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Sepsis Update 2009




                Troy Pennington DO
The First Physician                 c. 2980 BC




 Ancient Egyptians founded
 medical schools; Imhotep was the
 first known physician to receive
 a medical degree.
Early Scientific Papers
                                2735 BC




  Chinese Emperor Shen Nung
  wrote a treatise on the use
  of ch’ang shan in fever.
The Code of Hammurabi   1800 BC
The first Contagion                              c. 100 BC



       “small creatures invisible
       to the eye, fill the
       atmosphere, and
       breathed through the
       nose cause dangerous
       diseases.”
       – Marcus Terentius Varro, De re rustica
         libri III
Case One

36 year old female with URI symptoms
resolving after 5 days followed by high
fever, body aches, cough, nausea,
vomiting and diarrhea.
BP 90/50 responds to fluids
K3.1, serum CO2 14
Case Two

71 year old male with acute altered
mental status, fever and cough
CXR-multilobar pneumonia
BP 80/40, Pulse 136, no change in blood
pressure after 3 liters of fluid
Central line CVP is 5cm H2O
Case Three
69 year old female from a convalscent
home BIB EMS intubated, febrile, Bp
94/56, RR 30.
Labs: UA WBC TNTC, CBC 25K with
48% bands, Creatine 5, Glucose 328,
Lactate 1.4mmol, Coags nl, CXR
Negative
Severe Sepsis

• Approximately 950,000 cases per year

• Over 200,000 deaths per year

• Costs for sepsis and related diseases over
  $25 billion/year   (Angus Crit Care Med 2003)
The Numbers
•   Sepsis & Septic Shock account for about 2.9%
    of hospital admits and 10% of ICU admissions
•   Estimated 50% came from the ED
•   Early Goal Directed Therapy focused on the
    initial 6 hours of patient care
•   The Surviving Sepsis Campaign incorporated
    EM as a key component
Sepsis…How does it Stack up

Trauma                           Cardiac Arrest
150,000
Deaths



                                    AMI
                       SEPSIS     250,000
Stroke 700,000 yr.   950,000yr     deaths
140,000 deaths yr.
                      200,000
                       deaths
Changing Paradigms
 Fighting the old paradigm
   it doesn’t make a difference
   intensivist’s job
   way too complicated
 Goals
   show outcomes differences
   early intervention is essential
   Keep it simple
Epidemiology


     The Most Common sites of sepsis are:
      1.   Lungs               45%
      2.   Abdomen             17%
      3.   Urinary Tract       10%
      4.   Undetermined        20-30%


  The Incidence of Fungal Sepsis has tripled due to
transplant patients and those on immunosuppresive
                      therapy.
              (Accounts for only 5% of all cases of sepsis)




                       N Engl J Med 340 (3):207
Epidemiology

 Gm-positive sepsis has overtaken
         Gram-negative sepsis


  Common gram-positive bacteria include:
 Staphylococcus aureus, coagulase-negative
 staphylococci, enterococci, and streptococci;

Most common gram-negative pathogens are
Escherichia coli, Klebsiella, and Pseudomonas;
The Sepsis Continuum
    INSULT      SIRS                 SEPSIS          SEVERE SEPSIS




A clinical response arising                                 Refractory
   from a nonspecific insult,       SIRS with a            Hypotension
   including > or = 2 of the                                     &
   following                        Presumed               Septic Shock
                                         or
•   Temperature <36c or >38c
•   HR>90 beats per minute           confirmed
•   Respirations > 20 BPM or    infectious process
         PaCO2 <32
•   WBC Count <4,000 or
    >12,000or >10% bands
                                                Bone et al. Chest. 1992:101.1644.
Sepsis…defined

      Sepsis
      SIRS with

Documented or Presumed

       infection
Severe Sepsis

    Sepsis and organ
       dysfuntion

   May include but not
limitied to lactic acidosis,
       oliguria, AMS
Septic Shock
     Sepsis induced
  hypotension SBP <90

  May include >40mmhg
drop from baseline blood
pressure not relieved with
          fluids
Global Tissue Hypoxia


• “Early hemodynamic assessment on the
  basis of physical findings, vital signs,
  central venous pressure, and urinary
  output fails to detect persistent global
  tissue hypoxia.” Rivers NEJM Nov. 8, 2001
Early Lab Clues


•   Glucose > 120 mg/dl
•   Creatinine Increase > 0.5mg/dl
•   INR >1.5 or aPTT 60s
•   Thromobocytopenia <100,000
• Hyperbilirubinemia >4mg/dl
• Lactate Level > 1mmol

          •   Balk RA -DIS Mon - 01-APR-2004; 50(4): 168-213
The Sepsis Cascade
Systemic Inflammatory
   Response Syndrome (SIRS)

• Can be self limited or progress to severe
  sepsis & shock
  – Circulatory abnormalities
     •   Intravascular volume depletion
     •   Peripheral vasodilatation
     •   Myocardial depression
     •   Increased metabolism
• Lead to an imbalance between systemic
  oxygen delivery & demand…resulting in
  global tissue hypoxia or shock
Global Tissue Hypoxia

• A key development & indicator preceding
  multiorgan failure and death.

• The transition to serious illness often
  occurs in the “Golden hours” when early
  recognition and treatment in the
  emergency department provide maximal
  benefit in terms of outcome
Goal Directed Therapy

• Goal Oriented manipulation of
  – Cardiac Preload
  – Cardiac Afterload & Contractility
     • To achieve a balance between systemic
       oxygen delivery and oxygen demand
• End points of Resuscitation
  – Normalized values for mixed venous oxygen
    saturation, arterial lactate concentration, base
    deficit, and pH Rivers NEJM Nov. 8, 2001
Early Goal Directed Therapy

• A prospective randomized study looking at adult
  patients who presented to a Detroit emergency
  department over a 3 year period.

• Criteria for inclusion included at least 2 SIRS
  criteria and a systolic blood pressure of no
  higher than 90mm Hg (after a crystalloid –fluid
  challenge of 20-30cc/kg of body weight over a
  30 minute period or a blood lactate
  concentration of 4 mmol per liter or more.
Early Goal Directed Therapy

• The researchers enrolled 263 patients
     • 130 to Early GDT
     • 133 to Standard Therapy

• Detroit investigators examined whether early
  goal-directed therapy, instituted immediately in
  the emergency department (ED), reduced
  mortality in septic patients
Early Goal Directed Therapy

• In the GDT group, a protocol outlined a sequence
  of interventions (including fluids, vasoactive and
  inotropic drugs, and transfusions)
• Targeted central venous pressure was
  8 to 12 mm Hg
• Goal mean arterial pressure of 65 to 90 mm Hg
• Central venous oxygen saturation of 70 percent
  or higher
• Urine Output of >0.5cc/kg/hr
Early Goal Directed Therapy


• Results:

  – Early Goal-Directed Therapy

    associated with significantly
                     lower in-hospital mortality

       (47 percent vs. 31 percent of patients)
                               (p=.009)

    60-day mortality (57 percent vs. 44 percent)
Early Goal Directed Therapy

• Results:
  – After admission the patients that had received
    Early Goal Directed therapy had:
     • A higher mean central venous oxygen
       saturation
     • A lower lactate concentration
     • A lower base deficit
     • And a higher PH
Early Goal Directed Therapy

      What were the differences?

GDT vs. Standard Therapy
• More fluids…500cc q 30minutes over the 1st 6 hours,
  an average of 5 liters vs 3.5
• Increased transfusion rate in GDT to goal HCT of at
  least 30
• More inotropic support
• Similar use of mechanical ventilation & vasopressors
Antibiotics-GO BIG or GO HOME!

   Choose the appropriate antibotic.

      Early empiric antibiotic coverage


In a series of patients with gram negative sepsis those
treated with appropriate antibiotics had an 18% mortality
        compared to the inappropriate group 34%



     Bochud PY - Crit Care Med -010NOV-2004;32(11suppl): S495-512
Antibiotics
                     Choose Wisely

•Empiric Choices
  •Sources
     •Lung
     •Bloodstream
     •Urine
     •Abd / pelvis
     •Soft tissue
•Most Commonly Encountered Bugs
                    I
  •E-coli, klebisella, pseudomonas
  •Staph aureus, coagulase-negative staphylococci,
  enterococci, and streptococci

•Don’t Forget Fungal………….. (5%)
Fluids
• No superiority of colloids
  over crystalloids
  regarding; pulmonary
  edema, length of stay or
  survival
• Serial crystalloid bolus of
  500cc or serial colloid
  bolus of 300cc

   Balk RA - DIS Mon -01-APR-2004; 50(4):168-213
Pressors

• Appears that the jury is still out
• In most studies the initial drug of choice is
  still Dopamine
• Norepinephrine is supported by many
  – Has better alpha activity
  – Less associated tachycardia
Blood

• Lack of significant
  outcome benefit to raising
  hemoglobin above 10g/dl
  in non-bleeding critically ill
  patients without active
  coronary / cerebral
  ischemia.

   Balk RA - DIS Mon -01-APR-2004; 50(4):168-213
Vasoactive Agents

• Consider Ionotropic therapy: Patients with
  persistent SCVO2< 70% with MABP>65 mm
  HG and CVP within the 8-12 range.
• Dobutamine titrated 2.5mcg/kg/min every
  20-30 minutes to a SCVO2 >70%
• Consider a phosphodiesterase inhibitor,
  Milrinone, in tachycardiac patients

         Rivers EP- CMAJ -25-OCT-2005; 173 (9): 1054-65
Lower Blood Glucose

• A surprising result emerged from a randomized study of
  1548 patients in a surgical ICU, most of whom had
  undergone cardiac surgery.
• Although most of the patients were not diabetic, they
  received either intravenous insulin (to keep blood
  glucose between 80 and 110 mg/dL) or conventional
  treatment (insulin infusion started if blood glucose
  exceeded 215 mg/dL).
• In-hospital mortality was significantly lower in the
  intensive-insulin group (7.2 percent vs. 10.9 percent);
  this difference was attributable to fewer deaths from
  multiple organ failure with proven infection.
          (JW Dec 15, p. 191, accession number 011116001, and N Engl J Med Nov 8; 345:1359).
• In a meta-analysis
  published in 1992, NIH
  researchers reported that
  steroid use was not
                                 Steroids
  beneficial

• Now, the latest meta-
  analysis indicates that
  steroids are useful but only
  when started later and
  delivered in lower doses
  over a longer period

• The analysis also confirmed
  that a delayed, low-dose
  five- to seven-day steroid
  regimen followed by steroid
  taper for an equal period is
  effective regardless of
  response to corticotropin
  stimulation test
Lower Tidal Volume Ventilation
  Patients with acute lung injury and the acute respiratory
     distress syndrome were enrolled in a multicenter,
                      randomized trial.


• Traditional ventilation treatment… initial TV of 12 ml per kg
  of predicted body weight
                                VS
• Lower tidal volume, of 6 ml per kilogram of predicted body
  weight
• The first primary outcome was death before a patient was
  discharged home and was breathing without assistance.
• The second primary outcome was the number of days
  without ventilator use from day 1 to day 28.
                                        NEJM Vol.342:1302-1308 May 4, 2000 Number 18
Lower Tidal Volume Ventilation

Results:
• The trial was stopped after the
  enrollment of 861 patients
  because mortality was lower in
  the group treated with lower
  tidal volumes than in the group
  treated with traditional tidal
  volumes (31.0 percent vs. 39.8)
           (P=0.007)
Xigris
•   Xigris is the first FDA-approved therapy with a proven ability to increase survival
    in adult patients with high-risk severe sepsis
•   A recent randomized, double blinded, placebo-controlled trial of 164 centers in
    11 countries, demonstrated statistically significant reduction in mortality with
    one life saved for every 16 patients treated
•   Endorsed by the Surviving Sepsis Campaign Guidelines
Case One

36 year old female with URI symptoms resolving
after 5 days followed by high fever, body aches,
cough, nausea, vomiting and diarrhea.

BP 90/50 responds to fluids

K3.1, serum CO2 14
Case One

Consideration For:

  Early antibiotic therapy

  Placement of a central venous catheter

  Early Goal Directed Therapy

  ICU Admission and monitoring
Case Two

71 year old male with acute altered mental status,
fever and cough

CXR-multilobar pneumonia

BP 80/40, Pulse 136, no change in blood pressure
after 3 liters of fluid

Central line CVP is 5cm H2O
Case Two
Consideration For:

  Serial crystalloid boluses

  If CVP 8-12mmHG and pt. hypotensive initiate
  vasopressor therapy to reach goal of MAP >
  65mmHG

  If MAP goal attained & lactate remains
  elevated or increasing or SCVO< 70% the add
  Dobutamine or Milrinone to improve cardiac
  output
Case Three

69 year old female from a convalscent home BIB
EMS intubated, febrile, Bp 94/56, RR 30.

Labs: UA WBC TNTC, CBC 25K with 48%
bands, Creatine 5, Glucose 328, Lactate 1.4mmol,
Coags nl, CXR Negative
Case Three

Consideration For:

  Central line placement for monitoring
  purposes

  Insulin drip for tight glycemic control

  Activated protein C administration
Conclusions

– Other things to consider

  • Xigris or activated protein C reduces mortality in a
    subset of patients with severe sepsis and septic
    shock
  • Use Dexamethasone at or 15-20 minutes prior to
                           I
    antibotics in cases of bacterial menigitis
  • Use a pressor you are comfortable with
  • Transfuse to keep your HCT 30 or above
  • Use inotropes early
  • In GAS consider the use of IVIG in addition to your
    antibotics
Conclusions


• In sepsis
  – Early Goal Directed therapy reduces morbidity
    and mortality of patients with sepsis and
    septic shock
  – Be aggressive with your fluids & early
    antibiotic administration
                           I

  – Use low tidal volumes on ventilator patients
  – Consider optimization of blood glucose
  – Low dose (physiologic steroids) show some
    benefit

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Sepsis 2009 update final

  • 1. Sepsis Update 2009 Troy Pennington DO
  • 2. The First Physician c. 2980 BC Ancient Egyptians founded medical schools; Imhotep was the first known physician to receive a medical degree.
  • 3. Early Scientific Papers 2735 BC Chinese Emperor Shen Nung wrote a treatise on the use of ch’ang shan in fever.
  • 4. The Code of Hammurabi 1800 BC
  • 5. The first Contagion c. 100 BC “small creatures invisible to the eye, fill the atmosphere, and breathed through the nose cause dangerous diseases.” – Marcus Terentius Varro, De re rustica libri III
  • 6. Case One 36 year old female with URI symptoms resolving after 5 days followed by high fever, body aches, cough, nausea, vomiting and diarrhea. BP 90/50 responds to fluids K3.1, serum CO2 14
  • 7. Case Two 71 year old male with acute altered mental status, fever and cough CXR-multilobar pneumonia BP 80/40, Pulse 136, no change in blood pressure after 3 liters of fluid Central line CVP is 5cm H2O
  • 8. Case Three 69 year old female from a convalscent home BIB EMS intubated, febrile, Bp 94/56, RR 30. Labs: UA WBC TNTC, CBC 25K with 48% bands, Creatine 5, Glucose 328, Lactate 1.4mmol, Coags nl, CXR Negative
  • 9. Severe Sepsis • Approximately 950,000 cases per year • Over 200,000 deaths per year • Costs for sepsis and related diseases over $25 billion/year (Angus Crit Care Med 2003)
  • 10. The Numbers • Sepsis & Septic Shock account for about 2.9% of hospital admits and 10% of ICU admissions • Estimated 50% came from the ED • Early Goal Directed Therapy focused on the initial 6 hours of patient care • The Surviving Sepsis Campaign incorporated EM as a key component
  • 11. Sepsis…How does it Stack up Trauma Cardiac Arrest 150,000 Deaths AMI SEPSIS 250,000 Stroke 700,000 yr. 950,000yr deaths 140,000 deaths yr. 200,000 deaths
  • 12. Changing Paradigms Fighting the old paradigm it doesn’t make a difference intensivist’s job way too complicated Goals show outcomes differences early intervention is essential Keep it simple
  • 13. Epidemiology The Most Common sites of sepsis are: 1. Lungs 45% 2. Abdomen 17% 3. Urinary Tract 10% 4. Undetermined 20-30% The Incidence of Fungal Sepsis has tripled due to transplant patients and those on immunosuppresive therapy. (Accounts for only 5% of all cases of sepsis) N Engl J Med 340 (3):207
  • 14. Epidemiology Gm-positive sepsis has overtaken Gram-negative sepsis Common gram-positive bacteria include: Staphylococcus aureus, coagulase-negative staphylococci, enterococci, and streptococci; Most common gram-negative pathogens are Escherichia coli, Klebsiella, and Pseudomonas;
  • 15. The Sepsis Continuum INSULT SIRS SEPSIS SEVERE SEPSIS A clinical response arising Refractory from a nonspecific insult, SIRS with a Hypotension including > or = 2 of the & following Presumed Septic Shock or • Temperature <36c or >38c • HR>90 beats per minute confirmed • Respirations > 20 BPM or infectious process PaCO2 <32 • WBC Count <4,000 or >12,000or >10% bands Bone et al. Chest. 1992:101.1644.
  • 16. Sepsis…defined Sepsis SIRS with Documented or Presumed infection
  • 17. Severe Sepsis Sepsis and organ dysfuntion May include but not limitied to lactic acidosis, oliguria, AMS
  • 18. Septic Shock Sepsis induced hypotension SBP <90 May include >40mmhg drop from baseline blood pressure not relieved with fluids
  • 19.
  • 20. Global Tissue Hypoxia • “Early hemodynamic assessment on the basis of physical findings, vital signs, central venous pressure, and urinary output fails to detect persistent global tissue hypoxia.” Rivers NEJM Nov. 8, 2001
  • 21. Early Lab Clues • Glucose > 120 mg/dl • Creatinine Increase > 0.5mg/dl • INR >1.5 or aPTT 60s • Thromobocytopenia <100,000 • Hyperbilirubinemia >4mg/dl • Lactate Level > 1mmol • Balk RA -DIS Mon - 01-APR-2004; 50(4): 168-213
  • 23. Systemic Inflammatory Response Syndrome (SIRS) • Can be self limited or progress to severe sepsis & shock – Circulatory abnormalities • Intravascular volume depletion • Peripheral vasodilatation • Myocardial depression • Increased metabolism • Lead to an imbalance between systemic oxygen delivery & demand…resulting in global tissue hypoxia or shock
  • 24.
  • 25. Global Tissue Hypoxia • A key development & indicator preceding multiorgan failure and death. • The transition to serious illness often occurs in the “Golden hours” when early recognition and treatment in the emergency department provide maximal benefit in terms of outcome
  • 26. Goal Directed Therapy • Goal Oriented manipulation of – Cardiac Preload – Cardiac Afterload & Contractility • To achieve a balance between systemic oxygen delivery and oxygen demand • End points of Resuscitation – Normalized values for mixed venous oxygen saturation, arterial lactate concentration, base deficit, and pH Rivers NEJM Nov. 8, 2001
  • 27. Early Goal Directed Therapy • A prospective randomized study looking at adult patients who presented to a Detroit emergency department over a 3 year period. • Criteria for inclusion included at least 2 SIRS criteria and a systolic blood pressure of no higher than 90mm Hg (after a crystalloid –fluid challenge of 20-30cc/kg of body weight over a 30 minute period or a blood lactate concentration of 4 mmol per liter or more.
  • 28. Early Goal Directed Therapy • The researchers enrolled 263 patients • 130 to Early GDT • 133 to Standard Therapy • Detroit investigators examined whether early goal-directed therapy, instituted immediately in the emergency department (ED), reduced mortality in septic patients
  • 29. Early Goal Directed Therapy • In the GDT group, a protocol outlined a sequence of interventions (including fluids, vasoactive and inotropic drugs, and transfusions) • Targeted central venous pressure was 8 to 12 mm Hg • Goal mean arterial pressure of 65 to 90 mm Hg • Central venous oxygen saturation of 70 percent or higher • Urine Output of >0.5cc/kg/hr
  • 30.
  • 31.
  • 32. Early Goal Directed Therapy • Results: – Early Goal-Directed Therapy associated with significantly lower in-hospital mortality (47 percent vs. 31 percent of patients) (p=.009) 60-day mortality (57 percent vs. 44 percent)
  • 33. Early Goal Directed Therapy • Results: – After admission the patients that had received Early Goal Directed therapy had: • A higher mean central venous oxygen saturation • A lower lactate concentration • A lower base deficit • And a higher PH
  • 34. Early Goal Directed Therapy What were the differences? GDT vs. Standard Therapy • More fluids…500cc q 30minutes over the 1st 6 hours, an average of 5 liters vs 3.5 • Increased transfusion rate in GDT to goal HCT of at least 30 • More inotropic support • Similar use of mechanical ventilation & vasopressors
  • 35. Antibiotics-GO BIG or GO HOME! Choose the appropriate antibotic. Early empiric antibiotic coverage In a series of patients with gram negative sepsis those treated with appropriate antibiotics had an 18% mortality compared to the inappropriate group 34% Bochud PY - Crit Care Med -010NOV-2004;32(11suppl): S495-512
  • 36. Antibiotics Choose Wisely •Empiric Choices •Sources •Lung •Bloodstream •Urine •Abd / pelvis •Soft tissue •Most Commonly Encountered Bugs I •E-coli, klebisella, pseudomonas •Staph aureus, coagulase-negative staphylococci, enterococci, and streptococci •Don’t Forget Fungal………….. (5%)
  • 37. Fluids • No superiority of colloids over crystalloids regarding; pulmonary edema, length of stay or survival • Serial crystalloid bolus of 500cc or serial colloid bolus of 300cc Balk RA - DIS Mon -01-APR-2004; 50(4):168-213
  • 38. Pressors • Appears that the jury is still out • In most studies the initial drug of choice is still Dopamine • Norepinephrine is supported by many – Has better alpha activity – Less associated tachycardia
  • 39. Blood • Lack of significant outcome benefit to raising hemoglobin above 10g/dl in non-bleeding critically ill patients without active coronary / cerebral ischemia. Balk RA - DIS Mon -01-APR-2004; 50(4):168-213
  • 40. Vasoactive Agents • Consider Ionotropic therapy: Patients with persistent SCVO2< 70% with MABP>65 mm HG and CVP within the 8-12 range. • Dobutamine titrated 2.5mcg/kg/min every 20-30 minutes to a SCVO2 >70% • Consider a phosphodiesterase inhibitor, Milrinone, in tachycardiac patients Rivers EP- CMAJ -25-OCT-2005; 173 (9): 1054-65
  • 41. Lower Blood Glucose • A surprising result emerged from a randomized study of 1548 patients in a surgical ICU, most of whom had undergone cardiac surgery. • Although most of the patients were not diabetic, they received either intravenous insulin (to keep blood glucose between 80 and 110 mg/dL) or conventional treatment (insulin infusion started if blood glucose exceeded 215 mg/dL). • In-hospital mortality was significantly lower in the intensive-insulin group (7.2 percent vs. 10.9 percent); this difference was attributable to fewer deaths from multiple organ failure with proven infection. (JW Dec 15, p. 191, accession number 011116001, and N Engl J Med Nov 8; 345:1359).
  • 42. • In a meta-analysis published in 1992, NIH researchers reported that steroid use was not Steroids beneficial • Now, the latest meta- analysis indicates that steroids are useful but only when started later and delivered in lower doses over a longer period • The analysis also confirmed that a delayed, low-dose five- to seven-day steroid regimen followed by steroid taper for an equal period is effective regardless of response to corticotropin stimulation test
  • 43. Lower Tidal Volume Ventilation Patients with acute lung injury and the acute respiratory distress syndrome were enrolled in a multicenter, randomized trial. • Traditional ventilation treatment… initial TV of 12 ml per kg of predicted body weight VS • Lower tidal volume, of 6 ml per kilogram of predicted body weight • The first primary outcome was death before a patient was discharged home and was breathing without assistance. • The second primary outcome was the number of days without ventilator use from day 1 to day 28. NEJM Vol.342:1302-1308 May 4, 2000 Number 18
  • 44. Lower Tidal Volume Ventilation Results: • The trial was stopped after the enrollment of 861 patients because mortality was lower in the group treated with lower tidal volumes than in the group treated with traditional tidal volumes (31.0 percent vs. 39.8) (P=0.007)
  • 45. Xigris • Xigris is the first FDA-approved therapy with a proven ability to increase survival in adult patients with high-risk severe sepsis • A recent randomized, double blinded, placebo-controlled trial of 164 centers in 11 countries, demonstrated statistically significant reduction in mortality with one life saved for every 16 patients treated • Endorsed by the Surviving Sepsis Campaign Guidelines
  • 46. Case One 36 year old female with URI symptoms resolving after 5 days followed by high fever, body aches, cough, nausea, vomiting and diarrhea. BP 90/50 responds to fluids K3.1, serum CO2 14
  • 47. Case One Consideration For: Early antibiotic therapy Placement of a central venous catheter Early Goal Directed Therapy ICU Admission and monitoring
  • 48. Case Two 71 year old male with acute altered mental status, fever and cough CXR-multilobar pneumonia BP 80/40, Pulse 136, no change in blood pressure after 3 liters of fluid Central line CVP is 5cm H2O
  • 49. Case Two Consideration For: Serial crystalloid boluses If CVP 8-12mmHG and pt. hypotensive initiate vasopressor therapy to reach goal of MAP > 65mmHG If MAP goal attained & lactate remains elevated or increasing or SCVO< 70% the add Dobutamine or Milrinone to improve cardiac output
  • 50. Case Three 69 year old female from a convalscent home BIB EMS intubated, febrile, Bp 94/56, RR 30. Labs: UA WBC TNTC, CBC 25K with 48% bands, Creatine 5, Glucose 328, Lactate 1.4mmol, Coags nl, CXR Negative
  • 51. Case Three Consideration For: Central line placement for monitoring purposes Insulin drip for tight glycemic control Activated protein C administration
  • 52. Conclusions – Other things to consider • Xigris or activated protein C reduces mortality in a subset of patients with severe sepsis and septic shock • Use Dexamethasone at or 15-20 minutes prior to I antibotics in cases of bacterial menigitis • Use a pressor you are comfortable with • Transfuse to keep your HCT 30 or above • Use inotropes early • In GAS consider the use of IVIG in addition to your antibotics
  • 53. Conclusions • In sepsis – Early Goal Directed therapy reduces morbidity and mortality of patients with sepsis and septic shock – Be aggressive with your fluids & early antibiotic administration I – Use low tidal volumes on ventilator patients – Consider optimization of blood glucose – Low dose (physiologic steroids) show some benefit

Editor's Notes

  1. In ancient Egypt, Imhotep, the chief minister to King Djoser in the third millennium BC, was the first physician to gain wide recognition, and in later years, he became known as the Egyptian god of medicine. Edwin Smith, an Egyptologist, found clinical case histories recorded on Egyptian papyrus dating from circa 1600.
  2. Emperor Shen Nung&amp;#x2019;s treatise is thought to be one of the first scientific papers. It described the antifever capabilities of ch&amp;#x2019;ang shan, an herbal substance, which since has been found to contain antimalarial alkaloids.
  3. The Code of Hammurabi, King of Babylon, addresses various issues, including personal injury and punishment.
  4. Marcus Terentius Varro, in De re rustica libri III (three books on agriculture), was the first to articulate the notion of contagion. Marcus Terentius Varro, in De re rustica libri III (three books on agriculture), was the first to articulate the notion of contagion. Marcus Terentius Varro, in De re rustica libri III (three books on agriculture), was the first to articulate the notion of contagion. Marcus Terentius Varro, in De re rustica libri III (three books on agriculture), was the first to articulate the notion of contagion.
  5. SST&amp;#x2026;septic survival team&amp;#x2026;Dr.Stein Olive View UCLA, David Tallon and Gregory Moran
  6. Sepsis is a heterogenous clinical syndrome that can be caused by any class of microorganism. Although both gram negative and gram positive bacteria account for the majority of cases, fungi, mycobacteria, viruses, protozans, and rickettsai may cause similar presentations. For example in children it often begins with nasopharyngeal colonization and then hematogenous spread of encapsulated organisms which in turn stimulates a release of inflammatory mediators&amp;#x2026;.and if not corrected host defense mechanisms can fail resulting in severe sepsis refractory hypotension and death.
  7. SST&amp;#x2026;septic survival team&amp;#x2026;Dr.Stein Olive View UCLA, David Tallon and Gregory Moran
  8. SST&amp;#x2026;septic survival team&amp;#x2026;Dr.Stein Olive View UCLA, David Tallon and Gregory Moran
  9. SST&amp;#x2026;septic survival team&amp;#x2026;Dr.Stein Olive View UCLA, David Tallon and Gregory Moran
  10. SST&amp;#x2026;septic survival team&amp;#x2026;Dr.Stein Olive View UCLA, David Tallon and Gregory Moran
  11. SST&amp;#x2026;septic survival team&amp;#x2026;Dr.Stein Olive View UCLA, David Tallon and Gregory Moran
  12. Mixed venous oxygen saturation has been shown to be a surrogate for the cardiac index as a target for hemodynamic therapy
  13. Once severe sepsis and septic shock are established, interventions to reverse the syndrome frequently are ineffective
  14. Those that were in the GDT group got GDt for 6 hours and then went to the ICU, the intensivists that managed the patients in the unit were blinded to the treatment received in the ED.
  15. From 7 to 72 hours
  16. 50mg hydrocortisone q6hr.
  17. 50mg hydrocortisone q6hr.