and anti-factor Xa activity. Reversal strategies are discussed, including general measures and the specific antidote idarucizumab for dabigatran. Case examples demonstrate challenges in patients presenting with bleeding or traumatic injuries while on NOACs.
Natriuretic peptides like BNP and NT-proBNP are important biomarkers for the diagnosis and management of congestive heart failure (CHF). BNP is released from cardiac ventricles in response to increased wall stress and levels correlate with left ventricular dysfunction. While both BNP and NT-proBNP can help diagnose CHF, NT-proBNP is more stable and its levels better predict mortality and rehospitalization risk in patients with CHF. The diagnostic accuracy of BNP and NT-proBNP can be affected by factors like renal function, obesity, and atrial fibrillation.
This document summarizes the ROCKET-AF clinical trial which compared the efficacy of rivaroxaban versus warfarin in preventing thromboembolic events in patients with non-valvular atrial fibrillation. The trial had a large multi-center international design with over 1,100 sites across 45 countries. It enrolled patients at moderate to high risk of stroke and had rigorous exclusion criteria to reduce risk of bleeding and confounding variables. The primary objective was to demonstrate rivaroxaban was non-inferior to warfarin in preventing strokes and other thromboembolic events.
This document summarizes a study examining the cellular uptake of siRNA nanoparticles for drug delivery in whole blood and lymphocytes. The study introduces fluorescently tagged RNA nanoparticles to both whole blood samples and isolated lymphocytes from human donors. Flow cytometry is used to measure fluorescence changes indicating the relative uptake of nanoparticles by blood cells. Preliminary results show a marked difference in nanoparticle uptake depending on whether the samples are diluted or undiluted, which may affect apoptosis and cell morphology of lymphocytes and their interaction with nanoparticles. Further experimentation will examine which nanoparticles and cells have the most efficient uptake, the best lipid-like carrier, and mechanisms of cellular entry.
This document advertises income tax services and provides links to profiles of two bullies named Gran Torino and Honey Bee Combe on the website Bully Pedia. It encourages checking out the profiles to learn more about these two bullies.
Group No.1 recommends that companies provide benefits rather than cash payments to employees to gain tax deductions and increase company liquidity, while also motivating employees through periodic benefits. Companies can amend employee basic salaries to implement a benefits program instead of cash payments.
Same day loans can help you prepare for unexpected expenses and emergencies. They provide a short term loan option of between £100-£1500 that can be approved within 24 hours and deposited directly into your bank account. You may qualify for a same day loan even if you have a bad credit history, as long as you are a UK citizen, have a bank account, have been employed for at least 6 months, and are over 18 years old. The loan must be repaid by your next monthly paycheck, with no fees or collateral required.
El documento presenta información sobre Fernanda Valarezo, una estudiante de arquitectura en su primer ciclo. Describe las ventajas de las herramientas colaborativas de la Web 2.0, incluyendo la capacidad de crear y mejorar páginas de forma instantánea, generar conocimiento colectivo y promover el pensamiento crítico. También destaca las ventajas de acceder a archivos y programas desde cualquier computadora conectada a Internet y comunicarse de forma organizada y rápida a través del mundo digital.
O documento é uma partitura de um samba intitulado "Mar do Maranhão", composto por Edmilson Capelupi e arranjado por Toninho Nascimento. A partitura contém a letra, a melodia, as harmonias e as indicações rítmicas da canção em português. Foi concluída em outubro de 1999.
La matemática puede ser vista desde diferentes perspectivas como una ciencia, un arte, un pasatiempo o un problema, y a veces puede generar conflictos.
Entre Trocadéro et Tour Eiffel, admirez le pont d'Iéna, avec ses quatre cavalier et ses aigles impériaux. En savoir plus : http://www.histoires-de-paris.fr/pont-iena/
Este documento presenta una guía de atención temprana para padres y educadores sobre el desarrollo de niños de 0 a 3 años. La guía incluye indicadores de desarrollo por edades, así como pautas educativas para estimular el desarrollo psicomotor, cognitivo, del lenguaje, personal y social de los niños. También contiene consejos sobre higiene, alimentación y temas generales relacionados con el cuidado infantil temprano.
Este documento presenta una rutina de calentamiento y ejercicios para los músculos. La rutina consta de dos partes: 1) ejercicios de carrera como correr en línea recta, levantar las rodillas lateralmente, y correr en círculos, y 2) ejercicios de fuerza, pliometría y equilibrio como apoyarse en los antebrazos de forma estática y dinámica, levantar y bajar la cadera lateralmente, e inclinarse hacia adelante para trabajar los isquiotibiales. La
This document provides guidelines for the management of severe sepsis and septic shock according to the Surviving Sepsis Campaign. It outlines diagnostic criteria for sepsis, septic shock, and organ dysfunction. It also details bundles of care that should be completed within 3 and 6 hours of diagnosis, including measuring lactate levels, administering antibiotics and fluids, and applying vasopressors if needed. The guidelines provide recommendations on initial resuscitation, antibiotic therapy, source control, infection prevention, fluid therapy, vasopressors, corticosteroids, mechanical ventilation, and other supportive care measures for managing sepsis.
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.The definition of sepsis was updated in 2016 following publication of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This recommended that organ dysfunction should be defined using the Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria or the "quick" (q)SOFA criteria.
This document provides an overview of sepsis and septic shock. It defines the clinical syndromes related to sepsis including systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock. It outlines the goals of treating septic shock which include initial fluid resuscitation, stabilizing hemodynamics with pressors, administering antibiotics, and interrupting inflammatory mediators. It discusses early goal directed therapy for septic shock patients, which aims to achieve specific goals regarding central venous pressure, mean arterial pressure, and central venous oxygen saturation within the first 6 hours in order to decrease mortality.
1. The document outlines new definitions and guidelines for diagnosing and managing sepsis and septic shock according to the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.
2. Key changes include removing SIRS criteria and defining sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock requires vasopressors to maintain blood pressure and elevated lactate levels.
3. Management guidelines cover initial patient assessment, diagnostic testing, antimicrobial therapy, fluid resuscitation, vasopressors, corticosteroids, mechanical ventilation, glucose control, nutrition, and thromboembolism prophylaxis
1. Sepsis is a major cause of morbidity and mortality worldwide, with mortality rates ranging from 15-60% depending on the severity. The guidelines provide recommendations for the management of sepsis, severe sepsis, and septic shock.
2. The initial focus is on early recognition and treatment within the first hour including antibiotics, fluid resuscitation, lactate monitoring, and source control. Vasopressors, inotropes, steroids and other supportive care measures are also addressed.
3. Goals are to diagnose and treat the infection while restoring tissue perfusion and organ function through a coordinated response and supportive therapies.
Approach to Management of Fever & Sepsis (2) copy.pptxHarryArwin1
1) Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. It can be identified at the bedside using qSOFA, which is positive if a patient has at least two of respiratory rate above 22, altered mentation, or systolic blood pressure of 100 or less.
2) Initial management of sepsis involves administering antibiotics within 1 hour, giving IV fluids aggressively, and completing other resuscitation bundles like the Sepsis Six within 3 hours to support vital organ function.
3) Beyond initial resuscitation, source control, additional organ support, and adjustment of care based on clinical response are important for managing sepsis.
The document discusses sepsis treatment bundles which include early goal directed therapy, corticosteroids, antibiotics, ARDSnet ventilator management, stress ulcer prophylaxis, deep vein thrombosis prophylaxis, and Drotrecogin alpha. It provides details on the components, goals, and guidelines for each bundle element aimed at improving outcomes for patients with sepsis.
The document summarizes guidelines for managing severe sepsis and septic shock according to bundles of care elements that should be completed within specific timeframes. The bundles include a sepsis resuscitation bundle with elements that should be completed within 6 hours, and a sepsis management bundle with elements that should be completed within 24 hours. Both bundles are aimed at reducing mortality from sepsis through early intervention and treatment.
The document defines different types of acute coronary syndrome (ACS), including unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). It provides guidelines for the initial management and treatment of ACS, including medications, revascularization procedures, and timelines for invasive strategies depending on patient risk factors. The treatment guidelines are from organizations such as ACC/AHA, ESC, and Uptodate and aim to rapidly diagnose and treat ACS to reduce mortality.
This document summarizes the 2016 guidelines from the Surviving Sepsis Campaign for the management of severe sepsis and septic shock. It outlines recommendations for initial resuscitation with IV fluids, vasopressors, corticosteroids, antibiotics, source control, blood products, glucose control, and bicarbonate therapy. The guidelines emphasize early recognition and treatment, with IV fluids, broad-spectrum antibiotics within 1 hour, and measuring lactate and targeting MAP of 65 mmHg as priorities in initial resuscitation of sepsis and septic shock.
The document provides an overview of the management of sepsis and septic shock. It discusses that early goal-directed therapy within the first 6 hours including antibiotics, fluids, vasopressors and inotropes if needed can significantly improve outcomes. Other key points covered include the definitions and diagnostic criteria for sepsis; appropriate antibiotic therapy and vasopressor use; importance of lung-protective ventilation; role for activated protein C, steroids, tight glucose control and renal replacement therapy. Prognosis depends on early recognition and treatment as mortality increases significantly with delayed or inadequate care.
This document defines septic shock and outlines its management. Septic shock is a subset of sepsis with circulatory or metabolic abnormalities and high mortality. It involves sepsis with hypotension requiring vasopressors or lactate above 2mmol/L despite fluid resuscitation. Causative organisms include bacteria and viruses. Risk factors include age extremes, immunosuppression, and invasive devices. Symptoms include low blood pressure, altered mental status, and respiratory distress. Complications affect the heart, lungs, kidneys, blood clotting, and brain. Treatment involves rapid antibiotic administration, fluid resuscitation, vasopressors, and corticosteroids if needed to restore blood pressure. Source control and supportive care are
1. Sepsis is defined as infection plus systemic manifestations of infection. Severe sepsis is sepsis plus organ dysfunction, while septic shock is sepsis-induced hypotension despite fluid resuscitation.
2. Initial management of septic shock includes administering broad-spectrum antibiotics within 1 hour, fluid resuscitation of at least 30 mL/kg of crystalloids, and vasopressors like norepinephrine to maintain a mean arterial pressure of 65 mmHg or higher.
3. Other recommended treatments include source control, glucose control with insulin to keep blood glucose under 180 mg/dL, stress ulcer prophylaxis as needed, and early enteral nutrition over total parenteral nutrition.
Traumatic brain injury (TBI) is a major public health problem in Egypt. The document outlines guidelines for the management of severe TBI based on the PROTECT III trial. It describes protocols for airway management, oxygenation, ventilation, blood pressure control, volume resuscitation, and intracranial pressure (ICP) monitoring. The guidelines provide a tiered approach for controlling ICP that includes head elevation, sedation, ventricular drainage, mannitol, hypertonic saline, barbiturates, and decompressive craniectomy. It also covers other aspects of care such as seizures prophylaxis, metabolic monitoring, surgery indications, and nutritional support.
The study randomized 1554 ICU patients with septic shock to either a restrictive or standard IV fluid therapy strategy. The restrictive group could only receive IV fluids if certain criteria for hypoperfusion were met, while the standard group had no limits. The primary outcome of death within 90 days was 42.3% in the restrictive group and 42.1% in the standard group, indicating no significant difference. Serious adverse events and other secondary outcomes were also similar between the two groups, suggesting that a restrictive IV fluid strategy for septic shock is not inferior to standard therapy.
Sepsis is a life-threatening organ dysfunction caused by a dysregulated response to infection. Early identification and treatment improves outcomes. The document outlines recommendations for screening and managing sepsis in three steps: 1) Screening and managing the initial infection. 2) Screening for organ dysfunction. 3) Identifying and managing initial hypotension. Key recommendations include administering broad-spectrum antibiotics within 1 hour, using lactate levels and qSOFA to identify organ dysfunction, giving 30mL/kg crystalloids for hypotension and lactate over 4mmol/L, and applying vasopressors like norepinephrine to maintain a MAP over 65mmHg.
ICU_vasopressors. infographic presenatation by one pageDr.Rakesh Reddy
This document provides guidance on treating vasopressor refractory shock. It recommends considering the underlying cause of shock and treating that directly rather than just increasing vasopressors. When vasopressors are needed, norepinephrine is often used first due to its combined vasoconstriction and inotropic effects. Phenylephrine, vasopressin, dopamine, and epinephrine are also discussed as options. The goal is to match the vasopressor to the patient's physiology and treat any acidosis or other underlying issues contributing to the shock.
This document outlines the diagnosis, screening, management, and treatment of sepsis and septic shock. It discusses initial investigations including labs and imaging that should be performed. It recommends goals for resuscitation including hemodynamic and lactate targets. It also outlines the priorities for immediate evaluation and management which include securing the airway, giving IV fluids and antibiotics within 1 hour, and starting vasopressors for refractory hypotension. Additional therapies discussed include glucocorticoids, inotropes, transfusion thresholds, nutrition, and VTE prophylaxis. Prognostic factors and post-discharge follow up are also summarized.
The document summarizes new guidelines for managing sepsis and septic shock published in 2016. Key points include:
- Sepsis is now defined as life-threatening organ dysfunction caused by infection. Septic shock involves circulatory and metabolic abnormalities with high mortality risk.
- Guidelines recommend early treatment including source control, broad-spectrum antibiotics within 1 hour, and at least 30mL/kg fluids for initial resuscitation to guide tissue perfusion.
- Ongoing resuscitation should be guided by frequent reassessment of hemodynamic status and lactate normalization when elevated. Vasopressors, steroids, and mechanical ventilation may be needed depending on individual patient circumstances.
- Performance improvement programs including sepsis screening are
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise stimulates the production of endorphins in the brain which elevate mood and reduce stress levels.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
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Guidelines poster septic shock
1. Surviving Sepsis Campaign Guidelines for
Management of Severe Sepsis and Septic Shock
This is a summary of the Surviving Sepsis Campaign In patients requiring vasopressors, place an arterial Prone ARDS patients requiring potentially injurious levels
Guidelines for Management of Severe Sepsis and Septic catheter as soon as practical. of FiO2 or plateau pressure. Only prone patients not at
Shock condensed from Dellinger RP, Carlet JM, Masur H, high risk from positional changes.
et al: Surviving Sepsis Campaign guidelines for management Consider vasopressin in patients with refractory shock
of severe sepsis and septic shock. Crit Care Med 2004; despite adequate fluid resuscitation and high-dose con- To prevent ventilator-associated pneumonia maintain
32:858-871. This version does not contain the rationale ventional vasopressors. Vasopressin is not recommended mechanically ventilated patients in a semirecumbent
or appendices contained in the primary publication. as a replacement for norepinephrine or dopamine as a position (head of bed raised 45 degrees), unless con-
Please refer to the guidelines for additional information first-line agent. Administer vasopressin at infusion rates traindicated.
at www.survivingsepsis.org. of 0.01–0.04 units/minute in adults.
Use a weaning protocol and have mechanically ventilated
∆ Indicates one of the goals chosen for implementation in Inotropic Therapy patients undergo a spontaneous breathing trial (SBT), at
the Institute of Healthcare Improvement's change pack- Consider dobutamine in patients with low cardiac output least daily, to evaluate for ventilation discontinuation.
age, i.e. part of the “sepsis bundle.” despite fluid resuscitation. Continue to titrate vasopressor
to mean arterial pressure of 65 mm Hg or greater. SBT options include a low level of pressure support with
continuous positive airway pressure 5 cm H2O or a
Initial Resuscitation Do not increase cardiac index to achieve an arbitrarily T-piece. Prior to SBT, patients should: 1) be arousable;
∆ Begin resuscitation immediately in patients with predefined elevated level of oxygen delivery. 2) be hemodynamically stable without vasopressors;
hypotension or elevated serum lactate. Resuscitation 3) have no new potentially serious conditions; 4) have low
goals: Steroids ventilatory and end-expiratory pressure requirement; and
• Central venous pressure: 8–12 mm Hg ∆ Treat patients who still require vasopressors despite fluid 5) require FiO2 levels that can be safely delivered with a
• Mean arterial pressure ≥65 mm Hg replacement with hydrocortisone 200–300 mg/day, for face mask or nasal cannula.
• Urine output ≥0.5 mL.kg -1.hr -1 7 days in three or four divided doses or by continuous
• Central venous or mixed venous oxygen infusion. Consider extubation if SBT is successful.
saturation ≥70%
Optional: Sedation, Analgesia, and Neuromuscular
∆ If central venous oxygen saturation or mixed venous • Perform 250-microgram adrenocorticotropic Blockade in Sepsis
oxygen saturation of 70% is not achieved with a central hormone (ACTH) stimulation test and discontinue Use sedation protocols for critically ill mechanically
venous pressure of 8–12 mm Hg, then transfuse packed steroids in patients who are responders (increase ventilated patients. Measure the sedation goal with a
red blood cells to achieve a hematocrit of ≥30% and/or in cortisol of > 9 µg/dL). standardized subjective sedation scale.
administer a dobutamine infusion of up to a maximum of
20 µg.kg-1.min-1. • Decrease steroid dose if septic shock resolves. Target sedation to predetermined endpoints (sedation
score). Use either intermittent bolus sedation or continu-
Diagnosis • Taper corticosteroid dose at end of therapy. ous infusion sedation with daily interruption/lightening
Before starting antibiotics obtain two or more blood to produce awakening. Retitrate if necessary.
cultures. At least one blood draw should be percutaneous • Add fludrocortisone (50µg orally once a day)
and one should be through each vascular assist device to this regimen. Avoid neuromuscular blockers (NMBs), if at all possible.
that has been in place longer than 48 hours. Obtain If NMBs must be utilized for longer than the first 2 to 3
cultures from other sites as indicated – cerebrospinal fluid, Do not use corticosteroids >300 mg/day of hydrocorti- hours of mechanical ventilation, use either intermittent
respiratory secretions, urine, wounds, and other body fluids. sone to treat septic shock. bolus as required or continuous infusion with monitoring
of depth of block with train of four monitoring.
Antibiotic Therapy Do not use corticosteroids to treat sepsis in the absence
∆ Begin intravenous antibiotics within first hour of recog- of shock unless the patient’s endocrine or corticosteroid Glucose Control
nition of severe sepsis. history warrants. ∆ Maintain blood glucose <150 mg/dL (8.3mmol/L)
following initial stabilization. Use continuous insulin
Administer one or more drugs that are active against likely Recombinant Human Activated and glucose infusion. Monitor blood glucose every 30 – 60
bacterial or fungal pathogens. Consider microorganism Protein C (rhAPC) minutes until stabilized, then monitor every 4 hours.
susceptibility patterns in the community and hospital. ∆ rhAPC is recommended in patients at high risk of death
(APACHE II(≥25, sepsis-induced multiple organ failure, Include a nutritional protocol for glycemic control.
Reassess antimicrobial regimen 48–72 hours after septic shock, or sepsis-induced acute respiratory distress
starting treatment with the objective of using a narrow syndrome) and with no absolute contraindication related Renal Replacement
spectrum antibiotic. to bleeding risk or relative contraindication that outweighs Intermittent hemodialysis and continuous veno venous
the potential benefit of rhAPC. hemofiltration (CVVH) are considered equivalent.
Consider combination therapy for neutropenic patients CVVH offers easier management in hemodynamically
and those with Pseudomonas infections. Blood Product Administration unstable patients.
Following resolution of tissue hypoperfusion, and in the
Stop antimicrobial therapy immediately if the condition absence of significant coronary artery disease or acute Bicarbonate Therapy
is determined to be a noninfectious cause. hemorrhage, transfuse red blood cells when hemoglobin Do not use bicarbonate therapy for the purpose of
decreases to <7.0 g/dL (<70 g/L) to target a hemoglobin improving hemodynamics or reducing vasopressor
Source Control of 7.0 – 9.0 g/dL. requirements when treating hypoperfusion induced lactic
∆ Evaluate patient for a focus of infection amenable to acidemia with pH ≥7.15.
source control measures including abscess drainage or Do not use erythropoietin to treat sepsis-related anemia.
tissue debridement. Erythropoietin may be used for other accepted reasons. Deep Vein Thrombosis (DVT) Prophylaxis
Use either low-dose unfractionated heparin or low-mole-
Choose the source control measure that will cause the Do not use fresh frozen plasma to correct laboratory cular weight heparin. Use a mechanical prophylactic
least physiologic upset and still accomplish the clinical clotting abnormalities unless there is bleeding or planned device, such as compression stockings or an intermittent
goal. invasive procedures. compression device, when heparin is contraindicated.
Use a combination of pharmacologic and mechanical
Institute source control measures as soon as an infection Do not use antithrombin therapy. therapy for patients who are at very high risk for DVT.
focus in need of source countrol has been identified.
Administer platelets when counts are <5000/mm3 (5 X Stress Ulcer Prophylaxis
Remove intravascular access devices that are a potential 109/L) regardless of bleeding. Transfuse platelets when Provide stress ulcer prophylaxis. The preferred agents
infection source promptly after establishing other vascu- counts are 5000 to 30,000/mm3 (5–30 X 109/L) and there are H2 receptor inhibitors.
lar access. is significant bleeding risk. Higher platelet counts
(≥50,000/mm3 [50 X 109/L]) are required for surgery or Consideration for Limitation of Support
Fluid Therapy invasive procedures. Discuss advance care planning with patients and
(see initial resuscitation timing recommendations) families. Describe likely outcomes and set realistic
Mechanical Ventilation of Sepsis-Induced expectations.
Use crystalloids or colloids. Acute Lung Injury (ALI)/ARDS
∆ Avoid high tidal volumes coupled with high plateau
∆ Give fluid challenge to patients with suspected inade- pressures. Reduce tidal volumes over 1–2 hours to a low Sponsoring Organizations: American Association of Critical-Care
quate tissue perfusion at a rate of 500 –1000 mL of tidal volume (6 ml per kilogram of lean body weight) as Nurses; American College of Chest Physicians; American
crystalloids or 300–500 mL of colloids over 30 minutes a goal in conjunction with the goal of maintaining College of Emergency Physicians; American Thoracic Society;
and repeat if blood pressure and urine output do not end-inspiratory plateau pressures <30 cm H2O. Australian and New Zealand Intensive Care Society; European
increase and there is no evidence of intravascular volume Society of Clinical Microbiology and Infectious Diseases;
overload. If necessary, minimize plateau pressures and tidal volumes European Society of Intensive Care Medicine; European
by allowing PaCO2 to increase above normal. Respiratory Society; Infectious Disease Society of America;
Vasopressors International Sepsis Forum; Society of Critical Care Medicine;
Start vasopressor therapy when fluid challenge fails to Set a minimum amount of positive end-expiratory pressure Surgical Infection Society.
restore adequate blood pressure and organ perfusion, or (PEEP) to prevent lung collapse at end expiration.
transiently until fluid resuscitation restores adequate Set PEEP based on severity of oxygenation deficit and
perfusion. guided by the FiO2 required to maintain adequate oxy-
genation (ARDSnet guidelines) or titrate PEEP accord-
Either norepinephrine or dopamine administered through ing to bedside measurements of thoracopulmonary com-
a central catheter is the initial vasopressor of choice. pliance.
This wall chart distributed by the Society of Critical Care Medicine
Do not use low-dose dopamine for renal protection.
Revised June 2004