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SEPSIS

SEPSIS. Trevor Langhan October 4 th , 2007 Thanks to Dr. Jason Lord FRCPC CCM. M & M Case Presentation. 59 year old male 5 day Hx generalized abdo pain and diarhea with rigors PMHx Liver abscess 1999 Shoulder abscess 1990 EtOH abuse Pancreatitis DM II HTN. Case Presentation.

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SEPSIS

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  1. SEPSIS Trevor Langhan October 4th, 2007 Thanks to Dr. Jason Lord FRCPC CCM

  2. M & M Case Presentation • 59 year old male • 5 day Hx generalized abdo pain and diarhea with rigors • PMHx • Liver abscess 1999 • Shoulder abscess 1990 • EtOH abuse • Pancreatitis • DM II • HTN

  3. Case Presentation • Meds: Insulin, Metoprolol, Lipitor • Sept 25 23:13 • Temp 40.2 • HR 132 • BP 140/90 • RR 32 • Sat 88% RA • Confused, flushed, dry mucous membranes

  4. Case Presentation • P/E: • Abdomen: • generalized tenderness but no peritoneal signs, no Murphy’s, • Chest: • clear bilat • CVS: • HS normal, No murmurs • Remainder of exam non-contributory

  5. Case Presentation • Labs • WBC 4.1 (3.2 neuts, 0.2 bands) • Hgb 142 • Platelets 110 • Cr 116 • AP 206, TBili 26, ALT 56, GGT/Lipase N • ABG 7.52/29/49/24 Lactate 1.1

  6. Case Presentation • ECG Sinus Tach • CXR #1 clear • Urine small blood nil else • CT abdo: • thickened dilated GB wall with pericolic fluid • No stones, no CBD thickening • c/w acute cholecystitis suggest U/S for confirmation

  7. Resuscitation Measures

  8. Resuscitation Measures

  9. Vital Signs

  10. Interesting quotes on chart • 04:00 • “patient looks relatively well despite BP” • 05:45 • “patient likely septic but no obvious focus” • 05:45 • “if no response to fluids consider CVP and pressors if patient symptomatic” • 07:30 • “consult ICU to see if patient safe for CT abd”

  11. Sepsis • Why are we talking about this AGAIN! • Sepsis and spectrum of infectious disease presentations to ED poorly recognized • Mild under-resuscitation – perk up pt well enough for ward followed by ICU admit 1-2 days later

  12. Case One • 42 year old woman • c/o epigastric pain • Onset 2 hours after eating • ROS • Mildly obese • Nil else

  13. Case One • PMHx • Gall stones • Meds and Allergies • none

  14. Case One • Vitals • HR 110 • RR 16 • BP 118/70 • Sat 96% room air • Temp 37.6 C • Glucose 9.0 • Physical • Tender epigastrum, no peritonitis

  15. Case One • Labs: • Hgb 140 • Platelets 289 • WBC 14.2 • Lytes, creatinine normal • Lipase 2029 • LFTs normal • CT abdomen • Acute pancreatitis

  16. Case One • IV fluid • 500 cc NS bolus • 125 cc NS per hour maintenance • Analgesia • Morphine prn • Gravol prn • Plan • NPO, Admit to general surgery • Diagnosis?

  17. Case Two • 14 year old male • c/o sore throat x 3 days • Still going to school and playing golf • PMHx: nil • Meds/Allergies: nil

  18. Case Two • HR 95 • BP 110/70 • RR 16 • Temp 38.4 • Sat 99% • Glucose 6.0 • Throat Swab done by GP yesterday • +ve for GAS

  19. Case Two • Plan • Oral antibiotics • Increase oral fluids • RTER prn • Diagnosis?

  20. Case Three • 32 year old woman • 3 day Hx productive cough • Chills, feeling unwell • PMHx: nil • Meds: none • Allergies: none

  21. Case Three • HR: 110 • RR: 22 • O2 Sat: 91% • BP: 140/76 • Temp: 38.6 C

  22. What would you order next? • ABC’s OK • O2, IV, monitor applied • CBC, lytes, BUN, Cr, cultures sent • CXR ordered Are there any other investigations?

  23. The Septic Spectrum • Two of: • HR > 90 • RR > 30 • T > 38 or < 36 • WBC > 12 or <4 SIRS SIRS + Infection SEPSIS Mortality:10%

  24. The Septic Spectrum SEPSIS • Lactic Acidosis • Oliguria • Altered mental status SEPSIS + Organ Dysfunction SEVERE SEPSIS Mortality:16%

  25. The Septic Spectrum SEVERE SEPSIS • Severe Sepsis +/- hypotension despite adequate fluid resuscitation SEPTIC SHOCK Mortality:46%

  26. The Septic Spectrum SIRS SEPSIS Mortality:10% SEVERE SEPSIS Mortality:16% SEPTIC SHOCK Mortality:46%

  27. The Septic Spectrum EARLY Goal Directed Therapy can decrease mortality SEPTIC SHOCK Mortality:30%

  28. Partially RCT • Early (< 6 hours) goal directed protocol vs. standard of care • Inclusion: • Systolic BP < 90 after 30cc/kg bolus • 2 of 4 SIRS criteria • Outcomes: • Inhospital mortality • A priori Power Calculation

  29. 500cc boluses as needed to get CVP 8-12 • sBP<90  pressors • Central venous O2 sats measured • <70%  pRBC to achieve HCT >.30 • Dobutamine if optimized HCT and MVO2 sats <70% • ETI if not already done if unable to achieve HD goals

  30. Results: N=263

  31. Case Three • HR: 110 • RR: 22 • O2 Sat: 91% • BP: 140/76 • Temp: 38.6 C

  32. What would you do next? Successful resuscitation requires quick intervention Trauma: The Golden hour Myocardial Infarct: Door-to-needle times Septic Shock: Early Goal Directed Therapy

  33. What would you order next? • Lactate • If not available…venous or arterial blood gas • Why? • You can’t act early if you don’t know the clock is ticking!

  34. Patient’s condition is worsening… • HR: 145 • RR: 28 • BP: 85/35 • 2 litres of NS • O2Sat: • 92% on FiO2 100% • CXR shows RLL consolidation • Lactate 6.4 Septic Shock

  35. What kind of shock is this? • Hypovolemic • Vasodilatory • Cardiogenic • Obstructive √ √ √ Hinsaw/Cox 1972

  36. What kind of shock is this? • Hypovolemic • Vasodilatory • Cardiogenic • Obstructive CVP 8-12 MAP > 65 ScvO2 >70% The goals of “Early Goal Directed Therapy” address the 3 types of shock present in a septic patient

  37. Hypovolemic ShockGoal: CVP 8-12 • Why are septic patients hypovolemic?

  38. Hypovolemic ShockGoal: CVP 8-12 • Why are septic patients hypovolemic? • 3rd spacing • Diaphoresis • Increased losses (vomiting, diarrhea, etc) Main reason is not because of less fluid, but because of a larger container… …Venodilation

  39. Different fluids distribute to different places • Doesn’t matter what – just give enough! Carlson RW. Fluid Resus. in Circulatory ShockCrit. Care Clin. 1993;9:313.

  40. Distributive Shock Goal: MAP > 65 • Once ‘tank is full’ CVP 8-12 mmHg • Need to increase vascular tone • Vasoactive agents • Vasopressors • Inotropes

  41. Vasoactive Agents

  42. Adrenergic Receptors • Alpha adrenergic receptors: • vascular walls - peripheral vasoconstriction • Beta adrenergic receptors • Beta 1: myocardium - increase inotropy (force of contraction) and chronotropy (heart rate) • Beta 2: vascular walls - peripheral vasodilatation lungs - bronchial smooth muscle relaxation • Dopamine receptors • renal and splanchnic arteries - vasodilatation and inc blood flow

  43. Norephinephrine (Levophed) • Acts mainly on Alpha1 receptors • (small clinical effect on Beta receptors) • Inc BP through peripheral perfusion • slight tachycardia • Inc afterload by vasoconstriction • Use cautiously in cardiogenic shock • Dec perfusion to kidneys and peripheries • “Leave ‘em Dead”

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