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Patient Scenario

The New Paradigm: Goal-Directed Therapy for Severe Sepsis and Septic Shock Jamie Cowan April 25, 2006 Emergency Medicine Clerkship. Patient Scenario. 45 yo male CC “Not feeling well” Known alcoholic w/cirrhosis Temp 96.2 BP 100/65 HR 100 RR 18.

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Patient Scenario

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  1. The New Paradigm:Goal-Directed Therapy for Severe Sepsis and Septic ShockJamie CowanApril 25, 2006Emergency Medicine Clerkship

  2. Patient Scenario • 45 yo male • CC “Not feeling well” • Known alcoholic w/cirrhosis • Temp 96.2 • BP 100/65 • HR 100 • RR 18

  3. SIRS – System Inflammatory Response Syndrome • Criteria: 2 or more of the following • Temp > 38C or < 36 C • HR > 90 • RR > 20 • PaCO2 < 32 • WBC > 12,000 or < 4,000 • Bands > 10%

  4. Patient History and Exam • Patient looks ill • Known alcoholic with acute/chronic pancreatitis • Says he had an operation to remove dead pancreas 7 days ago • Started feeling bad 2 days ago, felt much worse last night, developed N/V/D • Complains of severe abdominal and back pain

  5. Labs • Na – 141 • K – 4.2 • Cl – 100 • Cr – 1.8 • Glucose – 191 • WBC – 13 with 15% bands • Lactate 4.1

  6. Definition Sepsis • Sepsis • SIRS + probable site of infection • Severe Sepsis • Organ Dysfunction (Oliguria, INR, Cr) • Hypotension • Hypoperfusion • Delta MS • Lactate • Septic Shock • Sepsis induced Hypotension with perfusion abnormalities despite fluid resuscitation • Multiple Organ System Failure (MOSF or MODS) • Shock, ARDS, ARF, DIC, Liver Failure, Hyperglycemia

  7. Sepsis Epidemiology • Estimated 750,000 severe sepsis cases in USA per year • 387,000 initially present to ED • Mortality rate ranges from 23-46% • 500 deaths per day • Estimated annual cost is $16.7 billion • Global estimates range from 51-206 cases per 100,000

  8. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic ShockNEJM, Nov 2001 Rivers EP et al.

  9. Please see the following tables and figures from this article: • Figure 2 • Table 2 • Table 3 • Table 4 • Pubmed link: Rivers et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. PMID: 11794169

  10. Key points from article • Goal-oriented therapy for sepsis • Balancing oxygen therapy and demand by managing preload, afterload, and contractility • Primary focus of ICU management • Study examined role of goal-oriented therapy in ED setting and effects on mortality and organ dysfunction • Goal directed therapy in the ED setting was associated with: • Decreased in-hospital mortality than standard therapy (72 hour comparison) • Less severe organ dysfunction (APACHE II scores)

  11. Key points • Fluid resuscitation • Monitor MAP, CVP • Tx = Crystalloid/colloid, vasopressors, ionotropes • Estimate total body ischemia • Monitor lactate and SvO2 • Tx = PRBC transfusions

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