This document discusses septic shock, its definitions, signs, symptoms, causes, risk factors, pathophysiology, management, and treatment. It defines septic shock as persisting hypotension requiring vasopressors to maintain blood pressure and a serum lactate above 2 mmol/L despite fluid resuscitation. Management involves early antibiotic therapy, source control, fluid resuscitation, vasopressor support, and organ support. The key goals are starting appropriate antibiotics quickly, resuscitating from shock, identifying and treating the infection source, and maintaining organ function.
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.
Latest definition of sepsis, application of qSOFA, latest evidence on treatment of septic shock,role of fluids, role of steroids, isobalance salt solution
It includes new definition, pathophysiology, management of sepsis, septic shock and neutropenic sepsis and even newer evolving concepts or types of sepsis.
Septic shock, updated presentation, including latest guidelines from Intensive care societies and how to approach to the diagnosis with few notes about Early Goal Directed Therapy and role of steroids
Latest definition of sepsis, application of qSOFA, latest evidence on treatment of septic shock,role of fluids, role of steroids, isobalance salt solution
It includes new definition, pathophysiology, management of sepsis, septic shock and neutropenic sepsis and even newer evolving concepts or types of sepsis.
Septic shock, updated presentation, including latest guidelines from Intensive care societies and how to approach to the diagnosis with few notes about Early Goal Directed Therapy and role of steroids
Interstitial lung diseases (ILDs) are a group of more than 200 different disorders that cause scarring in the lungs. Scar tissue in the lungs can make it harder for you to breathe normally. In ILDs, scarring damages tissues in or around the lungs’ air sacs and airways.
To prevent the spread of COVID-19:
Clean your hands often. Use soap and water, or an alcohol-based hand rub.
Maintain a safe distance from anyone who is coughing or sneezing.
Wear a mask when physical distancing is not possible.
Don’t touch your eyes, nose or mouth.
Cover your nose and mouth with your bent elbow or a tissue when you cough or sneeze.
Stay home if you feel unwell.
If you have a fever, cough and difficulty breathing, seek medical attention.
Calling in advance allows your healthcare provider to quickly direct you to the right health facility. This protects you, and prevents the spread of viruses and other infections.
Masks
Masks can help prevent the spread of the virus from the person wearing the mask to others. Masks alone do not protect against COVID-19, and should be combined with physical distancing and hand hygiene. Follow the advice provided by your local health authority.
This ppt describes in brief about the anatomy of bowel, types and properties of suture materials, types of bowel anastomosis, method of doing a bowel anastomosis and factors affecting integrity of anastomosis.
A 2019 update on the current role of robotics and simulation in neurosurgery with updates from the recent edition of Youman and Winn's Textbook of Neurosurgery. Videos in the presentation cannot be uploaded but can be viewed from youtube.
A brief overview of pituitary adenomas, their subtypes, classification, investigation protocols, radiological evaluation, and their medical management.
A Prospective Study of Evaluation of Operative Duration as a Predictor of Mortality in Pediatric Emergency Surgery: Concept of 100 Minutes Laparotomy in Resource-limited Setting
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
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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.
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
2. Introduction
■ Earlier
Systemic inflammatory response syndrome (SIRS) → sepsis → severe sepsis
→ septic shock → multiple organ dysfunction syndrome (MODS) → death
■ Now
Sepsis → septic shock → organ dysfunction/multiple organ dysfunction
syndrome (MODS) → multiple organ failure syndrome → death
■ SIRS is defined as 2 or more of the following variables
– Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
– Heart rate of more than 90 beats per minute
– Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide
tension (PaCO 2) of less than 32 mm Hg
– Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10%
immature [band] forms)
3. ■ New 2016 definition, also called Sepsis-3, eliminates the requirement for the
presence of systemic inflammatory response syndrome (SIRS) to define sepsis, and
it removed the severe sepsis definition. What was previously called severe sepsis is
now the new definition of sepsis.
■ Sepsis is defined as life-threatening organ dysfunction due to dysregulated host
response to infection.
■ Bacteremia is defined as the presence of viable bacteria within the liquid
component of blood.
– May be primary (without an identifiable focus of infection) or, more often,
secondary (with an intravascular or extravascular focus of infection).
– Although sepsis is associated with bacterial infection, bacteremia is not a
necessary ingredient in the activation of the inflammatory response that results
in severe sepsis.
– Septic shock is associated with culture-positive bacteremia in only 30-50% of
cases.
4. ■ Septic Shock is defined by persisting hypotension requiring vasopressors
to maintain a mean arterial pressure of 65 mm Hg or higher; and a serum
lactate level greater than 2 mmol/L (18 mg/dL) despite adequate volume
resuscitation.
■ Organ Dysfunction is defined as an acute change in total Sequential
Organ Failure Assessment (SOFA) score greater than 2 points secondary to
the infectious cause.
■ For screening purposes, a shorter version of the SOFA score, termed quick SOFA
(qSOFA), demonstrated to have reasonable accuracy in the settings outside the
ICU.
■ qSOFA is defined by two or more of a total of the following three components:
– altered mental status,
– respiratory rate of 22 or higher, and
5.
6. ■ Multiple organ dysfunction syndrome (MODS) is defined as the
presence of altered organ function in a patient who is acutely ill and in
whom homeostasis cannot be maintained without intervention.
■ MODS may eventually lead to multiple organ failure syndrome (MOFS) and
death.
■ Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are
common manifestations of MODS or MOFS.
■ However, other conditions besides sepsis can cause MODS, including
trauma, burns, and severe hemorrhagic shock.
7. ■ Acute lung injury and acute respiratory distress syndrome : Berlin
Definition of ARDS classifies ARDS as mild, moderate, or severe :
– Mild ARDS – An oxygenation abnormality with a PaO2/FIO2 ratio of 200-300
and a positive end-expiratory pressure (PEEP) or continuous positive airway
pressure (CPAP) of 5 cm H2O or higher
– Moderate ARDS – A PaO2/FIO2 ratio of 100-200 and a PEEP of 5 cm H2O or
higher
– Severe ARDS – A PaO2/FIO2 ratio of 100 or less and a PEEP of 5 cm H2O or
higher
– Bilateral opacities on chest radiographs that are not fully explained by
effusions, lobar/lung collapse, or nodules
– Edema not of cardiac origin or caused by fluid overload – In the absence of
risk factors for ARDS, this requires objective assessment (eg, via
echocardiography)
– Occurrence within 1 week of a known clinical insult or worsening respiratory
symptoms
8. ■ MODS staging : Two well-defined forms of MODS exist.
1. In the more common form of MODS, the lungs are the predominant, and often the only,
organ system affected until very late in the disease.
– Present with a primary pulmonary disorder (eg, pneumonia, aspiration, lung contusion, near-
drowning, chronic obstructive pulmonary disease [COPD] exacerbation, hemorrhage, or
pulmonary embolism [PE]).
– Pulmonary dysfunction may be accompanied by encephalopathy or mild coagulopathy and
persists for 2-3 weeks. At this time, the patient either begins to recover or progresses to
develop fulminant dysfunction in other organ systems.
– Patients who develop another major organ dysfunction often do not survive.
2. In the second, less common, form of MODS, the presentation is quite different.
– Inciting source of sepsis in organs other than the lung; the most common sources are intra-
abdominal sepsis, extensive blood loss, pancreatitis, and vascular catastrophes.
– Not only does ARDS develop early, but dysfunction also develops in other organ systems,
including the hepatic, hematologic, cardiovascular, and renal systems and central nervous
system (CNS).
– Patients remain in a pattern of compensated dysfunction for several weeks, then either
recover or deteriorate further.
10. Causative microorganisms
■ Before the introduction of antibiotics, gram-positive bacteria were the principal organisms that
caused sepsis.
■ Subsequently, gram-negative bacteria became the key pathogens causing severe sepsis and septic
shock.
■ Currently, however, the rates of severe sepsis and septic shock due to gram-positive organisms are
rising again because of the more frequent use of invasive procedures and lines in critically ill
patients.
■ As a result, gram-positive and gram-negative microorganisms are now about equally likely to be
causative pathogens in septic shock.
■ Respiratory tract and abdominal infections are the most frequent causes of sepsis, followed by
urinary tract and soft-tissue infections.
■ Lower respiratory tract infections cause septic shock in 35-50% of patients. The following are the
common pathogens:
– Streptococcus pneumoniae
– Klebsiella pneumoniae
– Escherichia coli
– Legionella spp
– Haemophilus spp
– Staphylococcus aureus
11. ■ Abdominal and GI tract infections cause septic shock in 20-40% of patients.
The following are the common pathogens:
– E coli
– Enterococcus spp
– Bacteroides fragilis
– Acinetobacter spp
– Pseudomonas spp
– Enterobacter spp
– Salmonella spp
– Klebsiella spp
– Anaerobes
■ Urinary tract infections cause septic shock in 10-30% of patients. The
following are the common pathogens:
– E coli
– Proteus spp
– Klebsiella spp
– Pseudomonas spp
12. ■ Infections of the male and female reproductive systems cause septic shock in 1-
5% of patients. The following are the common pathogens:
– Neisseria gonorrhoeae
– Gram-negative bacteria
– Streptococci
– Anaerobes
■ Soft-tissue infections cause septic shock in 5-10% of patients. The following are
the common pathogens:
– S aureus
– Staphylococcus epidermidis
– Streptococci
– Clostridium spp
■ Infections due to foreign bodies cause septic shock in 1-5% of patients. S aureus,
S epidermidis, and fungi (eg, Candida species) are the common pathogens.
■ Miscellaneous infections, such as CNS infections, also cause septic shock in 1-5%
of patients. Neisseria meningitidis is a common cause of such infections.
13. A 72-year-old woman comes to you 52 hours following uncomplicated
laparoscopic cholecystectomy for gallstone disease. She was found
unconscious on the ward with generalized tonic-clonic seizures, requiring 20
mg diazepam. Her sodium level is 112 mmol/L. During surgery she received
3 L of 5% dextrose with 20 mmol/L potassium chloride. Her potassium and
urea and creatinine are within normal limits. There are no signs of heart
failure. Her plasma osmolality is 265 mOsm/kg and her urinary osmolality is
566 mOsm/kg. Which of the following is the most likely cause for her low
sodium?
A. Excess 5% dextrose
B. Addison's disease
C. Syndrome of inappropriate antidiuretic hormone secretion
D. Nephrotic syndrome
E. Congestive cardiac failure
14. Risk factors
■ Extremes of age (< 10 years and >70 years)
■ Primary diseases (eg, liver cirrhosis, alcoholism, diabetes mellitus,
cardiopulmonary diseases, solid malignancy, and hematologic malignancy)
■ Immunosuppression (eg, from neutropenia, immunosuppressive therapy [eg, in
organ and bone marrow transplant recipients], corticosteroid therapy, injection or
IV drug use, complement deficiencies, asplenia)
■ Major surgery, trauma, burns
■ Invasive procedures (eg, placement of catheters, intravascular devices, prosthetic
devices, hemodialysis and peritoneal dialysis catheters, or endotracheal tubes)
■ Previous antibiotic treatment
■ Prolonged hospitalization
■ Underlying genetic susceptibility
■ Other factors (eg, childbirth, abortion, and malnutrition)
15. Signs and symptoms
■ Signs and symptoms of sepsis are often nonspecific and include the
following :
– Fever, chills, or rigors
– Confusion
– Anxiety
– Difficulty breathing
– Fatigue, malaise
– Nausea and vomiting
■ Typical symptoms of systemic inflammation may be absent in severe
sepsis, especially in elderly individuals.
■ Identify any potential source of infection.
16. Laboratory tests
■ Complete blood count with differential count
– WBC count higher than 15,000/µL or a neutrophil band count higher than
1500/µL has about a 50% correlation with bacterial infection.
– WBC counts higher than 50,000/µL or lower than 300/µL are associated with
significantly decreased survival rates.
– Hemoglobin concentration dictates oxygen-carrying capacity in blood, keeping
the hemoglobin concentration above 7 g/dL is usually practiced.
– Platelet count will fall with persistent sepsis, and disseminated intravascular
coagulation (DIC) may develop.
■ Coagulation studies (eg, prothrombin time [PT], activated partial
thromboplastin time [aPTT], fibrinogen levels)
– PT and the aPTT are elevated in DIC, fibrinogen levels are decreased, and
fibrin split products are increased.
17. ■ Blood chemistry (eg, sodium, chloride, magnesium, calcium, phosphate,
glucose, lactate)
– Sodium and chloride levels are abnormal in severe dehydration.
– Decreased bicarbonate can point to acute acidosis - sodium bicarbonate
therapy is not recommended to improve hemodynamics or replace
vasopressor requirements in patients with metabolic acidemia from
hypoperfusion whose pH level is 7.15 or greater.
– Hyperglycemia is associated with higher mortality.
– Serum lactate is perhaps the best serum marker for tissue perfusion. Lactate
levels > 2.5 mmol/L are associated with an increase in mortality. Lactate
levels higher than 4 mmol/L in patients with suspected infection have been
shown to yield a 5-fold increase in the risk of death and are associated with a
mortality approaching 30%.
■ Renal and hepatic function tests (eg, creatinine, blood urea nitrogen,
bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate
aminotransferase, albumin, lipase)
18. ■ American College of Critical Care Medicine (ACCCM) does not recommend
the routine use of free cortisol measurements in critically ill patients.
■ Blood cultures (Surviving Sepsis Campaign recommends obtaining at
least 2 blood cultures before antibiotics are administered, with 1
percutaneously drawn and the other(s) obtained through each vascular
access) - blood cultures are positive in fewer than 50% of cases of sepsis.
■ Urinalysis and urine cultures - Urinary tract infection (UTI) is a common
source for sepsis, especially in elderly individuals. Adults who are febrile
without localizing symptoms or signs have a 10-15% incidence of occult
UTI.
■ Gram stain and culture of secretions and tissue
19. Imaging studies
■ Chest, abdominal, or extremity radiography
– Most patients who present with sepsis have pneumonia.
– Chest radiography detects infiltrates in about 5% of febrile adults without localizing
signs of infection.
– Chest radiography is useful in detecting radiographic evidence of ARDS - bilateral hazy,
symmetric homogeneous opacities, which may demonstrate air bronchograms, ground-
glass opacities.
– Supine and upright or lateral decubitus abdominal radiographs - bowel obstruction or
perforation
– Osteomyelitis, necrotizing fasciitis, gas gasgrene
■ Abdominal ultrasonography
– acute cholecystitis or ascending cholangitis, acute pancreatitis
■ Computed tomography of the abdomen or head
– intra-abdominal abscess or a retroperitoneal source of infection, meningitis (Lumbar
Puncture)
20.
21. Management
■ Admission to the hospital – responders (general ward); non-responders (ICU)
■ Cardiac monitoring, noninvasive blood pressure monitoring, and pulse
oximetry.
■ Goal-directed therapy VS direct and aggressive individualized care [United
States (ProCESS [Protocolized Care for Early Septic Shock]), Australia (ARISE
[Australasian Resuscitation In Sepsis Evaluation]), and the United Kingdom
(ProMISe [Protocolised Management In Sepsis]).
■ Measuring lactate, targeting ScvO2 values, and insertion of a central venous
catheter were not associated with improved outcomes. What was important
was the direct and aggressive individualized care each patient received,
including early bacteriologic cultures of appropriate sites (eg, blood, urine,
sputum), early and correct institution of broad-spectrum antibiotics,
restoration of blood pressure, and reversal of evidence of end-organ
perfusion.
22. Management (contd…)
■ Management principles for septic shock include the following:
– Early recognition
– Early and adequate antibiotic therapy
– Source control
– Early hemodynamic resuscitation and continued support
– Proper ventilator management with low tidal volume in patients with acute respiratory distress
syndrome (ARDS)
■ Treatment of patients with septic shock has the following major goals:
– Start adequate antibiotics (proper spectrum and dose) as early as possible
– Resuscitate the patient from septic shock by using supportive measures to correct hypoxia,
hypotension, and impaired tissue oxygenation (hypoperfusion)
– Identify the source of infection and treat with antimicrobial therapy, surgery, or both (source
control)
– Maintain adequate organ system function, guided by cardiovascular monitoring, and interrupt the
23.
24.
25. ■ First 6 hours of resuscitation of a critically ill patient with sepsis or septic
shock are critical. The following should be completed within 3 hours:
– Obtain the lactate level
– Obtain blood cultures before administering antibiotics
– Administer broad-spectrum antibiotics
– Administer 30 mL/kg of crystalloid solution for hypotension or for lactate
levels of 4 mmol/L or higher
■ Following should be completed within 6 hours:
– Administer vasopressors for hypotension that does not respond to initial fluid
resuscitation to maintain a mean arterial pressure (MAP) of 65 mm Hg or
higher
– If hypotension persists despite volume resuscitation or the initial lactate level
is 4 mmol/L or higher, then measure central venous pressure (CVP) (aiming
for ≥8 mm Hg), measure central venous oxygen saturation (ScvO 2) (aiming
for ≥70%), and normalize lactate levels
26. Steps in Management
1. Venous access
2. Urinary catheterization
3. Respiratory support
4. Intubation and mechanical ventilation
5. Circulatory support
6. Correction of anemia and coagulopathy
7. Antimicrobial therapy
8. Temperature control
9. Metabolic and nutritional support
29. Surgery
■ Certain conditions will not respond to standard treatment for septic shock
until the source of infection is surgically removed -
– Intra-abdominal sepsis [perforation, abscesses]
– Empyema
– Mediastinitis
– Cholangitis
– pancreatic abscesses
– pyelonephritis or renal abscess from ureteric obstruction
– infective endocarditis
– septic arthritis
– infected prosthetic devices
– deep cutaneous or perirectal abscess
– necrotizing fasciitis
30. ■ Urgent management is indicated for hemodynamically stable patients
without evidence of acute organ failure, delay of invasive procedures for as
long as 24 hours may be possible if the patient receives very close clinical
monitoring and appropriate antimicrobial therapy.
■ When possible, percutaneous drainage of abscesses and other well-
localized fluid collections is preferred to surgical drainage.
■ However, any deep abscess or suspected necrotizing fasciitis should
undergo drainage in the surgical suite.
Editor's Notes
In either, the development of ARDS is of key importance, though ARDS is the earliest manifestation in all cases.