1 / 44

Bootcamp - Sepsis

Bootcamp - Sepsis. Adam Manko , M.D. PGY-3 Internal Medicine University Hospitals Case Medical Center. Goals. Sepsis – Definition Initial Management Medications Mechanical Ventilation - Briefly What Your Senior Expects From You Summary. Case.

nili
Download Presentation

Bootcamp - Sepsis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Bootcamp- Sepsis Adam Manko, M.D. PGY-3 Internal Medicine University Hospitals Case Medical Center

  2. Goals • Sepsis – Definition • Initial Management • Medications • Mechanical Ventilation - Briefly • What Your Senior Expects From You • Summary

  3. Case • 69 y/o Male presented to ER with shortness of breath. • VS 38.3 88/46 114 28 86% • He is placed onto 50% ventimask, but continues to have low oxygen saturation and is intubated in the ER. • He is given 2L of NS and repeat BP is 92/44

  4. The Patient arrives in the MICU…..what do you do next?

  5. Defining Sepsis 1 • Sepsis is a continuum….. • SIRS • Sepsis • Severe Sepsis • Septic Shock • Refractory Septic Shock • Multi-Organ Dysfunction Syndrome (MODS)

  6. Defining Sepsis 2 • SIRS Criteria • Temperature >38.3 (or >38.0 for 1 hour) or <36.0 • WBC >12k or <4k, or >10% bandemia • RR >20, or paCO2 <32mmHg • HR >90

  7. Defining Sepsis 3 • Sepsis = SIRS + suspected infection • Does not have to be culture proven infection to begin treatment for Sepsis

  8. Defining Sepsis 4 • Severe sepsis = sepsis + and signs of at least one organ dysfunction thought to be from tissue hypoperfusion • Hypotension • Elevated lactate • Urine output <0.5ml/kg • Acute Lung Injury with PaO2/FiO2 ratio of <250 • ARDS • Acute Renal Failure • Elevated bilirubin • Platelet Count <100,000 • Coagulopathy with INR >1.5 • Altered Mental Status • Abnormal EEG findings • Cardiac Dysfunction

  9. Initial Management • “Early Goal Directed Therapy” • Goal SBP >90 • Goal MAP >65 • Goal Hemoglobin 7-9 • Goal urine output >0.5ml/kg/hr • Goal normalized serum lactate • Goal Mixed Venous >70% • Central Venous >65%

  10. Hypotension • Goal SBP >90, MAP >65, Hgb 7-9 • IVF bolus with NS • What if you give IVF and remains hypotensive? • Need to check a CVP!!!

  11. What is a CVP • CVP • = Central Venous Pressure • What is the utility of a CVP • Estimates the Right Atrial Pressure • What is a Normal Right Atrial Pressure • <6

  12. What do you need for a CVP? • Place a CVC = Central Venous Catheter • Locations include • Internal Jugular • Subclavian

  13. Goal CVP • CVP >8 • If intubated, CVP >12 • What if still hypotensive but at goal CVP?

  14. Pressors • Norepinephrine • First Line pressor (preferred agent over dopamine • (NEJM 2010 Comparison of Dopamine and Norepinephrine in the Treatment of Shock) • Mainly A1, some B1 • Dosing in mcg/min • Typically uptitrate to max of ~30 mcg/min • Vasopressin • Second line pressor • Entirely V1 • Can be titrated, however we typically turn it “on or off” at dose of 0.04 U/min

  15. Pressors - 2 • Phenylephrine • Weaker pressor, A1 activity • Less arrhythmogenic • Dopamine • Dose dependent • Low dose 1-3mcg/kg/min = “renal” dosing, almost all D1 • Medium dose 3-10mcg/kg/min = B1 and D1 • High Dose >10mcg/kg/min = “pressor” dosing

  16. Pressors - 3 • Epinephrine • “king of pressors” • Used as last line pressor at our institution • Side effect includes increased risk of intestinal ischemia

  17. Pressor photo

  18. Mixed Venous and Central Venous Saturations • Mixed Venous >70 • Mixed venous taken from a swan-ganz catheter • Central Venous >65% • Taken from Central Line in the SVC

  19. Venous Saturation • High Venous saturation with unclear utility • Low Venous saturation means increased extraction peripherally • How to increase mixed venous saturation, you have 2 option • Increase hematocrit • Increase cardiac output • Dobutamine

  20. Corticosteroids • Consider when refractory hypotension • when you are adding 2ndpressor, think of adding steroids!! • No longer recommended to do ACTH stim or random cortisol • Empirically add hydrocortisone, dose 50mg q6h

  21. Antibiotics • Antibiotics within 1 hour • Typically vancomycin and zosyn are first line agents if unclear of source • Start broad and narrow when source identified

  22. ABX photo from UH guide

  23. Glycemic Control • Maintain tight blood glucose control with goal 140-180 • If unable to manage easily (you get 2 tries with SQ insulin) then start on insulin gtt • Protocol driven by nursing • FYI this is different than the DKA protocol • (2010 NEJM – Glycemic Control in the ICU)

  24. Prophylaxis • DVT • If no contra-indications…. • Heparin SQ preferred agent • If contraindications • SCDs and TED hose • Stress Ulcer • PPI or H2 blocker

  25. Mechanical Ventilation • Protective Lung Ventilation Strategy • ARDSnet protocol • Low tidal volumes • 6ml/kg of IBW • PEEP • Goal plateau pressure <30 • (2007 NEJM - Low Tidal Volume Ventilation in the Acute Respiratory Distress Syndrome) • (2000 NEJM – Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome)

  26. ARDS NET photo

  27. RRT, HD, UF, CRRT,CVVH, CVVHD…..What? • RRT = Renal Replacement Therapy • HD = Hemodialysis • UF = Ultrafiltration • CRRT = Continuous Renal Replacement Therapy • CVVH = Continuous veno-venous hemofiltration • CVVHD = Continuous veno-venous hemodialysis

  28. Indications for RRT • A • Acidosis • E • Electrolyte imbalance • I • Intoxication • O • Fluid Overload • U • Uremia

  29. Miscellaneous • Sedation • Versed for anxiety • Fentanyl for pain • Haldol for agitation • Propofyl • Precedex

  30. What Your Senior Expects From You • Assess the patient!!(Go into room, not look in EMR first) • Labs • CBC • RFP • LFTs • Coag • Type and Screen • Lactate!!! • In the right setting • Troponin, amylase, lipase, etc • Microbiology • Blood cultures x2 • UA and culture • +/- sputum culture • Imaging • CXR, +/- KUB • CT in right setting

  31. What Your Senior Expects From You • Check for Access • Prep for CVC • If hypotensive, need invasive hemodynamic monitoring • Central Line (CVC) • Arterial Line • Other • HD Catheter? • Introducer (Cordis)?

  32. What Your Senior Expects From You • Get us if you are uncomfortable in a situation, aka the patient is very sick and crashing!! • STAY CALM!!! • Nurses are your friend or worst enemy, the choice is yours!! • They have taken care of more patients than you, they often know what the next step is, use them as a resource!!

  33. In Summary, the Goals of Sepsis are……

  34. Our ICU Algorithm for Sepsis

  35. Case • 69 y/o Male presented to ER with shortness of breath. • VS 38.3 88/46 114 28 86% • He is placed onto 50% ventimask, but continues to have low oxygen saturation and is intubated in the ER. • He is given 2L of NS and repeat BP is 92/44

  36. The Patient arrives in the MICU…..what do you do next?

  37. Summary • Identify Severe Sepsis and Septic Shock Early • IVF • Early invasive hemodynamic monitoring • Goal endpoints • Urine output, SBP, MAP, lactate, central venous sat, CVP <8 or 12 • Pressors and Steroids • Cultures and ABX

  38. Questions? • Thank you!!!

More Related