early goal directed therapy in the treatment of sepsis nouf y.akeel general surgery demonstrator...
TRANSCRIPT
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Early goal directed therapy in the treatment of sepsis
Nouf Y.AkeelGeneral surgery demonstratorSaudi board trainee R3
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•Introduction •Case presentation•EGDT•Review •Summery
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صلوا على الحبيب
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•13 y/o male patient known to have IDDM
presented to ER with 3-day history of
abdominal pain. Hx of vomiting and fever.
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•He was confused
•T. 39.4 HR 130 RR 24 BP
77/50
•Abdomen on examination was distended
and rigid
•WBC 17,OOO Hb 11 HCT 31 PLT 251
•Na 134 K 4.1 Ur 7 Cr 119
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How to manage this patient?
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EGDT
•This approach involves adjustments of
cardiac preload, afterload, and
contractility to balance oxygen delivery
with an increased oxygen demand
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I. Fluid therapy
•Crystalloids vs colloids (no difference in the mortality)
•CVP 8-12 mmHg•Fluid challenge: *infusion of crystalloids boluses of 20ml/kg
over5-10 min (up to 3 boluses) *1L of crystalloids or 300-500ml of
colloids over 30min
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I. Fluid therapy
•Reduce the rate of fluid administration if there is sign of adequate cardiac filling with no hemodynamic improvement
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II. Vasopressors
•MAP 65-90 mmHg•Start with Dopamine or nor epinephrine
(centrally)•Insert A-line for continues monitoring•Low-dose dopamine doesn’t protect the
kidneys!
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III. ScvO2 monitoring
•ScvO2 > 70%
DO2=CO X 1.34 X Hb X SaO2 X 10
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•These benefits arise from the early identification of patients at high risk for cardiovascular collapse and from early therapeutic intervention to restore a balance between oxygen delivery and oxygen demand.
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•EGDT results in significant reductions in morbidity, mortality, vasopressor use, and health-care resource consumption
•Mortality reduction at 28-d is 16%
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49.2%
33.3%
0
10
20
30
40
50
60
Standard Therapy N=133
EGDTN=130
P = 0.01*
Early Goal-Directed Therapy Results:28 Day Mortality
NEJM 2001;345:1368-77.
Mortality
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• Initial resuscitation
• Diagnosis
• Antibiotic therapy
• Source control
• Fluid therapy
• Vasopressors
• Inotropic therapy
• Corticosteroids
• rhAPC
• Blood products
administration
• Mechanical ventilation
(ARDS/ALI)
• Sedation, analgesia, and
neuromuscular blockade
• Glucose control
• Renal replacement
• Bicarbonate therapy
• DVT prophylaxis
• Stress ulcer prophylaxix
• Consideration for
limitation of support
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Summery
• Approach targeted on the first 6 hours of care in the emergency department and ICU.
• Focuses on 1.adequate fluid replacement 2.vasopressors3.optimizing oxygen delivery
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Thank You : )
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