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.
It includes new definition, pathophysiology, management of sepsis, septic shock and neutropenic sepsis and even newer evolving concepts or types of 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.
It includes new definition, pathophysiology, management of sepsis, septic shock and neutropenic sepsis and even newer evolving concepts or types of 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.
The recent definition, concept and terminologies of septic shock, surviving sepsis campaign, management techniques, SOFA score. Also includes antibiotics and supportive modalities.
The recent definition, concept and terminologies of septic shock, surviving sepsis campaign, management techniques, SOFA score. Also includes antibiotics and supportive modalities.
Combination fixed-dose beta agonist and steroid inhaler as required for adults or children with mild asthma -
Crossingham I, Turner S, Ramakrishnan S, Fries A, Gowell M, Yasmin F, Richardson R, Webb P, O'Boyle E, Hinks TSC. Combination fixed-dose beta agonist and steroid inhaler as required for adults or children with mild asthma. Cochrane Database of Systematic Reviews 2021, Issue 5. Art. No.: CD013518.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. INTRODUCTION
• Rapid diagnosis (within the first 6 hours) and
expeditious treatment are critical, since early,
goal directed therapy can be very effective.
• Multiple approaches are necessary in the
treatment of sepsis and shock.
• It is important to select patients for each given
therapy with great care, because the efficacy
of treatment — as well as the likelihood and
type of adverse results — will vary, depending
on the patient.
3. EPIDEMIOLOGY
• Major cause of morbidity and mortality
worldwide.
• Sepsis ranks in the top 10 causes of death.
• Mortality in Septic Shock ranges from 40 to
60% .
• Mortality rate is proportional to the number
of organ systems that fail.
• Less defined in developing countries.
4. EPIDEMIOLOGY
• Increasing incidence of severe sepsis in the USA is
attributable to the aging of the population, the
increasing longevity of patients with chronic
diseases, and the relatively high frequency with
which sepsis develops in patients with AIDS.
• Widespread use of antimicrobial agents,
glucocorticoids, indwelling catheters and
mechanical devices, and mechanical ventilation
also plays a role.
5. DEFINITIONS
• Bacteremia - Presence of bacteria in blood, as
evidenced by positive blood cultures.
• Septicemia - Presence of microbes or their toxins in
blood.
• Systemic Inflammatory Response syndrome(SIRS) Two or more of the following conditions:
–
–
–
–
(1) fever (oral temperature >38C) or hypothermia (<36C);
(2) tachypnea (>24 breaths/min);
(3) tachycardia (heart rate > 90 beats/min);
(4) leukocytosis (>12,000/L), leukopenia (<4,000/L), or 10%
bands; may have a noninfectious etiology
6. • Sepsis - SIRS that has a proven or suspected
microbial etiology.
• Severe sepsis (similar to“sepsis syndrome”)
Sepsis with one or more signs of organ
dysfunction—for example:
1. Cardiovascular: Arterial systolic blood pressure
≤ 90 mmHg or mean arterial pressure ≤ 70 mmHg
that responds to administration of intravenous
fluid
2. Renal: Urine output < 0.5 mL/kg per hour for 1 h
despite adequate fluid resuscitation
7. • 3. Respiratory: PaO₂ /FIO₂ ≤ 250 or, if the lung is the
only dysfunctional organ, ≤ 200
• 4. Hematologic: Platelet count < 80,000/L or 50%
decrease in platelet count from highest value
recorded over previous 3 days
• 5. Unexplained metabolic acidosis: A pH ≤ 7.30 or a
base deficit ≥ 5.0 mEq/L and a plasma lactate level >
1.5 times upper limit of normal for reporting lab.
8. Septic shock - Sepsis with hypotension
(arterial blood pressure < 90 mmHg systolic, or
40 mmHg less than patient’s normal blood
pressure) for at least 1 h despite adequate
fluid resuscitation;
Or
Need for vasopressors to maintain systolic
blood pressure ≥ 90 mmHg or mean arterial
pressure ≥ 70 mmHg
9. • Refractory septic shock - Septic shock that
lasts for 1 h and does not respond to fluid or
pressor administration
• Multiple-organ Dysfunction Syndrome (MODS)
Dysfunction of more than one organ, requiring
intervention to maintain homeostasis
18. MANAGEMENT
• cornerstone of emergency management of
sepsis is early, goal-directed therapy, plus
lung-protective ventilation, broad-spectrum
antibiotics.
19. Early, Goal-directed Therapy
• decreased mortality at 28 and 60 days as well
as the duration of hospitalization.
• mechanisms of the benefit of EGDT are
unknown but may include reversal of tissue
hypoxia and a decrease in inflammation and
coagulation defects.
20. EGDT – River`s trial
• Crystalloids were administered to maintain CVP
at 8 to 12 mm Hg.
• Vasopressors were added if the MAP was less
than 65 mm Hg.
• If central venous oxygen saturation was less than
70%, erythrocytes were transfused to maintain a
hematocrit of more than 30%.
• Dobutamine was added if the CVP, MAP, and
hematocrit were optimized yet venous oxygen
saturation remained below 70%.
21. Surviving Sepsis Campaign:
International guidelines - SSC
• Initial resuscitation (first 6 hrs) – hypotension
or elevated serum lactate 4 mmol/L.
Resuscitate using crystalloids or colloids
• Resuscitation goals
– CVP 8–12 mm Hg
– Mean arterial pressure ≥ 65 mm Hg.
– Urine output ≥ 0.5 mL/kg/hr.
– Central venous (superior vena cava) oxygen
saturation ≥ 70% or mixed venous ≥ 65%.
22. Vasopressors - SSCG
• Maintain MAP > 65 mm Hg.
• Norepinephrine and dopamine centrally
administered are the initial vasopressors of
choice.
• Use epinephrine as the first alternative agent.
• Do not use low-dose dopamine for renal
protection
23. VASOPRESSIN
• I.V. infusion of low-dose vasopressin (0.03 to
0.04 U per minute) has been reported to
increase BP, urinary output, and creatinine
clearance, permitting a dramatic decrease in
vasopressor therapy.
• Side effects –
– intestinal ischemia,
– decreased cardiac output,
– skin necrosis,
– cardiac arrest
24. VENTILATION
• lung-protective ventilation (TV of 6 ml/kg or as
low as 4 ml if the plateau pressure exceeds 30
cm H2O) decreases mortality and is beneficial
in septic acute lung injury.
• Advantages –
– decrease the mortality rate (from 40 to 31%),
– lessen organ dysfunction,
– lower levels of cytokines.
• PEEP – no significant difference in mortality
25. VENTILATION
• Patients receiving ventilation require
appropriate but not excessive sedation.
• Titrating sedation and interrupting sedation
daily until patients are awake decrease the
risks associated with sedation.
• Neuromuscular blocking agents should be
avoided.
26. SSCG
• Diagnosis - Obtain appropriate cultures before
starting antibiotics.
– Obtain two or more BCs
– One or more BCs should be percutaneous
– One BC from each vascular access device in place
> 48 hrs .
– Culture other sites as clinically indicated
27. ANTIBIOTICS - SSCG
• Begin intravenous antibiotics as early as
possible and always within the first hour of
recognizing severe sepsis and septic shock.
• Reassess antimicrobial regimen daily to
optimize efficacy, prevent resistance, avoid
toxicity, and minimize costs.
28. ANTIBIOTICS
• Immunocompetent adult –
– ceftriaxone (2 g q24h) or ticarcillin-clavulanate
(3.1 g q4–6h) or piperacillin-tazobactam (3.375 g
q4–6h).
– imipenem-cilastatin (0.5 g q6h) or meropene (1 g
q8h) or cefepime (2 g q12h).
– Gentamicin or tobramycin (5–7 mg/kg q24h).
– Ciprofloxacin (400 mg q12h) or levofloxacin (500–
750 mg q12h) plus clindamycin (600 mg q8h).
29. ANTIBIOTICS
• Neutropenia (500 neutrophils/L) –
– imipenem-cilastatin (0.5 g q6h) or meropenem (1
g q8h) or cefepime (2 g q8h).
– ticarcillin-clavulanate (3.1 g q4h) or piperacillintazobactam (3.375 g q4h) plus tobramycin (5–7
mg/kg q24h).
30. • Splenectomy –
– Cefotaxime (2 g q6–8h) or ceftriaxone (2 g q12h).
– vancomycin (15 mg/kg q12h) plus ciprofloxacin
(400 mg q12h) or levofloxacin (750 mg q12h) or
aztreonam (2 g q8h).
• AIDS –
– Cefepime (2 g q8h), ticarcillin-clavulanate (3.1 g
q4h), or piperacillin tazobactam (3.375 g q4h) plus
tobramycin (5–7 mg/kg q24h).
– ciprofloxacin (400 mg q12h) or levofloxacin (750
mg q12h) plus vancomycin (15 mg/kg q12h) plus
tobramycin
31. ACTIVATED PROTEIN C
• Therapy with APC (24 μg / kg / hr for 96 hours)
has been reported to decrease mortality and
to ameliorate organ dysfunction in patients
with severe sepsis.
• Approved for administration to patients with
severe sepsis and an increased risk of death.
• Absolute decrease in the mortality rate of
13%.
32. ACTIVATED PROTEIN C
• Contraindications – PROWESS trial
– Recent trauma or surgery (within 12 hours),
– Active hemorrhage,
– Concurrent therapeutic anticoagulation,
– Thrombocytopenia (defined as a platelet count of
less than 30,000 per cubic millimeter),
– Recent stroke
33. ACTIVATED PROTEIN C
• Mechanism of action –
– increase protein C.
– decrease markers of thrombin generation.
– prevents hypotension.
34. ANEMIA IN SEPSIS
• Mediators of sepsis (TNF-α and interleukin-1β)
decrease the expression of the erythropoietin
gene and protein.
• Rivers et al. used a hematocrit of 30% and Hebert
et al. compared hemoglobin values of 70 and 100
g per liter as a threshold for transfusion.
• SSCG - Give RBC`s when Hb decreases to 7.0 g/dL
(70 g/L) to target a Hb of 7.0–9.0 g/dL in adults .
35. STEROIDS
• SSCG –
– Consider i.v. hydrocortisone for adult septic shock
when hypotension responds poorly to adequate
fluid resuscitation and vasopressors.
– Hydrocortisone is preferred to dexamethasone.
– Hydrocortisone dose should be 300 mg/day .
– Do not use corticosteroids to treat sepsis in the
absence of shock
36. STEROIDS
• Important adverse effects in patients with
sepsis –
– Neuromyopathy
– Hyperglycemia,
– Decreased numbers of lymphocytes,
– Immunosuppression (leading to nosocomial
infection and impaired wound healing ),
– Loss of intestinal epithelial cells.
37. HYPERGLYCEMIA AND INTENSIVE
INSULIN THERAPY
• Hyperglycemia - acts as a procoagulant,
induces apoptosis, impairs neutrophil
function, increases the risk of infection,
impairs wound healing.
• Insulin - control hyperglycemia and improve
lipid levels , has anti inflammatory,
anticoagulant, and anti apoptotic actions.
38. HYPERGLYCEMIA AND INTENSIVE
INSULIN THERAPY
• The appropriate target glucose range and insulin
dose in patients with sepsis are unknown.
• SSCG - Aim to keep blood glucose 150 mg/dL (8.3
mmol/L).
• Although intensive insulin therapy appears to be
beneficial in surgical patients, the lack of efficacy
in medical patients, indicates clinical equipoise
and the need for a randomized, controlled trial in
patients with Sepsis.
39. RENAL DYSFUNCTION AND DIALYSIS
• ARF is associated with increased morbidity, mortality.
• Continuous renal-replacement therapy decreases the
incidence of adverse biomarkers, but there is little
evidence that it changes outcomes.
• Low-dose dopamine (2 to 4 μg / kg / min) neither
decreases the need for renal support nor improves
survival and, consequently, is not recommended.
• Lactic acidosis is a common complication of septic
shock; however, sodium bicarbonate improves neither
hemodynamics nor the response to vasopressor
medications.
40. Deep vein thrombosis prophylaxis SSCG
• Use either low-dose UFH or LMWH, unless
contraindicated .
• Use a mechanical prophylactic device, such as
compression stockings or an intermittent
compression device, when heparin is
contraindicated.
41. Stress ulcer prophylaxis - SSCG
• Provide stress ulcer prophylaxis using H2
blocker or proton pump inhibitor.
42. NUTRITION
• Enteral nutrition is important because it is
generally safer and more effective than total
parenteral Nutrition.
• However, total parenteral nutrition may be
required in patients who have had abdominal
sepsis, surgery, or trauma.
43. INEFFECTIVE THERAPIES
• Anti lipopolysaccharide therapy was
ineffective.
• Therapies that block proinflammatory
cytokines have failed.
• Excessively immunosuppressive , Ibuprofen,
platelet-activating factor acetylhydrolase,
bradykinin antagonists, and other therapies
have not improved survival among patients
with sepsis.
44. POTENTIAL NEW THERAPIES
• Interferon gamma improved macrophage
function and increased survival in one study.
• Inhibition of apoptosis (e.g., with anticaspases)
improved survival in an animal model.
• Lipid emulsion (which binds and neutralizes
lipopolysaccharide) is being evaluated in a phase
3 trial.
• Superantigens and mannose.
• Inhibition of tissue factor, a proximal target,
might mitigate excessive procoagulant activity.
• Strategies to boost immunity could improve the
outcome of sepsis when applied early in sepsis
45. PROGNOSIS
• Approximately 20 to 35% of patients with
severe sepsis and 40 to 60% of patients with
septic shock die within 30 days.
• Septic shock is also a strong predictor of
short- and long-term mortality.
• Case-fatality rates are similar for culturepositive and culture-negative severe sepsis.
46. SUMMARY
• Optimal management of sepsis requires early,
goal directed therapy; lung-protective ventilation;
antibiotics; and possibly activated protein C.
• corticosteroids, vasopressin, and intensive insulin
therapy requires further study.
• Later in the course of sepsis, appropriate
management necessitates organ support and
prevention of nosocomial infection.
• Studies focused on novel targets, mechanisms of
action, and combination therapy may improve
current treatment.
47. SEPSIS BUNDLE
• Sepsis resuscitation bundle – (within 6 hrs )
– Measure s.lactate.
– Obtain blood culture prior starting antibiotics.
– Give BS ABT within 3 hrs of ED admission/1 hr of
non ED admission.
– Treat hypotension and/or elevated lactate with
fluids (20 ml/kg crystalloids).
– Apply vasopressors for ongoing hypotension.
– Maintain adequate CVP (>8) and ScvO2 (>70%).
48. SEPSIS BUNDLE
• Sepsis management bundle – (within 24 hrs of
presentation), in accordance with ICU policy.
– Give low dose steroids for septic shock.
– Give rhAPC.
– Maintain glucose control lower limit of normal ,
but < 180 mg/dl.
– Maintain inspiratory plateau pressure < 30 cm H₂0
for ventillated patients.