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Bhagawan in Muddenahalli

Bhagawan in Muddenahalli. Surviving Sepsis. Sridhar, V. MD,. Isavaasyamidam sarvam yathkinchajagathyaam jagath Thena thyakthena bhunjeethaah, maa gridhah kasyaswid-dhanam. Antibiotics in Sepsis. Begin Intravenous antibiotics within the first hour after severe sepsis/shock is recognised.

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Bhagawan in Muddenahalli

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  1. Bhagawan in Muddenahalli

  2. Surviving Sepsis Sridhar, V. MD,

  3. Isavaasyamidam sarvam yathkinchajagathyaam jagathThena thyakthena bhunjeethaah, maa gridhah kasyaswid-dhanam

  4. Antibiotics in Sepsis • Begin Intravenous antibiotics within the first hour after severe sepsis/shock is recognised. • Use Broad spectrum agents with good penetration. • Reassess the antimicrobial regimen daily to optimize efficacy, prevent resistance, avoid toxicity and minimize costs.

  5. Loading dose .. • Depends on the volume of distribution. • Capillary leakage and fluid resuscitation. expand the Extracellular contents. Dilution effect ,third spacing is much more relevant in hydrophilic agents which distribute in Extracellular space. Hence Hydrophilic agents –need higher loading dose.

  6. Loading dose is independent of the renal function. • In Lipophilic antibiotics ,the dilution effect in the extracellular fluids is mitigated . • With Lipophilic antibiotics ,standard dosages ,ensure adequate loading.

  7. Hydrophilic Antibiotics… • B-lactams. • Aminiglycosides. • Glycopeptides. • Estimation of Creatinine Clearance (cockcroft). useful in acute ICU patients. Direct measurement of CLcr should be done in pts with lengthy hospital stay > 30 days.

  8. Cont.. • Hydrophilic antibiotics.. A. Limited Volume of Distribution. B. Inactive against intracellular pathogens. C. Renal Excretion . D. Unable to passively diffuse.

  9. Lipophilic antibiotics.. • Macrolides. • Fluoroquinolones. • Tetracyclines. • Chloramphenicol. • Rifampin. • Linezolid. • Active against intracellular pathogens, hepatic metabolism ,large volume of distribution.

  10. Renal Failure.. • Myocardial Depression ---sepsis. • Nephrotoxic agents----vanco,amino,furosemide. • Contrast agents. • In Renal failure-Vanco and Amino --dose reduction. • B-Lactams –no dose reduction. • Neurological toxicity –with Blactams.

  11. Glomerular Hyperfiltration in Sepsis • Consequence of Ionotropic agents. • Will increase drug excretion. • Hence ICU pts need daily assesments of CLcr.

  12. Hpoalbuminemia in Sepsis… • Promotes increase unbound fraction. • Extensive distribution . • Increased Clearance.

  13. Conc dependent Antibiotics.. • Levoquin. • Aminoglycosides. Once daily is as efficacious as dosing three times a day. Once daily is less Nephrotoxic

  14. Time dependent. • Blactams, • Glycopeptides. • Oxazolidinones. • Multiple daily dosing. • Extended infusions.

  15. Continuous Renal Replacement therapy. • Some pts have residual renal function. • Such pts need significant dosage increase as compared with renal failure. With Blactams, amino, levoquin and ciprofloxacin.

  16. MRSA • Vancomycin. • Lineolid.

  17. Neutropenic pts. • Combination Therapy with Aminiglycosides and ¾ generation Cephalosporins. • Cover for Pseudomonas. • Empiric antifungal treatment not recommended.

  18. Cefotaxime. • Gram positive • Gram Neg • Anerobes.

  19. Ceftazidime • Fortaz • Psedomonas • Gram neg

  20. Cefepime • Osteomyelitis • Neutropenic pts. • MRSA –Osteo—Vanco,linezolid. • MSSA- Osteo--Nafcillin ,cefazolin

  21. Linezolid • Mono amine oxidase inhibitors. • MRSA—gram positive. • Bone marrow supression.

  22. All things of this world, the transitory, the evanescent, are enveloped by the Lord who is the real reality of each. Therefore they have to be used with reverent renunciation, without covetousness or greed for they belong to the Lord and not to any one person".

  23. Age Specific Incidence of Sepsis

  24. Definition • Sepsis is defined as infection plus systemic manifestations of infection Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion.

  25. SEPSIS INFECTION +SYSTEMIC RESPONSE • SEVERE SEPSIS SEPSIS + TISSUE HYPOPERFUSION OR ORGAN DYSFUNTION

  26. Sepsis-induced hypotensionLactate greater than the upper limits of normal laboratory resultsUrine output< 0.5 mL/kg hr for 2 hrs, despite adequate fluid resuscitationALI with PaO2/FIO2 <250 in the absence of pneumonia as infection sourceALI with PaO2/FIO2 <200 in the presence of pneumonia as infection sourceCreatinine >2.0 mg/dL (176.8 mol/L)Bilirubin> 2 mg/dL (34.2 mol/L)Platelet count <100,000Coagulopathy >(INR 1.5)

  27. Septic Shock Pre-Fluid Resuscitation

  28. Starlings Law

  29. Case A 42 year old man is admitted to the ICU with fever, leucocytosis, elevated BUN and Creatinine, tachycardia and hypotension.He has an obvious infection of his distal left lower extremity as demonstrated. What is your diagnosis ?.

  30. Case..

  31. Case.. • A. Wet Gangrene. • B. Infected Bullous Pemphigoid. • C. Necrotising Fascitis. • D. Lymphedema and cellulitis. • E. Gas gangrene.

  32. Case.. • A. Wet Gangrene. • B. Infected Bullous Pemphigoid. • C. Necrotising Fascitis. • D. Lymphedema and cellulitis. • E. Gas gangrene.

  33. Case…

  34. Source Control Within 6 Hours

  35. Antibiotic Therapy Recommend beginning intravenous antibiotics within first hour of recognition of severe sepsis

  36. Antibiotics in Sepsis

  37. Antibiotic Therapy • Broad antibiotic coverage initially. • Narrow coverage after return of cultures. • Source control as soon as possible and within 6 hrs.

  38. Initial Resuscitation

  39. Probability of Survival

  40. Fluid Therapy • Recommend fluid resuscitation can consist of natural or artificial colloids or crystalloids.

  41. Fluid Challenge for SepsisInduced Hypotension 20 ml/kg crystalloid (or colloid equivalent)

  42. Resuscitation of SepsisInduced Tissue Hypoperfusion • Recommend MAP 65 mm Hg • Recommend urine output .5ml/kg/hr

  43. MAP = [(2 x diastolic) +systolic] / 3

  44. Which two adrenergic agents are most appropriate to maintain acceptable blood pressure in a patient with septic shock ? A.Dopamine or epinephrine. B.Epinephrine or vasopressin. C.Vasopressin or norepinephrine. D.Norepinephrine or dopamine

  45. Which two adrenergic agents are most appropriate to maintain acceptable blood pressure in a patient with septic shock ? A.Dopamine or epinephrine. B.Epinephrine or vasopressin. C.Vasopressin or norepinephrine. D.Norepinephrine or dopamine.

  46. Why not Epinephrine ? Epinephrine compromises splanchnic circulation. It is a second tier drug. It can be added if blood pressure does not respond to dopamine and Norepinephrine.

  47. How do you choose ? • Dopamine or Norepinephrine. Pay attention to heart rate, abnormal rhythm( atrial fibrillation). If tachycardia ,or atrial fibrillation prefer Norepinephrine over dopamine

  48. Vasopressors • Suggest either norepinephrine or dopamine administered through a central venous catheter is the initial vasopressor of choice to maintain a mean arterial pressure of 65mmHg.

  49. Phenylephrine • Pure vasoconstrictor in general should be avoided • Decreases cardiac output • Cardiac output measured? • Profound tachycardia

  50. Circulating Vasopressin Levels in Septic Shock

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