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Case Presentation Presented by: Dr.Safaa fadhl Supervised by: Dr.Kamal Marghani. 29 yrs male presented to ED at 1:40pm complaining of cough , S OB, and fever. At triage :. Pt was admitted to room A at 2:00pm - PowerPoint PPT Presentation
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Case PresentationPresented by: Dr.Safaa fadhl
Supervised by: Dr.Kamal Marghani
29 yrs male presented to ED at 1:40pm complaining of cough , SOB, and fever.
At triage :
RR Pulse rate
temp Bp Oxygen saturation
22 166 40.2 - 86
Pt was admitted to room A at 2:00pm
29 yrs old male whose known to be DM for 7yrs on mixtard insuline presented with cough , SOB, and fever for 7days prior to the presentation for which he received amoxicillin \clavunate tabs without any significant improvement .
OE: pt looks ill tachypnic vitals signs :- Pulse 144- Bp 160\80- SPO2 65% on room air- RBS 257- Chest : bronchial breathing ,and decrease air entery on the
RT side.
Plane :- Give oxygen via NRM rate 15 L\min.- Normal saline 1000ml.- Samixon 1g BD- Clarithromycin 500 BD - insulin mixtard- Take investigation, ABG,CXR
ABG on NRM:
PH PaCO2 PaO2 HCO3 PSO2
7.45 22.2 63 15.5 80.3
HG TWBCS
PLT PT PTT INR UREA
CREATININ
K NA
11.5 10.2 116 24.7 29.2 1.8 26.0 0.9 3.6 135
SO , the pt was diagnose as pneumoniaAt 9:30 pm pt was admitted to CCR .On admission he was looking ill ,tachypnic on
NRM.A : his airway was patent, on NRMB : RR 39, SPO2 85, both sides of the chest
moving equally, there was bronchial breathing and decrease breath sounds on Rt side.
C : pulse 130, BP 119\80 D : GCS 15\15 , RBS 296E : examination of all other systems were
unremarkable.
ABG on arrival:
The diagnose was sever sepsis( type I respiratory failure)
Plan :-NPO.-add DVT prophylaxis .-add peptic ulcer prophylaxis.-DNS 125 ml\hr.-RBS\4hr + sliding scale.-ABG \4hrs + when ever indicated
PH PCO2 PO2 HCO3 SPO2
7.47 26.5 51 19.3 86
Day 2 CCRA : airways patentB : distress using accessory muscle, RR 40,
SPO2 87C :pulse 128, BP 114\79 MAP 88, good UOP.D : GCS 15\15, RBS 98
PH PaCO2 PaO2 HCO3 SPO2
7.45 22.0 52 15.5 83.1
At 12:45pm , pt became more distress and not responsive , he was intubated and connected to MV .
Initial settings were:
mode
TV RR PS PEEP FIO2 Platue
SIMV 400 18 15 5 100 19
1hr after the intubation his ABG:
MV setting :
PH PaO2 PaCO2 HCO3 SPO2
7.24 78 47.9 20.9 92.9
mode TV RR PS PEEP FIO2SIMV 400 24 15 5 100
The plan was to keep the pt MASS zero.
1 hr later the pt became hypotensive ,
he received 2 L of nomal saline without improvement , so
noreadrenaline was added, then the BP was maintain on max dose of
inotropse ..
A clinical response arising from a nonspecific insult, with 2 of the following: HR >90
beats/min RR >20/min WBC
>12,000/mm3 or <4,000/mm3 or >10% bands
T >38oC or <36oC
SIRS = systemic inflammatory response syndrome
SIRS with a presumed or confirmed infectious process
Chest 1992;101:1644.
SepsisSIRSSevere Sepsis
SepticShock
Sepsis with organ dysfunction
Refractoryhypotension
Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis
TachycardiaHypotension
CVP PAOP
Jaundice Enzymes Albumin
PT
Altered Consciousness
ConfusionPsychosis
TachypneaPaO2 <70 mm Hg
SaO2 <90%PaO2/FiO2 300
OliguriaAnuria
Creatinine
Platelets PT/APTT Protein C D-dimer
Early Goal-directed Therapy in the Treatment of Severe Sepsis and Septic Shock
To Examine whether Early Goal Directed Therapy (EGDT) before admission to the
ICU is superior to standard hemodynamic therapy in patients with
sever sepsis and septic shock
Critical Influence of the Time to 1st Antibiotic Dose on Mortality in Septic Shock
Patient survival with delayed antibiotic administration in septic shock
5%
39%
48%50%58%
71%
33%
10%
0%
20%
40%
60%
80%
100%
0 5 10 15 20 25 30 35 40
Time to first appropriate antibiotic dose (hour)
Perc
ent S
urvi
val
Kumar et al. HSC and St. Boniface General Hospital. August 2003
N = 1004 patients
Every one-hour delay… you drop survival by 7.5%
Initial Resuscitation, Diagnosis, and Antibiotic Therapy
Recommend early goal-directed therapy
Give early appropriate antibioticsGive early appropriate fluidsGive appropriate inotropic supportTake early culturesTake early lactate levelTake early central venous oxygen
saturation(SVO2)
Inotropes in septic shock Noradrenaline Adrenaline Vasopressin Dopamine( selected cases)
NO RENAL DOSE DOPAMINE
Intensive insulin therapy
Target glucose 140 -200 mg
Improved survival Decreased infections Decreased organ failure
At this stage the pt went from sever sepsis to septic shock.
Plane :- NPO- N.S 125 ml\hr - Meropenum 1g TDS (given within 1hr of
diagnosis)- Noreadrenaline infusion titrated to keep map
more than 65mmhg- For septic screening .- VBG- RBS\4hrs + give insulin according to sliding
scale( Target 140-200)
2hr later the ABG:
PH PaO2 PaCO2 HCO3 SPO2
7.34 83 35.1 19.2 95.7
Day 3
- As the pt had a refractory hypoxymia ,he was kept MASS zero for another 48hrs.
-Noreadrenaline : weaned to off But the pt still febrile so vancomycine was
added
PH PaO2 PaCO2 HCO SPO2
7.52 51 35.4 28.9 89.5
Day 4Off Noreadrenaline.Sedation vacation done, GCS 11\15
MV setting:
DAY MODE TV RR PS PEEP FIO2
5 SIMV 500 15 15 8 100
6 SIMV 380 18 15 10 100
7 SIMV 380 12 15 10-5.5 90-55
8 SPONT 400 18 15 5.5 55
Day 9 CCR:
-Pt on spont for more than 24 hrs on minimal ps
- fully conscious communicating in tube. -Good cough reflex .- NPO .EXTUBATED AT 11:00 am and put on
simple mask
Timing
THE Message Time is life
Thank you for your
attention