bootcamp - sepsis
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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Bootcamp - SepsisAdam Manko, M.D.
PGY-3 Internal MedicineUniversity Hospitals Case Medical Center
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Sepsis – Definition Initial Management Medications Mechanical Ventilation - Briefly What Your Senior Expects From You Summary
Goals
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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
Case
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The Patient arrives in the MICU…..what do you do next?
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Sepsis is a continuum….. SIRS Sepsis Severe Sepsis Septic Shock Refractory Septic Shock Multi-Organ Dysfunction Syndrome (MODS)
Defining Sepsis 1
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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
Defining Sepsis 2
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Sepsis = SIRS + suspected infection◦ Does not have to be culture proven infection to
begin treatment for Sepsis
Defining Sepsis 3
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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
Defining Sepsis 4
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“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%
Initial Management
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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!!!
Hypotension
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CVP ◦ = Central Venous Pressure
What is the utility of a CVP◦ Estimates the Right Atrial Pressure◦ What is a Normal Right Atrial Pressure
<6
What is a CVP
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Place a CVC = Central Venous Catheter Locations include
◦ Internal Jugular◦ Subclavian
What do you need for a CVP?
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CVP >8 If intubated, CVP >12
What if still hypotensive but at goal CVP?
Goal CVP
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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
Pressors
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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
Pressors - 2
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Epinephrine◦ “king of pressors”◦ Used as last line pressor at our institution◦ Side effect includes increased risk of intestinal
ischemia
Pressors - 3
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Pressor photo
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Mixed Venous >70◦ Mixed venous taken from a swan-ganz catheter
Central Venous >65%◦ Taken from Central Line in the SVC
Mixed Venous and Central Venous Saturations
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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
Venous Saturation
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Consider when refractory hypotension◦ when you are adding 2nd pressor, think of adding
steroids!! No longer recommended to do ACTH stim or
random cortisol Empirically add hydrocortisone, dose 50mg
q6h
Corticosteroids
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Antibiotics within 1 hour Typically vancomycin and zosyn are first line
agents if unclear of source Start broad and narrow when source
identified
Antibiotics
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ABX photo from UH guide
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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)
Glycemic Control
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DVT◦ If no contra-indications….
Heparin SQ preferred agent◦ If contraindications
SCDs and TED hose
Stress Ulcer◦ PPI or H2 blocker
Prophylaxis
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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)
Mechanical Ventilation
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ARDS NET photo
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RRT = Renal Replacement Therapy◦ HD = Hemodialysis◦ UF = Ultrafiltration
CRRT = Continuous Renal Replacement Therapy◦ CVVH = Continuous veno-venous hemofiltration◦ CVVHD = Continuous veno-venous hemodialysis
RRT, HD, UF, CRRT,CVVH, CVVHD…..What?
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A◦ Acidosis
E◦ Electrolyte imbalance
I◦ Intoxication
O◦ Fluid Overload
U◦ Uremia
Indications for RRT
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Sedation◦ Versed for anxiety◦ Fentanyl for pain◦ Haldol for agitation◦ Propofyl◦ Precedex
Miscellaneous
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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
What Your Senior Expects From You
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Check for Access◦ Prep for CVC
If hypotensive, need invasive hemodynamic monitoring◦ Central Line (CVC)◦ Arterial Line
Other◦ HD Catheter?◦ Introducer (Cordis)?
What Your Senior Expects From You
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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!!
What Your Senior Expects From You
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In Summary, the Goals of Sepsis are……
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Our ICU Algorithm for Sepsis
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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
Case
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The Patient arrives in the MICU…..what do you do next?
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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
Summary
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Thank you!!!
Questions?