This document provides guidance on resuscitation for patients with sepsis and septic shock. It discusses recognizing sepsis and shock, delivering early targeted resuscitation within 1-6 hours through fluid administration and vasopressors/inotropes, and monitoring patients to meet resuscitation targets like blood pressure and urine output. It also covers special considerations for resuscitating pregnant women and pediatric patients with shock. The goal is to treat infection and tissue hypoperfusion through prompt antimicrobial therapy and resuscitation to prevent organ dysfunction.
This document provides guidelines for post-arrest care in pediatric patients. It outlines recommendations for respiratory care to maintain oxygen saturation between 94-99% and use of inotropic drugs like milrinone and epinephrine for cardiac care. It also discusses guidelines for neurological care, ongoing assessment, and treatment of hypotension. Specific recommendations are provided for ventilation, drug therapies including epinephrine, dopamine, norepinephrine and factors influencing outcomes. Targeted temperature management and control of blood glucose are also addressed.
This document provides guidance on assessing critically ill medical patients using the ABCDE approach. It summarizes the ABCDE assessment process and management steps for airway, breathing, circulation, disability and exposure. It also outlines important considerations when assessing patients, including fluid balance, blood sugar management, seizure management, sepsis management and gathering patient information. The overall goal is to familiarize medical staff with systematically assessing unwell patients using ABCDE and treating problems encountered.
Critical care medicine specializes in caring for the most seriously ill patients. These patients are best treated in an intensive care unit (ICU) staffed by experienced personnel. Some hospitals maintain separate units for special populations (eg, cardiac, trauma, surgical, neurologic, pediatric, or neonatal patients). ICUs have a high nurse:patient ratio to provide the necessary high intensity of service, including treatment and monitoring of physiologic parameters.
The document provides recommendations from an international conference of experts on intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). It recommends screening ICU patients for IAH/ACS risk factors and monitoring intra-abdominal pressure if risk factors are present. Serial measurements are necessary to guide management and prevent organ dysfunction. Medical and surgical interventions are outlined to treat IAH and ACS depending on severity, including maintaining adequate abdominal perfusion pressure. Further research is still needed to clarify unanswered questions.
Abdominal compartment syndrome (ACS) occurs when sustained elevated intra-abdominal pressure above 20 mmHg is associated with new organ dysfunction. Risk factors include aggressive fluid resuscitation, burns over 30% total body surface area, liver transplantation, and abdominal/retroperitoneal conditions. Physiologic consequences of increased intra-abdominal pressure include decreased cardiac preload and output, impaired pulmonary and renal function, and reduced splanchnic blood flow. Definitive diagnosis requires direct measurement of intra-abdominal pressure. Management involves supportive care, surgical decompression if medical therapies fail, and temporary abdominal closure during open abdomen treatment. Failure to recognize ACS can lead to multiple organ failure and death in 40
Post-resuscitation care involves monitoring for potential medical complications across multiple organ systems and providing appropriate interventions. Complications may include pneumonia, pneumothorax, or pulmonary hypertension. Therapeutic hypothermia reduces the risk of death and improves outcomes for moderate to severe hypoxic-ischemic encephalopathy if started within 6 hours of birth for infants over 1800g and 36 weeks gestation. Proper post-resuscitation care during the vulnerable "golden hour" can help prevent complications like hypothermia, hypoglycemia, brain bleeding, lung disease, and eye damage that increase mortality risks.
The PACU is designed to monitor and care for patients recovering from anesthesia and surgery. Specially trained nurses make up the PACU staff and are skilled in recognizing postoperative complications. When patients arrive, pertinent medical details are provided. Vital signs are closely monitored including oxygenation, ventilation, circulation, consciousness and temperature. Standards require appropriate post-anesthesia management and evaluation until patients are no longer at risk for complications before discharge from the PACU. Common complications include PONV, upper airway obstruction, hypoxemia, hypertension, hypotension, and delirium.
This document provides guidelines for post-arrest care in pediatric patients. It outlines recommendations for respiratory care to maintain oxygen saturation between 94-99% and use of inotropic drugs like milrinone and epinephrine for cardiac care. It also discusses guidelines for neurological care, ongoing assessment, and treatment of hypotension. Specific recommendations are provided for ventilation, drug therapies including epinephrine, dopamine, norepinephrine and factors influencing outcomes. Targeted temperature management and control of blood glucose are also addressed.
This document provides guidance on assessing critically ill medical patients using the ABCDE approach. It summarizes the ABCDE assessment process and management steps for airway, breathing, circulation, disability and exposure. It also outlines important considerations when assessing patients, including fluid balance, blood sugar management, seizure management, sepsis management and gathering patient information. The overall goal is to familiarize medical staff with systematically assessing unwell patients using ABCDE and treating problems encountered.
Critical care medicine specializes in caring for the most seriously ill patients. These patients are best treated in an intensive care unit (ICU) staffed by experienced personnel. Some hospitals maintain separate units for special populations (eg, cardiac, trauma, surgical, neurologic, pediatric, or neonatal patients). ICUs have a high nurse:patient ratio to provide the necessary high intensity of service, including treatment and monitoring of physiologic parameters.
The document provides recommendations from an international conference of experts on intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). It recommends screening ICU patients for IAH/ACS risk factors and monitoring intra-abdominal pressure if risk factors are present. Serial measurements are necessary to guide management and prevent organ dysfunction. Medical and surgical interventions are outlined to treat IAH and ACS depending on severity, including maintaining adequate abdominal perfusion pressure. Further research is still needed to clarify unanswered questions.
Abdominal compartment syndrome (ACS) occurs when sustained elevated intra-abdominal pressure above 20 mmHg is associated with new organ dysfunction. Risk factors include aggressive fluid resuscitation, burns over 30% total body surface area, liver transplantation, and abdominal/retroperitoneal conditions. Physiologic consequences of increased intra-abdominal pressure include decreased cardiac preload and output, impaired pulmonary and renal function, and reduced splanchnic blood flow. Definitive diagnosis requires direct measurement of intra-abdominal pressure. Management involves supportive care, surgical decompression if medical therapies fail, and temporary abdominal closure during open abdomen treatment. Failure to recognize ACS can lead to multiple organ failure and death in 40
Post-resuscitation care involves monitoring for potential medical complications across multiple organ systems and providing appropriate interventions. Complications may include pneumonia, pneumothorax, or pulmonary hypertension. Therapeutic hypothermia reduces the risk of death and improves outcomes for moderate to severe hypoxic-ischemic encephalopathy if started within 6 hours of birth for infants over 1800g and 36 weeks gestation. Proper post-resuscitation care during the vulnerable "golden hour" can help prevent complications like hypothermia, hypoglycemia, brain bleeding, lung disease, and eye damage that increase mortality risks.
The PACU is designed to monitor and care for patients recovering from anesthesia and surgery. Specially trained nurses make up the PACU staff and are skilled in recognizing postoperative complications. When patients arrive, pertinent medical details are provided. Vital signs are closely monitored including oxygenation, ventilation, circulation, consciousness and temperature. Standards require appropriate post-anesthesia management and evaluation until patients are no longer at risk for complications before discharge from the PACU. Common complications include PONV, upper airway obstruction, hypoxemia, hypertension, hypotension, and delirium.
1) The document provides guidelines for managing pediatric respiratory distress and failure in 4 parts, with Part 3 focusing on assessment, causes, and treatment of respiratory distress and failure.
2) Key signs of respiratory distress include tachypnea, retractions, and hypoxia; respiratory failure is indicated by bradypnia, cyanosis, and decreased consciousness. Causes include upper airway obstruction, lower airway obstruction, lung disease, and control disorders.
3) For upper airway emergencies like croup and epiglottitis, humidified oxygen, nebulized adrenaline, steroids, and intubation may be needed. For lower airway issues like asthma and bronchiolitis
The document discusses physiologic monitoring of critically ill patients. It describes four categories of patients that require monitoring, including those with unstable regulatory systems, suspected life-threatening conditions, at high risk of developing complications, and in a critical state. Common monitoring parameters are discussed for these patients such as pulse oximetry, blood pressure, ECG, temperature, urine output, and arterial blood gases. Specific monitoring techniques are also described for conditions like increased intracranial pressure, brain function, anesthesia depth, mixed venous oxygen saturation, and more.
The intensive care unit (ICU) provides specialized monitoring and treatment for critically ill patients. There are various types of ICUs depending on the specific medical needs, such as surgical ICU, cardiac ICU, and pediatric ICU. The ICU is equipped to provide life support and closely monitor vital functions through equipment like cardiac monitors, ventilators, and invasive pressure monitors. Patients admitted to the ICU typically have critical illnesses, organ failures, or require major surgery and post-operative care. The ICU aims to optimize life support and adequate monitoring through the use of specialized equipment, monitoring devices, catheters, drains, and medical staff expertise.
A 12-year-old girl with a history of an undiagnosed ventricular septal defect (VSD) presents with shortness of breath, headaches, dizziness, leg swelling, and blue lips. Examination finds cyanosis, clubbing, leg edema, tachycardia, and an enlarged liver. Chest x-ray shows enlarged right ventricle and pruned pulmonary arteries. She is diagnosed with Eisenmenger syndrome due to longstanding left-to-right shunt through her VSD reversing to right-to-left, and she requires management of complications like arrhythmias, bleeding, and right heart failure.
This document discusses the management of various medical emergencies. It covers topics like airway management, breathing issues including asthma, COPD, pneumothorax and ARDS. It also discusses circulation emergencies such as cardiac arrest, shock and myocardial infarction. For each topic, it provides guidance on diagnosis, treatment principles and protocols for first responders. The overall aim appears to be educating first responders and medical professionals on best practices for treating common life-threatening conditions in emergency situations.
This document presents definitions agreed upon by experts for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). IAH is defined as an intra-abdominal pressure of 12 mmHg or higher and is graded based on severity. ACS occurs when IAH is over 20 mmHg and is associated with new organ dysfunction. The definitions standardize measurement of intra-abdominal pressure via bladder at 25 ml saline and establish abdominal perfusion pressure as key. Primary ACS originates in the abdomen while secondary ACS occurs elsewhere and can recur after initial treatment.
1. The document discusses the key principles of emergency nursing including establishing an open airway, controlling hemorrhage, maintaining circulation, assessing neurological status, and rapidly assessing patients.
2. Common medical emergencies covered include acute abdomen, shock, respiratory issues, cardiac emergencies, neurological emergencies, trauma, and poisoning. Signs, symptoms, diagnostic tests, and treatment approaches are described for each condition.
3. The principles of emergency management are also summarized, which include early detection, reporting, response, providing good on-scene care and transportation to definitive care.
This document discusses investigations and management for chronic and acute adrenal insufficiency. For chronic illness, it recommends completing blood tests like a complete blood count, electrolytes, and thyroid and hormone function tests. It also recommends assessing glucocorticoid, mineralocorticoid and gonadocorticoid levels. For management of chronic illness, it recommends glucocorticoid replacement therapy with hydrocortisone, mineralocorticoid replacement with fludrocortisone, and androgen replacement if needed. For acute illness or adrenal crisis, it recommends immediate treatment, glucocorticoid replacement, correcting other abnormalities, and identifying the underlying cause.
د/ماجد الوراقي
Structured approach for critically ill patient
المحاضرة التي قدمت يوم الاربعاء 9 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
This document discusses abdominal compartment syndrome (ACS). It defines ACS as a sustained intra-abdominal pressure (IAP) above 20 mmHg associated with new organ dysfunction. Normal IAP is 5-7 mmHg. Intra-abdominal hypertension is defined as IAP above 12 mmHg and is graded. ACS can result from primary abdominal causes or secondary extra-abdominal causes and leads to organ dysfunction through reduced blood flow. Accurate IAP monitoring via bladder pressure is important for early detection and treatment to prevent organ failure.
This document discusses abdominal compartment syndrome (ACS), which refers to organ dysfunction caused by increased intra-abdominal pressure known as intra-abdominal hypertension (IAH). The key points are:
1. ACS can impair nearly every organ system but is often underdiagnosed. Diagnosis requires measuring intra-abdominal pressure via bladder catheter.
2. Management consists of supportive care initially but may require surgical decompression of the abdomen in severe cases.
3. Following decompression, temporary abdominal closure techniques are used until definitive closure can be achieved or a planned hernia results.
This document discusses cardiopulmonary cerebral resuscitation (CPCR) in dogs and cats. It defines key terms like respiratory arrest and cardiopulmonary arrest. It outlines that overall survival to discharge is around 6-7% for dogs and 3% for cats. The document then discusses the goals and steps of basic life support (BLS) including circulation, airway, and breathing. It also covers advanced life support (ALS) techniques like drug administration, electrical defibrillation, fluid therapy, and monitoring such as ECG and end-tidal CO2. Finally, it summarizes the RECOVER initiative which aimed to establish evidence-based guidelines for small animal CPR.
This document provides an overview of acute kidney injury (AKI), chronic kidney disease (CKD), end-stage renal disease (ESRD), and their treatment and management. It discusses the pathophysiology, stages, symptoms, complications, medical and surgical interventions, and nursing care for each condition. Dialysis methods like hemodialysis and peritoneal dialysis are explained in detail. Surgical procedures for the kidneys like nephrectomy and transplantation are also summarized.
1. The document discusses various surgical issues that may arise in intensive care unit (ICU) patients, including airway complications requiring procedures like tracheostomy, pulmonary issues like pneumothorax requiring chest tubes, cardiac tamponade requiring pericardial drainage, and abdominal issues like bowel obstruction.
2. Case studies are presented of patients with increased intra-abdominal pressures from hemorrhage and ileus that require decompression through laparotomy to treat abdominal compartment syndrome.
3. Guidelines are provided for management of issues like compartment syndrome through early diagnosis and fasciotomy if pressures are elevated.
This document discusses parenteral nutrition, including its indications, types, components, guidelines for administration and monitoring. Parenteral nutrition involves intravenous delivery of nutrients like protein, carbohydrates and fat. It is used when oral or enteral nutrition is not possible. The document outlines the different types of parenteral access, infusion schedules, nutrient components and their daily requirements. It also discusses complications of parenteral nutrition and their management. Studies have found that initiating parenteral nutrition later, around day 8, in critically ill pediatric patients results in fewer infections and shorter hospital stays compared to early initiation within 24 hours.
This document provides an overview of emergency medicine as a specialty. It discusses the top causes of death, the reception process in emergency departments, how cases are triaged from life-threatening to non-urgent, and examples of common illnesses and injuries seen in emergency medicine including chest pain, fractures, seizures, and psychiatric illnesses. It also outlines both the appeals and challenges of working in emergency medicine as well as potential career paths within the specialty.
The document outlines the importance of post resuscitation care to stabilize patients after return of spontaneous circulation, including supporting oxygenation and circulation, treating injuries from CPR, monitoring for recurrent cardiac arrest, and promptly transferring patients to intensive care units for specialized monitoring and treatment. Proper post resuscitation care is critical to optimize outcomes in the hours after resuscitation.
The document discusses basic life support (BLS) principles and procedures. It covers the ABCs of BLS - maintaining airway, breathing, and circulation. It describes the steps of CPR for adults, children, and infants, including assessment, calling for help, chest compressions, and rescue breathing. It also discusses special considerations for airway obstruction, shock, and triage in emergencies and disasters.
The most challenging scenario you can ever face is resuscitation of pediatric population in your ED, high level of stress is involved, so going systematic will make your work easy. The new PALS guidelines by AHA is quoted d here.
SEPSIS AND SEPTIC SHOCKDELIVER TARGETED RESUSCITATIONSandro Zorzi
WHO Critical Care Severe Acute Respiratory Infection Training
At the end of this lecture, you will be able to:•Describe how to deliver early, targeted resuscitation in patients (adults and children) with sepsis-induced tissue hypoperfusion and shock.•Understand the special considerations when resuscitating paediatricpatients in resource-limited settings.
This document discusses sepsis and septic shock. It defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock involves circulatory and metabolic abnormalities that increase mortality risk. The document reviews signs, laboratory findings, scoring systems, management principles, and treatment approaches for sepsis and septic shock such as early antibiotics, fluid resuscitation, vasopressors, inotropes, and glycemic control. The goal of treatment is to recognize sepsis early and provide timely, targeted resuscitation to improve outcomes.
1) The document provides guidelines for managing pediatric respiratory distress and failure in 4 parts, with Part 3 focusing on assessment, causes, and treatment of respiratory distress and failure.
2) Key signs of respiratory distress include tachypnea, retractions, and hypoxia; respiratory failure is indicated by bradypnia, cyanosis, and decreased consciousness. Causes include upper airway obstruction, lower airway obstruction, lung disease, and control disorders.
3) For upper airway emergencies like croup and epiglottitis, humidified oxygen, nebulized adrenaline, steroids, and intubation may be needed. For lower airway issues like asthma and bronchiolitis
The document discusses physiologic monitoring of critically ill patients. It describes four categories of patients that require monitoring, including those with unstable regulatory systems, suspected life-threatening conditions, at high risk of developing complications, and in a critical state. Common monitoring parameters are discussed for these patients such as pulse oximetry, blood pressure, ECG, temperature, urine output, and arterial blood gases. Specific monitoring techniques are also described for conditions like increased intracranial pressure, brain function, anesthesia depth, mixed venous oxygen saturation, and more.
The intensive care unit (ICU) provides specialized monitoring and treatment for critically ill patients. There are various types of ICUs depending on the specific medical needs, such as surgical ICU, cardiac ICU, and pediatric ICU. The ICU is equipped to provide life support and closely monitor vital functions through equipment like cardiac monitors, ventilators, and invasive pressure monitors. Patients admitted to the ICU typically have critical illnesses, organ failures, or require major surgery and post-operative care. The ICU aims to optimize life support and adequate monitoring through the use of specialized equipment, monitoring devices, catheters, drains, and medical staff expertise.
A 12-year-old girl with a history of an undiagnosed ventricular septal defect (VSD) presents with shortness of breath, headaches, dizziness, leg swelling, and blue lips. Examination finds cyanosis, clubbing, leg edema, tachycardia, and an enlarged liver. Chest x-ray shows enlarged right ventricle and pruned pulmonary arteries. She is diagnosed with Eisenmenger syndrome due to longstanding left-to-right shunt through her VSD reversing to right-to-left, and she requires management of complications like arrhythmias, bleeding, and right heart failure.
This document discusses the management of various medical emergencies. It covers topics like airway management, breathing issues including asthma, COPD, pneumothorax and ARDS. It also discusses circulation emergencies such as cardiac arrest, shock and myocardial infarction. For each topic, it provides guidance on diagnosis, treatment principles and protocols for first responders. The overall aim appears to be educating first responders and medical professionals on best practices for treating common life-threatening conditions in emergency situations.
This document presents definitions agreed upon by experts for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). IAH is defined as an intra-abdominal pressure of 12 mmHg or higher and is graded based on severity. ACS occurs when IAH is over 20 mmHg and is associated with new organ dysfunction. The definitions standardize measurement of intra-abdominal pressure via bladder at 25 ml saline and establish abdominal perfusion pressure as key. Primary ACS originates in the abdomen while secondary ACS occurs elsewhere and can recur after initial treatment.
1. The document discusses the key principles of emergency nursing including establishing an open airway, controlling hemorrhage, maintaining circulation, assessing neurological status, and rapidly assessing patients.
2. Common medical emergencies covered include acute abdomen, shock, respiratory issues, cardiac emergencies, neurological emergencies, trauma, and poisoning. Signs, symptoms, diagnostic tests, and treatment approaches are described for each condition.
3. The principles of emergency management are also summarized, which include early detection, reporting, response, providing good on-scene care and transportation to definitive care.
This document discusses investigations and management for chronic and acute adrenal insufficiency. For chronic illness, it recommends completing blood tests like a complete blood count, electrolytes, and thyroid and hormone function tests. It also recommends assessing glucocorticoid, mineralocorticoid and gonadocorticoid levels. For management of chronic illness, it recommends glucocorticoid replacement therapy with hydrocortisone, mineralocorticoid replacement with fludrocortisone, and androgen replacement if needed. For acute illness or adrenal crisis, it recommends immediate treatment, glucocorticoid replacement, correcting other abnormalities, and identifying the underlying cause.
د/ماجد الوراقي
Structured approach for critically ill patient
المحاضرة التي قدمت يوم الاربعاء 9 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
This document discusses abdominal compartment syndrome (ACS). It defines ACS as a sustained intra-abdominal pressure (IAP) above 20 mmHg associated with new organ dysfunction. Normal IAP is 5-7 mmHg. Intra-abdominal hypertension is defined as IAP above 12 mmHg and is graded. ACS can result from primary abdominal causes or secondary extra-abdominal causes and leads to organ dysfunction through reduced blood flow. Accurate IAP monitoring via bladder pressure is important for early detection and treatment to prevent organ failure.
This document discusses abdominal compartment syndrome (ACS), which refers to organ dysfunction caused by increased intra-abdominal pressure known as intra-abdominal hypertension (IAH). The key points are:
1. ACS can impair nearly every organ system but is often underdiagnosed. Diagnosis requires measuring intra-abdominal pressure via bladder catheter.
2. Management consists of supportive care initially but may require surgical decompression of the abdomen in severe cases.
3. Following decompression, temporary abdominal closure techniques are used until definitive closure can be achieved or a planned hernia results.
This document discusses cardiopulmonary cerebral resuscitation (CPCR) in dogs and cats. It defines key terms like respiratory arrest and cardiopulmonary arrest. It outlines that overall survival to discharge is around 6-7% for dogs and 3% for cats. The document then discusses the goals and steps of basic life support (BLS) including circulation, airway, and breathing. It also covers advanced life support (ALS) techniques like drug administration, electrical defibrillation, fluid therapy, and monitoring such as ECG and end-tidal CO2. Finally, it summarizes the RECOVER initiative which aimed to establish evidence-based guidelines for small animal CPR.
This document provides an overview of acute kidney injury (AKI), chronic kidney disease (CKD), end-stage renal disease (ESRD), and their treatment and management. It discusses the pathophysiology, stages, symptoms, complications, medical and surgical interventions, and nursing care for each condition. Dialysis methods like hemodialysis and peritoneal dialysis are explained in detail. Surgical procedures for the kidneys like nephrectomy and transplantation are also summarized.
1. The document discusses various surgical issues that may arise in intensive care unit (ICU) patients, including airway complications requiring procedures like tracheostomy, pulmonary issues like pneumothorax requiring chest tubes, cardiac tamponade requiring pericardial drainage, and abdominal issues like bowel obstruction.
2. Case studies are presented of patients with increased intra-abdominal pressures from hemorrhage and ileus that require decompression through laparotomy to treat abdominal compartment syndrome.
3. Guidelines are provided for management of issues like compartment syndrome through early diagnosis and fasciotomy if pressures are elevated.
This document discusses parenteral nutrition, including its indications, types, components, guidelines for administration and monitoring. Parenteral nutrition involves intravenous delivery of nutrients like protein, carbohydrates and fat. It is used when oral or enteral nutrition is not possible. The document outlines the different types of parenteral access, infusion schedules, nutrient components and their daily requirements. It also discusses complications of parenteral nutrition and their management. Studies have found that initiating parenteral nutrition later, around day 8, in critically ill pediatric patients results in fewer infections and shorter hospital stays compared to early initiation within 24 hours.
This document provides an overview of emergency medicine as a specialty. It discusses the top causes of death, the reception process in emergency departments, how cases are triaged from life-threatening to non-urgent, and examples of common illnesses and injuries seen in emergency medicine including chest pain, fractures, seizures, and psychiatric illnesses. It also outlines both the appeals and challenges of working in emergency medicine as well as potential career paths within the specialty.
The document outlines the importance of post resuscitation care to stabilize patients after return of spontaneous circulation, including supporting oxygenation and circulation, treating injuries from CPR, monitoring for recurrent cardiac arrest, and promptly transferring patients to intensive care units for specialized monitoring and treatment. Proper post resuscitation care is critical to optimize outcomes in the hours after resuscitation.
The document discusses basic life support (BLS) principles and procedures. It covers the ABCs of BLS - maintaining airway, breathing, and circulation. It describes the steps of CPR for adults, children, and infants, including assessment, calling for help, chest compressions, and rescue breathing. It also discusses special considerations for airway obstruction, shock, and triage in emergencies and disasters.
The most challenging scenario you can ever face is resuscitation of pediatric population in your ED, high level of stress is involved, so going systematic will make your work easy. The new PALS guidelines by AHA is quoted d here.
SEPSIS AND SEPTIC SHOCKDELIVER TARGETED RESUSCITATIONSandro Zorzi
WHO Critical Care Severe Acute Respiratory Infection Training
At the end of this lecture, you will be able to:•Describe how to deliver early, targeted resuscitation in patients (adults and children) with sepsis-induced tissue hypoperfusion and shock.•Understand the special considerations when resuscitating paediatricpatients in resource-limited settings.
This document discusses sepsis and septic shock. It defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock involves circulatory and metabolic abnormalities that increase mortality risk. The document reviews signs, laboratory findings, scoring systems, management principles, and treatment approaches for sepsis and septic shock such as early antibiotics, fluid resuscitation, vasopressors, inotropes, and glycemic control. The goal of treatment is to recognize sepsis early and provide timely, targeted resuscitation to improve outcomes.
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.
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.
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.
This document discusses the history and current guidelines for defining and managing sepsis and septic shock. It outlines how definitions of sepsis have changed over time, from the original 1991 definition focusing on systemic inflammatory response syndrome (SIRS) to the current Sepsis-3 definition requiring a known or suspected infection. The Surviving Sepsis Campaign was launched in 2002 to reduce sepsis mortality through guidelines, education, and performance improvement. The guidelines have been updated every four years, most recently in 2018, simplifying bundles and focusing on immediate resuscitation within 1 hour of recognition. The document reviews key elements of sepsis pathophysiology, diagnosis, source control, antibiotics, fluid resuscitation, vasopressors, corticost
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 provides guidelines for treating sepsis from 2016/2017. It defines sepsis as life-threatening organ dysfunction caused by infection. Early identification and treatment of sepsis in the initial hours improves outcomes. The guidelines recommend initial resuscitation within 1 hour of recognition, including administering IV fluids and antibiotics. Ongoing fluid management should be guided by frequent reassessment. The guidelines provide recommendations on screening, diagnosis, antimicrobial therapy, source control, and other treatment aspects of sepsis management.
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
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.
Severe sepsis and septic shock :evaluation and managementMd Shahid Iqubal
Sepsis and septic shock are life-threatening medical emergencies caused by dysregulated host response to infection leading to organ dysfunction. Management involves immediate evaluation and treatment, initial fluid resuscitation, early goal directed therapy including antibiotics and source control. Vasopressors, corticosteroids, glucose control, ventilation and DVT prophylaxis are also important supportive therapies to treat sepsis and prevent complications. The goal is to treat the infection and reverse the associated organ dysfunction.
1. The document provides learning objectives and an overview of dengue fever for post-graduate students. It defines dengue fever, lists its manifestations and complications, and describes both non-pharmacological and pharmacological management approaches.
2. Specific topics covered include IV fluid management, use of antipyretics and analgesics, management of bleeding and shock, intensive care management, and vaccines approved for dengue prevention.
3. Precautions for patients with comorbidities like hypertension and diabetes are also reviewed.
Total parenteral nutrition (TPN) involves infusing nutrients directly into the bloodstream, bypassing the gastrointestinal tract. It is indicated when enteral feeding is not possible or sufficient. TPN solutions provide calories, protein, fluids, electrolytes, vitamins and minerals. Central lines are used to administer concentrated TPN solutions while peripheral lines are used for more diluted formulations. Complications can include infections, metabolic issues like hyperglycemia, liver toxicity, and mechanical problems. Close monitoring is needed with TPN therapy.
This document provides guidance on monitoring patients with severe acute respiratory infection (SARI), including those with COVID-19. It emphasizes the importance of monitoring for early detection of clinical deterioration so that life-saving treatments can be administered promptly. Key parameters to monitor include respiratory rate, oxygen saturation, temperature, heart rate, blood pressure, and level of consciousness. Frequency of monitoring should be determined by the patient's condition and local resources, with critically ill patients monitored as often as every 5-15 minutes initially. Abnormal readings should prompt a clinical review and adjustment of care. Early warning scoring systems can help recognize deterioration earlier and trigger an escalated response.
CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC S...Bassel Ericsoussi, MD
This document provides guidelines for the management of severe sepsis and septic shock according to current international standards. It recommends initiating early goal-directed therapy as soon as hypoperfusion is recognized to target specific goals within the first 6 hours, including a central venous pressure of 8-12 mmHg and mixed venous oxygen saturation above 70%. Various methods for assessing fluid status and fluid responsiveness are discussed, including measurements of the inferior vena cava diameter and pulse pressure variation.
Assesment and treatment of acutely ill adultUzair Siddiqui
The document outlines an ABCDE approach for assessing and treating acutely ill adult patients, with A representing airway assessment, B for breathing, C for circulation, D for disability, and E for exposure. It provides guidance on evaluating each component through history, examination, and monitoring, while simultaneously aiming to reach a diagnosis to allow for definitive treatment. The approach emphasizes beginning oxygen therapy, intravenous access, fluid resuscitation, and monitoring as needed based on the patient's condition.
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.
This document provides guidelines for the treatment of severe sepsis and septic shock. It discusses initial resuscitation efforts such as fluid resuscitation, vasopressor therapy, and inotropic support to achieve hemodynamic targets. It also covers antimicrobial therapy, source control measures, and infection prevention strategies that should be implemented within the first hours and days for patients with severe sepsis.
This document discusses pandemic preparedness and ethical considerations for triage. It recommends developing a pandemic plan through public engagement and an interdisciplinary team. When demand exceeds resources, established triage protocols based on principles like utility, life-years saved, and equal opportunity can guide decisions. Younger patients may receive priority to access full life stages. The document also reviews triage tools and score systems to predict patient outcomes, noting limitations for children. Public trust requires transparency and fairness in resource prioritization during crises.
This document discusses quality improvement in critical care. It defines high quality care and describes the components of a critical care system. The document recommends selecting sepsis as a quality improvement project and outlines the steps to take, which include process mapping, setting objectives, pilot testing interventions, measuring outcomes, and continually improving processes. Quality improvement work aims to enhance patient outcomes through systematic and continuous activities.
The document provides guidance on liberating patients from invasive mechanical ventilation through the use of a daily spontaneous breathing trial (SBT) protocol. It outlines a 7-step approach to conducting SBTs, assessing readiness for extubation, and monitoring patients post-extubation. Implementing a protocol for daily SBTs can decrease ventilation times and ICU stays while improving patient outcomes when combined with the ABCDEF bundle to promote early mobility and reduce sedation, delirium, and weakness.
This document discusses best practices for preventing complications in critically ill patients. It describes how checklists and bundles can help implement interventions to reduce risks like ventilator-associated pneumonia, bloodstream infections, venous thromboembolism, and ICU-acquired weakness. TheABCDEF bundle is highlighted as a set of evidence-based practices that improves outcomes when reliably performed together, including reducing time on mechanical ventilation and in the ICU.
This document discusses management of acute respiratory distress syndrome (ARDS). It covers recognizing ARDS, initiating lung protective ventilation with low tidal volumes and plateau pressures, using PEEP appropriately, allowing permissive hypercapnia, and considering interventions for severe ARDS like prone positioning, higher PEEP, recruitment maneuvers, and neuromuscular blockade. Principles of lung protective ventilation are similar for children but tidal volumes should be based on ideal body weight and caution used with higher PEEP levels in young children.
This document provides guidance on prescribing antimicrobial therapy for patients with severe acute respiratory infection (SARI). It recommends empiric broad-spectrum antimicrobials and antivirals be given as soon as possible to patients with SARI and sepsis or severe pneumonia. It outlines antimicrobial regimens for bacterial and viral infections like COVID-19, influenza, and pneumonia. It stresses the importance of interpreting diagnostic tests correctly and narrowing or de-escalating treatment once the causative agent is identified.
This document provides guidance on oxygen therapy, including describing its importance, indications, administration methods, and monitoring. It emphasizes giving oxygen immediately to patients with severe respiratory distress or hypoxemia. Target oxygen saturation levels are outlined for different patient groups. Methods for titrating oxygen to reach targets using the appropriate flow rate and delivery device are also described.
This document provides guidance on diagnosing and treating patients with severe acute respiratory infection (SARI). It discusses developing a differential diagnosis considering community-acquired pathogens, hospital-associated pathogens, and respiratory viruses with pandemic potential. It recommends collecting upper and lower respiratory tract samples for diagnostic testing, emphasizing doing so early in illness and considering local epidemiology. Rapid diagnostic tests and PCR are described for detecting influenza and other respiratory viruses. Empiric treatment should not be delayed while awaiting diagnostic results.
This document provides guidance on screening, triage, and care of patients with severe acute respiratory infection (SARI). It outlines how to recognize SARI patients needing hospitalization, apply infection prevention measures, provide emergency care, and ensure safe transfer to intensive care units. The document emphasizes the need to identify critically ill SARI patients early, treat them promptly with evidence-based supportive therapies, and closely monitor their condition. It also discusses risk factors for severe disease and clinical signs suggestive of SARI that warrant hospitalization.
This document discusses the pathophysiology of sepsis and acute respiratory distress syndrome (ARDS). It describes sepsis as a dysregulated host response to infection that causes widespread inflammation and injury to the microvasculature. This leads to vasodilation, increased capillary permeability, hypovolaemia, and hypoperfusion, resulting in life-threatening organ dysfunction and shock. It describes ARDS as an overwhelming inflammatory process that injures alveoli, causing them to flood with protein-rich fluid. Alveolar collapse then creates ventilation-perfusion mismatch, clinically presenting as severe and refractory hypoxemia.
This document provides information on recognizing and treating patients with severe acute respiratory infection (SARI), pneumonia, acute respiratory distress syndrome (ARDS), and sepsis. It begins with learning objectives and definitions of SARI, COVID-19 symptoms, and the importance of early recognition of SARI patients. It then discusses recognizing severe pneumonia, ARDS, and sepsis based on symptoms, severity scores, and clinical criteria. It emphasizes the need for early treatment and resuscitation to improve outcomes.
This document provides guidance on infection prevention and control (IPC) measures for patients with severe acute respiratory infections (SARI), including those with pandemic potential like COVID-2019. It outlines general IPC principles like standard precautions, and specific precautions for SARI like droplet and contact precautions. It also provides recommendations for administrative controls, triage of patients, and proper use of personal protective equipment. The goal is to prevent transmission and protect healthcare workers when caring for patients with respiratory illnesses.
This document provides guidance on designing and operating a SARI treatment center to optimize care and strengthen infection prevention and control measures. It discusses key principles, basic facility design, ventilation, referral pathways, and surge capacity. The objectives are to provide best care for patients in a safe, private environment built around patient needs, while preventing disease transmission through isolation, proper airflow and waste management, training, and correct protocols. The document outlines considerations for layout, zoning by risk level, ventilation requirements, and patient flows through areas like triage, sampling, wards for mild, moderate and severe cases, and discharge.
This document provides an overview of the 2019 novel coronavirus (2019-nCoV) outbreak that began in Wuhan, China in December 2019. It describes the clinical presentation and management of 2019-nCoV, compares it to other coronaviruses like SARS and MERS, and outlines current WHO guidance on case definitions, investigations and infection control.
Temple of Asclepius in Thrace. Excavation resultsKrassimira Luka
The temple and the sanctuary around were dedicated to Asklepios Zmidrenus. This name has been known since 1875 when an inscription dedicated to him was discovered in Rome. The inscription is dated in 227 AD and was left by soldiers originating from the city of Philippopolis (modern Plovdiv).
This presentation was provided by Rebecca Benner, Ph.D., of the American Society of Anesthesiologists, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumMJDuyan
(𝐓𝐋𝐄 𝟏𝟎𝟎) (𝐋𝐞𝐬𝐬𝐨𝐧 𝟏)-𝐏𝐫𝐞𝐥𝐢𝐦𝐬
𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
- Understand the goals and objectives of the Edukasyong Pantahanan at Pangkabuhayan (EPP) curriculum, recognizing its importance in fostering practical life skills and values among students. Students will also be able to identify the key components and subjects covered, such as agriculture, home economics, industrial arts, and information and communication technology.
𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
-Define entrepreneurship, distinguishing it from general business activities by emphasizing its focus on innovation, risk-taking, and value creation. Students will describe the characteristics and traits of successful entrepreneurs, including their roles and responsibilities, and discuss the broader economic and social impacts of entrepreneurial activities on both local and global scales.
This presentation was provided by Racquel Jemison, Ph.D., Christina MacLaughlin, Ph.D., and Paulomi Majumder. Ph.D., all of the American Chemical Society, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
How to Setup Warehouse & Location in Odoo 17 InventoryCeline George
In this slide, we'll explore how to set up warehouses and locations in Odoo 17 Inventory. This will help us manage our stock effectively, track inventory levels, and streamline warehouse operations.
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
2. HEALTH
programme
EMERGENCIES
Learning objectives
At the end of this lecture, you will be able to:
• Describe how to deliver early, targeted resuscitation in patients (adults and
children) with sepsis-induced tissue hypoperfusion and shock.
• Understand the special considerations when resuscitating paediatric patients
in resource-limited settings.
|
3. HEALTH
programme
EMERGENCIES
COVID-2019 and sepsis shock
• SEPSIS-3 Definition
– suspected or documented infection
– And acute, life-threatening organ dysfunction
– caused by dysregulated host response to infection.
• Severe COVID-2019 presents with sepsis syndrome and severe
pneumonia
– prevalence of shock unknown.
– cardiopulmonary collapse has been reported.
4. HEALTH
programme
EMERGENCIES|
Five principles of sepsis management (1/2)
1. Recognize patients with sepsis and septic shock:
– Patients with sepsis have suspected or documented infection and
acute, life-threatening organ dysfunction.
– A subset of these patients, may have septic shock and show clinical
signs of circulatory failure and hypoperfusion.
– Patients with sepsis and septic shock need treatment and resuscitation
immediately!
5. HEALTH
programme
EMERGENCIES|
Five principles of sepsis management (2/2)
2. Give appropriate antimicrobials within 1 hour.
3. Give a targeted resuscitation during the first 6 hours.
4. Monitor-record-interpret-respond.
5. Deliver quality care (later lecture).
“As soon as sepsis is suspected the
clock has started.”
6. HEALTH
programme
EMERGENCIES
Obtain intravenous access
• Patients with sepsis and shock require immediate IV access to
initiate fluid resuscitation.
• Peripheral IV catheters are easy to place and adequate for initial
resuscitation.
• If unable to place peripheral IV within a few minutes, then
consider emergent placement of intraosseous (IO) catheter.
7. HEALTH
programme
EMERGENCIES
IOs
• Can be easily placed
in adults and children
during emergency
situations.
• Can be used to infuse
fluid therapy,
vasopressors,
antimicrobials and
blood transfusions at
rapid rate.
• Can be used to take
blood samples.
8. HEALTH
programme
EMERGENCIES
Central venous catheter (CVC)
• CVC may be needed in the
subset of patients with septic
shock that need
vasopressors.
• CVC should be placed under
complete sterile conditions,
using ultrasound guidance
when possible.
• CVC should be removed as
soon as no longer needed to
minimize risk of infection.
9. HEALTH
programme
EMERGENCIES
Interventions when shock is present
• crystalloid fluids
• vasopressors
• inotropes
• packed red blood cell (PRBC) transfusion with
severe anemia.
EARLY resuscitation combined with EARLY appropriate antimicrobial
therapy saves lives in patients with sepsis and shock.
Surviving Sepsis Campaign, 2016
11. HEALTH
programme
EMERGENCIES|
Improved BP:
• mean arterial pressure (MAP) ≥
65 mmHg
• SBP > 100 mmHg.
Adequate urine output:
• ≥ 0.5 mL/kg/hr.
Skin examination:
• capillary refill < 2–3 sec if < 65
years; < 4.5 if > 65 years
• absence of skin mottling
• well felt peripheral pulses
• warm dry extremities.
Improved sensorium
Normalized lactate levels
(if initial level high)
MAP = [SBP + (2 *DBP)] ÷ 3
MAP is driving the driving pressure of perfusion
Resuscitation targets (1/2)
12. HEALTH
programme
EMERGENCIES
Resuscitation: fluid type
• Crystalloid fluid is preferred:
– Lactate Ringers (LR*), Ringer’s Acetate (RA), PlasmaLyte (PL) or normal
saline (NS)
• NS is associated with hyperchloremic acidosis. Balanced solutions minimize this
risk. Avoid hyperchloraemia.
– Albumin as effective as crystalloids in septic shock
• Use in addition to crystalloid, when substantial crystalloids are needed for
intravascular volume repletion.
– Do NOT give hypotonic fluid.
– Do NOT give semisynthetic colloids
• i.e. starch-based colloids (HES, dextrans) have been associated with increased
acute kidney injury, renal replacement therapy and mortality. Gelatin safety
unknown..
13. HEALTH
programme
EMERGENCIES
• Give fluid for resuscitation as a fluid challenge (also
termed bolus or loading).
• Give initial fluid challenge of 20–30 mL/kg over 30–
60 minutes (or faster).
• Perform sequential evaluations to assess clinical
response.
• If shock persists, continue to give additional fluid
challenges (i.e. 250–500 mL) over 30 minutes as
long as there is a clinical response..
Resuscitation: fluid challenge
14. HEALTH
programme
EMERGENCIES
Resuscitation: Fluid responsive
• Fluid challenge aims to correct the
hypovolaemia associated with
sepsis.
• By improving hypovolaemia, stroke
volume and cardiac output improve;
and thus perfusion parameters also
improve.
• A fluid responsive patient shows
signs of improved perfusion with the
fluid challenge.
15. HEALTH
programme
EMERGENCIES
Predicting fluid responsiveness
● Administering fluid challenges when patient is no longer fluid
responsive can be harmful:
- i.e. organ oedema, prolonged days of MV.
● However, predicting fluid responsiveness is a challenge:
- Single, static parameters, such as CVP or inferior vena cava (IVC) size
do not reliably predict volume responsiveness in isolation.
● Dynamic variables may more reliably predict responsiveness,
however cut-off points, sensitivity and specificity remain in
question.
16. HEALTH
programme
EMERGENCIES
• Vasopressors maintain a minimum perfusion
pressure and adequate flow during life-threatening
hypotension.
• Vasopressors are potent vasoconstrictors and
increase myocardial contractility to a lesser extent:
– Administer through a CVC.
– Give at a strictly controlled rate, titrate to desired effect.
– Discontinue when no longer needed to minimize risks.
• Start vasopressors after initial fluid bolus:
– But can be given early, during ongoing resuscitation when
shock is severe and diastolic pressure is low.
– Do not delay administration.
If MAP remains < 65 mmHg,
start vasopressors
17. HEALTH
programme
EMERGENCIES
Vasopressors
• Norepinephrine (first choice, titrate):
– potent vasoconstrictor with less increase in HR.
• Epinephrine (alternative, titrate):
– potent vasoconstrictor, and also has inotropic effects
– can add as additional agent to achieve desired effect
– can use as an alternative to norepinephrine (if not available).
• Vasopressin (fixed dose 0.03 U/min):
– can be used to reduce norepinephrine dose
– can add as additional agent to achieve effect
– caution if patient not yet euvolemic.
• Restrict dopamine use because it may be associated with
increased mortality and increase in tachyarryhthmia.
18. HEALTH
programme
EMERGENCIES
Titrate vasopressors to desired effect
• Titrate to target MAP range ≥ 65–70 mmHg.
• Can individualize MAP target based on patient’s
clinical characteristics:
– i.e. consider higher MAP (i.e. ≥ 80 mmHg) in patients with chronic
hypertension to reduce risk of AKI, if patient responds better to higher
MAP.
• Titrate vasopressors to improve markers of perfusion:
– i.e. mental status, urine output, normalization of lactate* and skin
examination.
• Titrate down vasopressors if blood pressure in above
target range.
19. HEALTH
programme
EMERGENCIES
Inotropes for septic shock
● Add inotropes if patient shows continued signs of hypoperfusion despite
achieving adequate fluid loading and use of vasopressors to reach target
MAP.
• Measured or suspected low cardiac output (i.e.
echocardiogram).
• Dobutamine is first choice inotrope. If not available, then
epinephrine:
– Start at 2.5 μg/kg/min (max 20), titrate to improve clinical markers of
perfusion and cardiac output.
– Do not aim to increase cardiac output to supranormal levels.
– Risks include tachyarrhythmias and hypotension.
20. HEALTH
programme
EMERGENCIES
PRBCs for shock
● Give PRBCs transfusion when there is severe
anaemia:
- Hb ≤ 70g/L (7.0 g/dL) in absence of extenuating
circumstances such as myocardial infarction,
severe hypoxaemia, or acute haemorrhage.
• Targeting higher thresholds (≥ 90–100 g/L) does not
lead to better outcomes in patients with sepsis.
21. HEALTH
programme
EMERGENCIES
Peripheral administration of vasopressor
• Though preference is for central delivery,
norepinephrine, dopamine or
epinephrine can be given via
peripheral IV.
• Caution: Risk of peripheral infusion
is extravasation of medication
and local tissue necrosis.
• Requires close nursing care to check
infusion site:
– If necrosis, stop infusion and consider injection of
1 mL phentolamine solution subcutaneously.
– Phentolamine is a vasodilator
– 5–10 mg in 10 mL of NS.
Permission C. Gomersall
http://www.aic.cuhk.edu.hk/web8/Dopamine_extra
vasation_1.jpg
22. HEALTH
programme
EMERGENCIES
Management of pregnant woman with shock
• Maternal positioning:
– Lateral tilt (elevating either hip 10–12 cm) or manual displacement of uterus to left will
augment venous return to heart.
– Enlarging gravid uterus compresses pelvic and abdominal vessels, inhibiting venous
return when patient is supine, thus tilting displace uterus.
– Maternal position should not be flat on back after 24 weeks.
23. HEALTH
programme
EMERGENCIES
• Even before maternal haemodynamics are
compromised, blood may shunt away from placenta.
• Monitor woman and fetus.
• Once maternal BP or SpO2 are reduced, then fetus will
become rapidly distress.
• Early recognition and resuscitation are essential.
• During pregnancy, there is an overall increase in blood
volume, HR and cardiac output, and reduction in oncotic
pressure.
24. HEALTH
programme
EMERGENCIES
Management of pregnant woman with shock
• Ensure adequate hydration, use IV fluids as necessary:
– Close attention to fluid balance to prevent fluid overload and pulmonary oedema.
– Oncotic pressure decreases throughout pregnancy and in the postpartum period.
• Vasopressors – use cautiously with appropriate available monitoring:
– May decrease uterine perfusion.
– Administer with IV fluids – uteroplacental flow will not be adequate with vasopressors
alone.
– Must monitor fetus when administering.
26. HEALTH
programme
EMERGENCIES
Special considerations for
children with shock
• See WHO Pocket Book of Hospital Care for
Children for detailed management if child has:
– severe acute malnutrition
– severe malaria with profound anaemia (i.e. Hb < 5)
– diarrhoea and severe dehydration
– severe dengue shock syndrome.
27. HEALTH
programme
EMERGENCIES
ICU capacity
• Consider local resources to delver intensive care to
children, availability of the following:
– advanced respiratory support, ventilators
– haemodynamic monitoring
– skilled and experienced staff (i.e. paediatric intensivists).
– If any of the above are limited, consider using WHO guidance
over PALS guidance for treatment of septic child with shock.
28. HEALTH
programme
EMERGENCIES
WHO ETAT shock definition
• Presence of all of the following three clinical
criteria required to diagnose shock:
– delayed capillary refill ≥ 3 sec
– cold extremities
– weak and fast pulse.
• Or frank hypotension.
29. HEALTH
programme
EMERGENCIES|
Reach resuscitation targets
within 6 hours
Improved BP:
• age-appropriate SBP and MAP.
Adequate urine output:
• ≥ 1.0 mL/kg/hr.
Skin examination:
• capillary refill ≤ 2 sec
• absence of skin mottling
• well felt peripheral pulses
• warm dry extremities.
Improved sensorium
Normal calcium and
glucose levels
Threshold heart rates:
• up to 1 year: 120–180 bpm
• up to 2 years: 120–160 bpm
• up to 7 years: 100–140 bpm
• Up to 15 years: 90–140 bpm.
BP is less reliable endpoint because children have potent vasoconstrictor response.
If the child is hypotensive, cardiovascular collapse may occur soon.
30. HEALTH
programme
EMERGENCIES
First: fluid loading
WHO ETAT 2016 PALS Guidance 2015
Initial bolus 10 –20 mL/kg over 30–60 minutes
(faster if profound hypotension).
20 mL/kg over 5–10 minutes.
Reassessment Reassess perfusion indicators between fluid challenges. Examine for fluid
overload.
Second bolus If after first bolus, child is still in
shock, repeat fluid bolus.
10 mL/kg over 30 minutes
providing no signs of fluid
overload.
If after first bolus, child still in shock, give
another 20 mL/kg challenge over 15–20
minutes.
Can be repeated.
Max fluid at 1
hour
30 mL/kg 60 mL/kg
When to stop fluid
therapy
Fluid therapy should be stopped once shock resolves (targets are met) or
there are signs of fluid overload or cardiac failure.
31. HEALTH
programme
EMERGENCIES
Second: inotropes and vasopressors
• If child remains in shock after initial fluid load then
start inotrope/vasopressors:
– titrate epinephrine, 0.05–0.5 mcg/kg/min (IV or IO) or dopamine
– if child has hypotension (warm shock) add norepinephrine, 0.05–0.3
mcg/kg/min.
• Monitor child frequently and regularly:
– children may cycle between these shock states as their illness evolves.
32. HEALTH
programme
EMERGENCIES
When to stop fluid therapy
• Stop fluids once resuscitation targets have been met
to avoid harmful effects of fluid overload.
• Stop fluids if patient is no longer fluid responsive and
develops signs of fluid overload:
– Very high CVP (interpreted in context of high intra-thoracic pressures,
pulmonary hypertension and RV dysfunction).
– Pulmonary oedema (e.g. crackles on auscultation, chest X-ray or
ultrasound).
– Hepatomegaly and cardiac failure are also a signs of overload.
33. HEALTH
programme
EMERGENCIES
Risks of excess fluid therapy
• Increased tissue oedema.
• Worsened hypoxaemia.
• Worsens cardiac function in patients with cardiac
failure.
• Increased length of stay.
• Increased morbidity and may increase mortality.
35. HEALTH
programme
EMERGENCIES
Corticosteroids and shock
• Consider low dose IV hydrocortisone, if adequate fluid
resuscitation and vasopressors fail to restore
hemodynamic stability:
– 50 mg every 6 hours or continuous for adults for (i.e. 5 days)
– 50 mg/m2/24 hours (1–2 mcg/kg 6 hourly) in children
– taper when vasopressors no longer needed
• i.e. 50 mg twice daily for days 6–8; 50 mg once daily days 9–11.
– risks are hyperglycaemia and hypernatraemia.
• Precaution:
– Do not administer high doses steroids (i.e. > 300 mg daily).
– Do not use in sepsis without shock.
– Do not use to treat influenza pneumonitis alone, but can be used for other
respiratory indications.
|
36. HEALTH
programme
EMERGENCIES
Hyperglycaemia and sepsis
• Initiate a protocolized approach to blood glucose management
when two consecutive measurements >10 mmol/L (180 mg/dL):
– target glucose of < 180 mg/dL
– avoid intensive insulin for tight glucose control (4.5–6 mmol/L, 80–110
mg/dL), this approach causes harm
– avoid wide swings in glucose levels.
• Frequently monitor blood glucose, every 1–2 hours until stable,
then every 4 hours, to prevent hypoglycaemia.
• Major risk is severe hypoglycaemia:
– caution: point of care measurement can be falsely high in shock, interpret with
caution.
38. HEALTH
programme
EMERGENCIES
Summary
• Early targeted resuscitation combined with early appropriate
antimicrobial therapy saves lives in patients with sepsis and
septic shock.
• Early resuscitation with crystalloid fluid and vasopressors are the
most common intervention for septic shock.
• Resuscitation targets include improved blood pressure and
other markers of tissue perfusion (mental status, urine output,
skin, pulses, lactate).
• Modify resuscitation strategies for children with shock if child
has severe malaria with anaemia or severe malnutrition; or is
being cared for in setting with limited ICU capacity.
39. HEALTH
programme
EMERGENCIES
Acknowledgements
Dr Shevin Jacob, University of Washington, Seattle, WA
Dr Janet V Diaz, WHO Consultant, San Francisco CA, USA
Dr Neill Adhikari, Sunnybrook Health Sciences Centre, Toronto, Canada
Dr Edgar Bautista, Instituto Nacional de Enfermedades Respiratorias, México City, Mexico
Dr Paula Lister, Great Ormond Street Hospital, London, United Kingdom
Dr Steven Webb, Royal Perth Hospital, Perth, Australia
Dr Niranjan Bhat, Johns Hopkins University, Baltimore, USA
Dr Timothy Uyeki, Centers for Disease Control and Prevention, Atlanta, USA
Dr Paula Lister, Great Ormond Street Hospital, London, UK
Dr Niranjan "Tex" Kissoon, British Colombia Children’s Hospital and Sunny Hill Health Centre for Children, Vancouver, Canada
Dr Ashoke Banarjee, Westmead Hospital, New South Wales, Australia
Dr Christopher Seymour, University of Pittsburgh Medical Center, USA
Dr Derek Angus, University of Pittsburgh Medical Center, USA
Dr Sergey Shlapikov, St Petersburg State Medical Academy, Saint Petersburg, Russian Federation
Dr Paul McGinn, Geelong, Victoria, Australia
Dr Bin Du, Peking Union Medical College Hospital, Beijing, China
Dr Kath Maitland, Imperial College of Science, Technology and Medicine, London, UK
Editor's Notes
* Hartmann’s solution, Ringers Acetate can also be used.