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Case Presentation Presented by: Dr.Safaa fadhl Supervised by: Dr.Kamal Marghani

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

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Case Presentation Presented by: Dr.Safaa fadhl Supervised by: Dr.Kamal Marghani

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  1. Case Presentation Presented by: Dr.Safaafadhl Supervised by: Dr.KamalMarghani

  2. 29 yrs male presented to ED at 1:40pm complaining of cough , SOB, and fever. At triage :

  3. Pt was admitted to room A at 2:00pm 29 yrs old male whose known to be DM for 7yrs on mixtardinsuline 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.

  4. Plane : • Give oxygen via NRM rate 15 L\min. • Normal saline 1000ml. • Samixon 1g BD • Clarithromycin 500 BD • insulin mixtard • Take investigation, ABG,CXR

  5. ABG on NRM:

  6. SO , the pt was diagnose as pneumonia At 9:30 pm pt was admitted to CCR . On admission he was looking ill ,tachypnic on NRM. A: his airway was patent, on NRM B: 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 296 E: examination of all other systems were unremarkable.

  7. 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

  8. Day 2 CCR A : airways patent B : distress using accessory muscle, RR 40, SPO2 87 C :pulse 128, BP 114\79 MAP 88, good UOP. D : GCS 15\15, RBS 98

  9. At 12:45pm , pt became more distress and not responsive , he was intubated and connected to MV . Initial settings were:

  10. 1hr after the intubation his ABG: MV setting :

  11. 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 ..

  12. A clinical response arising from a nonspecific insult, with 2 of the following: HR >90 beats/min RR >20/min WBC >12,000/mm3or <4,000/mm3 or >10% bands T >38oC or <36oC Severe Sepsis Septic Shock SIRS Sepsis SIRS with a presumed or confirmed infectious process Sepsis with organ dysfunction Refractory hypotension SIRS = systemic inflammatory response syndrome Chest 1992;101:1644.

  13. Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis Altered Consciousness Confusion Psychosis Tachycardia Hypotension  CVP  PAOP Tachypnea PaO2 <70 mm Hg SaO2 <90% PaO2/FiO2300 Oliguria Anuria  Creatinine Jaundice  Enzymes  Albumin  PT  Platelets  PT/APTT  Protein C  D-dimer

  14. 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

  15. Critical Influence of the Time to 1st Antibiotic Dose on Mortality in Septic Shock Every one-hour delay… you drop survival by 7.5% N = 1004 patients

  16. Initial Resuscitation, Diagnosis, and Antibiotic Therapy Recommend early goal-directed therapy Give early appropriate antibiotics Give early appropriate fluids Give appropriateinotropic support Take early cultures Take earlylactate level Take earlycentral venous oxygen saturation(SVO2)

  17. Inotropes in septic shock • Noradrenaline • Adrenaline • Vasopressin • Dopamine( selected cases) NO RENAL DOSE DOPAMINE

  18. Intensive insulin therapy Target glucose 140 -200 mg Improved survival Decreased infections Decreased organ failure

  19. 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)

  20. 2hr later the ABG:

  21. 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

  22. Day 4 Off Noreadrenaline. Sedation vacation done, GCS 11\15

  23. MV setting:

  24. 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

  25. Timing THE Message Time is life

  26. Thank you for your attention

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