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Bootcamp - Sepsis. Adam Manko , M.D. PGY-3 Internal Medicine University Hospitals Case Medical Center. Goals. Sepsis – Definition Initial Management Medications Mechanical Ventilation - Briefly What Your Senior Expects From You Summary. Case. - PowerPoint PPT Presentation
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Bootcamp - SepsisAdam Manko, M.D.
PGY-3 Internal MedicineUniversity Hospitals Case Medical Center
Sepsis – Definition Initial Management Medications Mechanical Ventilation - Briefly What Your Senior Expects From You Summary
Goals
69 y/o Male presented to ER with shortness of breath.
VS 38.3 88/46 114 28 86%
He is placed onto 50% ventimask, but continues to have low oxygen saturation and is intubated in the ER.
He is given 2L of NS and repeat BP is 92/44
Case
The Patient arrives in the MICU…..what do you do next?
Sepsis is a continuum….. SIRS Sepsis Severe Sepsis Septic Shock Refractory Septic Shock Multi-Organ Dysfunction Syndrome (MODS)
Defining Sepsis 1
SIRS Criteria◦ Temperature >38.3 (or >38.0 for 1 hour) or <36.0◦ WBC >12k or <4k, or >10% bandemia◦ RR >20, or paCO2 <32mmHg◦ HR >90
Defining Sepsis 2
Sepsis = SIRS + suspected infection◦ Does not have to be culture proven infection to
begin treatment for Sepsis
Defining Sepsis 3
Severe sepsis = sepsis + and signs of at least one organ dysfunction thought to be from tissue hypoperfusion◦ Hypotension◦ Elevated lactate◦ Urine output <0.5ml/kg◦ Acute Lung Injury with PaO2/FiO2 ratio of <250◦ ARDS◦ Acute Renal Failure◦ Elevated bilirubin◦ Platelet Count <100,000◦ Coagulopathy with INR >1.5◦ Altered Mental Status◦ Abnormal EEG findings◦ Cardiac Dysfunction
Defining Sepsis 4
“Early Goal Directed Therapy”◦ Goal SBP >90◦ Goal MAP >65◦ Goal Hemoglobin 7-9◦ Goal urine output >0.5ml/kg/hr◦ Goal normalized serum lactate◦ Goal Mixed Venous >70%◦ Central Venous >65%
Initial Management
Goal SBP >90, MAP >65, Hgb 7-9 IVF bolus with NS What if you give IVF and remains
hypotensive?◦ Need to check a CVP!!!
Hypotension
CVP ◦ = Central Venous Pressure
What is the utility of a CVP◦ Estimates the Right Atrial Pressure◦ What is a Normal Right Atrial Pressure
<6
What is a CVP
Place a CVC = Central Venous Catheter Locations include
◦ Internal Jugular◦ Subclavian
What do you need for a CVP?
CVP >8 If intubated, CVP >12
What if still hypotensive but at goal CVP?
Goal CVP
Norepinephrine◦ First Line pressor (preferred agent over dopamine
(NEJM 2010 Comparison of Dopamine and Norepinephrine in the Treatment of Shock)
◦ Mainly A1, some B1◦ Dosing in mcg/min
Typically uptitrate to max of ~30 mcg/min Vasopressin
◦ Second line pressor◦ Entirely V1
Can be titrated, however we typically turn it “on or off” at dose of 0.04 U/min
Pressors
Phenylephrine◦ Weaker pressor, A1 activity◦ Less arrhythmogenic
Dopamine◦ Dose dependent◦ Low dose 1-3mcg/kg/min = “renal” dosing, almost
all D1◦ Medium dose 3-10mcg/kg/min = B1 and D1◦ High Dose >10mcg/kg/min = “pressor” dosing
Pressors - 2
Epinephrine◦ “king of pressors”◦ Used as last line pressor at our institution◦ Side effect includes increased risk of intestinal
ischemia
Pressors - 3
Pressor photo
Mixed Venous >70◦ Mixed venous taken from a swan-ganz catheter
Central Venous >65%◦ Taken from Central Line in the SVC
Mixed Venous and Central Venous Saturations
High Venous saturation with unclear utility Low Venous saturation means increased
extraction peripherally
How to increase mixed venous saturation, you have 2 option◦ Increase hematocrit◦ Increase cardiac output
Dobutamine
Venous Saturation
Consider when refractory hypotension◦ when you are adding 2nd pressor, think of adding
steroids!! No longer recommended to do ACTH stim or
random cortisol Empirically add hydrocortisone, dose 50mg
q6h
Corticosteroids
Antibiotics within 1 hour Typically vancomycin and zosyn are first line
agents if unclear of source Start broad and narrow when source
identified
Antibiotics
ABX photo from UH guide
Maintain tight blood glucose control with goal 140-180
If unable to manage easily (you get 2 tries with SQ insulin) then start on insulin gtt
Protocol driven by nursing◦ FYI this is different than the DKA protocol◦ (2010 NEJM – Glycemic Control in the ICU)
Glycemic Control
DVT◦ If no contra-indications….
Heparin SQ preferred agent◦ If contraindications
SCDs and TED hose
Stress Ulcer◦ PPI or H2 blocker
Prophylaxis
Protective Lung Ventilation Strategy ARDSnet protocol
◦ Low tidal volumes 6ml/kg of IBW
◦ PEEP◦ Goal plateau pressure <30
(2007 NEJM - Low Tidal Volume Ventilation in the Acute Respiratory Distress Syndrome) (2000 NEJM – Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute
Lung Injury and the Acute Respiratory Distress Syndrome)
Mechanical Ventilation
ARDS NET photo
RRT = Renal Replacement Therapy◦ HD = Hemodialysis◦ UF = Ultrafiltration
CRRT = Continuous Renal Replacement Therapy◦ CVVH = Continuous veno-venous hemofiltration◦ CVVHD = Continuous veno-venous hemodialysis
RRT, HD, UF, CRRT,CVVH, CVVHD…..What?
A◦ Acidosis
E◦ Electrolyte imbalance
I◦ Intoxication
O◦ Fluid Overload
U◦ Uremia
Indications for RRT
Sedation◦ Versed for anxiety◦ Fentanyl for pain◦ Haldol for agitation◦ Propofyl◦ Precedex
Miscellaneous
Assess the patient!!(Go into room, not look in EMR first)
Labs◦ CBC◦ RFP◦ LFTs◦ Coag◦ Type and Screen◦ Lactate!!!◦ In the right setting
Troponin, amylase, lipase, etc
Microbiology◦ Blood cultures x2◦ UA and culture◦ +/- sputum culture
Imaging◦ CXR, +/- KUB◦ CT in right setting
What Your Senior Expects From You
Check for Access◦ Prep for CVC
If hypotensive, need invasive hemodynamic monitoring◦ Central Line (CVC)◦ Arterial Line
Other◦ HD Catheter?◦ Introducer (Cordis)?
What Your Senior Expects From You
Get us if you are uncomfortable in a situation, aka the patient is very sick and crashing!!
STAY CALM!!! Nurses are your friend or worst enemy, the
choice is yours!!◦ They have taken care of more patients than you,
they often know what the next step is, use them as a resource!!
What Your Senior Expects From You
In Summary, the Goals of Sepsis are……
Our ICU Algorithm for Sepsis
69 y/o Male presented to ER with shortness of breath.
VS 38.3 88/46 114 28 86%
He is placed onto 50% ventimask, but continues to have low oxygen saturation and is intubated in the ER.
He is given 2L of NS and repeat BP is 92/44
Case
The Patient arrives in the MICU…..what do you do next?
Identify Severe Sepsis and Septic Shock Early
IVF Early invasive hemodynamic monitoring Goal endpoints
◦ Urine output, SBP, MAP, lactate, central venous sat, CVP <8 or 12
◦ Pressors and Steroids Cultures and ABX
Summary
Thank you!!!
Questions?