Emergency medicine sepsis and septic shock ppt pptx

Emergency medicine septic shock and sepsis

1. SEPSIS AND SEPTIC-SHOCK

2. Sepsis: Is diagnosed when there is evidence of proven or suspected infection source and organ dysfunction as evidenced by increase in sequential organ failure assessment (SOFA) score by two or more from baseline.

3. Septic shock : Sepsis with persistent hypotension/ hypo perfusion requiring vasopressor support to maintain MAP ≥ 65mmHg and initial blood lactate level 4mmol/l or >2mmol/l despite adequate fluid resuscitation.

4. The qSOFA score is easy to calculate since readily identifiable at the bedside and are allocated one point: ●Respiratory rate ≥22/minute ●Altered mentation ●Systolic blood pressure ≤100 mmHg

5. NEWS

6. case 1.The patient is intubated and receives 1.5L of IV crystalloid. His repeat vital signs are BP 84/42 mm Hg, HR 122 beats/minute, and oxygen saturation 92% on 100% (Fi O2 ) via endotracheal (ET) tube. GCS is 11/15 and lab cr 3.2mg/dl, bliru 4.1mg /dl and platelate is 76,000. write SOFA score what is the DX?

7. 2.A70 YEARS OLD PATIENT presented with cough and sob for 5days duration.up on exam v/s BP 120 /60 PR 110 RR 25 SPO2 85 ON FACE MASK, CXR rt side air broncheogram,plt 40,000 , cr normal bilu 2.5 and other ix are normal Write SOFA score What is the DX

8. CLINICAL PRESENTATION  —  Patients with suspected or documented sepsis typically present with hypotension, tachycardia, fever , and leukocytosis. As severity worsens, signs of shock ( eg , cool skin and cyanosis) and organ dysfunction develop ( eg , oliguria, acute kidney injury, altered mental status

9. Etiology Gram-positive bacteria are the predominant pathogens of sepsis. 11 Methicillin-resistant Staphylococcus aureus , vancomycin-resistant Enterococcus , and other multidrug-resistant organisms are common organisms. Fungal sources are more common now,

10. TREATMENT The cornerstones of the initial treatment and stabilization of severe sepsis are early recognition, earlyreversal ( orprevention ) ofhemodynamic compromise, and early infection control

11. Hour- 1 Bundle’ is adopted from the Surviving Sepsis campaign 2018 guideline. Measure lactate level, Re-measure if initial lactate is>2 mmol /L Obtain blood cultures prior to administration of antibiotics Administer broad-spectrum antibiotics Rapidly administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol /L Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥65 mm Hg

12. Fluid treatment Start balanced crystalloids (Ringer`s lactate/acetate), plasmalyte or normal saline (NS) 20-30ml/kg 0ver 30-60minutes or as needed to target in 6 hours; targeting MAP >65-70mmHg or >80mmhg in chronic hypertension, urine output >0.5ml/kg/ hr , capillary refill time<2-3 second, strong and full peripheral pulses, skin warmth and color, and improvement in mental status

13. Albumin is as effective as crystalloids in expanding intravascular volume when a substantial amount is needed. Avoid hypotonic fluid or semisynthetic colloids Packed RBC if Hct <21% unless patient has myocardial ischemia, severe hypoxemia, acute hemorrhage and cyanotic heart disease. Targeting Hct 27-30% doesn`t improve outcome. Platelet transfusion if the platelet is <5000/microliter or if there is significant bleeding.

14. Vasopressor and inotrope treatment 1. Nor-epinephrine Is the first choice and titrate to desired effect Is potent vasoconstrictor with less increase in HR

15. 2. Epinephrine Can be used as an alternative to norepinephrine or as additional to achieve desired effect Is potent vasoconstrictor, and also with inotropic effect Titrate to desired effect

16. 3. Vasopressin Can be used to reduce norepinephrine dose Caution if not euvolumic Fixed dose at 0.03 U/min

17. 4. Dopamine Restrict as it may be associated with increase mortality and increase in tachyarrhythmia 5. Dobutamine First choice inotrope in warm shock with borderline BP Start at 2.5μg/kg/min and titrate to desired effect maximum 20 μg /kg/min Risks include tachyarrhythmia and hypotension

18. Antibiotics Methicillin-resistant  S. aureus  – There is growing recognition that methicillin-resistant  S. aureus  (MRSA) is a cause of sepsis not only in hospitalized patients, but also in community dwelling individuals without recent hospitalization . For these reasons, we suggest empiric intravenous  vancomycin

19. if  Pseudomonas  is an unlikely pathogen, we favor combining  vancomycin  with one of the following: Cephalosporin , 3rd generation ( eg ,  ceftriaxone  or  cefotaxime ) or 4th generation ( cefepime ), or Beta-lactam/beta-lactamase  inhibitor ( eg ,  piperacillin- tazobactam ,  ticarcillin-clavulanate ), or Carbapenem ( eg ,  imipenem  or  meropenem )

20. Pseudomonas  , if  Pseudomonas  is a likely pathogen, we favor combining  vancomycin  with two of the following, Antipseudomonal cephalosporin ( eg ,  ceftazidime ,  cefepime ), or Antipseudomonal carbapenem ( eg ,  imipenem ,  meropenem ), or Antipseudomonal beta-lactam/beta-lactamase inhibitor ( eg ,  piperacillin- tazobactam ,  ticarcillin-clavulanate ), or Fluoroquinolone with good anti- pseudomonal activity ( eg ,  ciprofloxacin ), or Aminoglycoside ( eg ,  gentamicin ,  amikacin ), or Monobactam ( eg ,  aztreonam )

21. Invasive fungal infections – The   routine  administration of empirical antifungal therapy is not generally warranted in  non-neutropenic  critically-ill patients .

22. Duration of antimicrobials : 7–10 days is usually adequate. Longer courses may be required in patients who have a slow clinical response, undrain able foci of infection, bacteremia with S. aureus , some fungal and viral infections, or immunologic deficiencies, including neutropenia

23. Steroids: Hydrocortisone (200mg/day) divided every 6h for 5 days if refractory shock despite fluid and vasopressors, or if corticosteroid history warrants it. Titrate down to twice daily the next 5-8 days, then daily on the next 9-11 days before discontinuation.

24. Mechanical ventilation : Renal replacement therapy: Hemodialysis only if there are clear indications. Ulcer and venous thromboembolic prophylaxis with proton pump inhibitors/H2 blockers & unfractionated heparin. Glycemic control: Target a blood sugar of 140 – 180mg/dl.

25. Monitoring Static   MAP CVP at a target of 8 to 12 mmHg ScvO 2  ≥70 percent (≥65 percent if sample is drawn off a PAC)

26. Dynamic   – Respiratory changes in the vena caval diameter, radial artery pulse pressure, aortic blood flow peak velocity, left ventricular outflow tract velocity-time integral, and brachial artery blood flow velocity

27. Hemodynamic monitoring: BP , mean arterial pressure (MAP), HR , Urine output, cardiothoracic ultrasound , lactate clearance

28. Poor prognostic factors include the inability to mount a fever , leukopenia, age >40 years, certain comorbidities ( eg , AIDS, hepatic failure, cirrhosis, cancer, alcohol dependence, immunosuppression), a non-urinary source of infection, a nosocomial source of infection, and inappropriate or late antibiotic coverage

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