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15506707552055Aims: ? oxygen transport – rapidly produce normotensive, hypervolaemic hyperperfusion via high flow O2 +/- ventilatory support, and volume loadingEarly goal directed therapy (now controversial): Shown to improve survival; results of Rivers Trial may not be applicable to Australasia, as our mortality rates were much lower than USA; ?more recent research doesn’t support this study1) IV fluid resus: ASAP; no evidence of colloid over crystalloid Therapeutic aims: CVP 8-12, MAP 65-90, urine output >0.5ml/kg/hr (>1ml/kg/hr in children), CVO2 saturations >70% 500ml Q5-10minly (or 10ml/kg boluses); look for changes suggesting improved CO / O2 delivery (? HR, ? MAP, ? SaO2, improved colour; look for adverse effects on pulmonary function (? airway pressure, ? SaO2, frothing) repeat in beneficial If CV O2 saturations >70% not achieved by CVP 8-12 transfuse to HCt >30% (controversial) +/or start dobutamine PRBC not recommended unless Hb <70 (aiming Hb 70-90) FFP only if clinicaly bleeding; platelets if <5 (?50)00Aims: ? oxygen transport – rapidly produce normotensive, hypervolaemic hyperperfusion via high flow O2 +/- ventilatory support, and volume loadingEarly goal directed therapy (now controversial): Shown to improve survival; results of Rivers Trial may not be applicable to Australasia, as our mortality rates were much lower than USA; ?more recent research doesn’t support this study1) IV fluid resus: ASAP; no evidence of colloid over crystalloid Therapeutic aims: CVP 8-12, MAP 65-90, urine output >0.5ml/kg/hr (>1ml/kg/hr in children), CVO2 saturations >70% 500ml Q5-10minly (or 10ml/kg boluses); look for changes suggesting improved CO / O2 delivery (? HR, ? MAP, ? SaO2, improved colour; look for adverse effects on pulmonary function (? airway pressure, ? SaO2, frothing) repeat in beneficial If CV O2 saturations >70% not achieved by CVP 8-12 transfuse to HCt >30% (controversial) +/or start dobutamine PRBC not recommended unless Hb <70 (aiming Hb 70-90) FFP only if clinicaly bleeding; platelets if <5 (?50)2438407552055Management00Management2457456274435Investigation00Investigation15538456274434Blood culture: pathogen identified in 70%; bacteraemia detected in 50% severe sepsisBloods: WCC 40-90% sensitivity, 45-65% specificity; if add L shift, 75-100% sensitivity, 4-11% specificity; ? WCC common Lactate (good for risk stratification; lactate <2.5 = 4% mortality, lactate >4 = 28% mortality) Procalcitonin (>0.2 = 80-100% sensitivity, 30-50% specificity for bacteraemia; measurable after 2 hours, peaks at 12-24 hours) Early respiratory alkalosis, late metabolic acidosis; ? CK and LDH; ? platelets00Blood culture: pathogen identified in 70%; bacteraemia detected in 50% severe sepsisBloods: WCC 40-90% sensitivity, 45-65% specificity; if add L shift, 75-100% sensitivity, 4-11% specificity; ? WCC common Lactate (good for risk stratification; lactate <2.5 = 4% mortality, lactate >4 = 28% mortality) Procalcitonin (>0.2 = 80-100% sensitivity, 30-50% specificity for bacteraemia; measurable after 2 hours, peaks at 12-24 hours) Early respiratory alkalosis, late metabolic acidosis; ? CK and LDH; ? platelets2533655632450Assessment00Assessment15538455632450History: contacts, immunosuppression, prosthetic devicesMEDS score: based on terminal illness / RR or sats / septic shcok / platelets / 10% bands / age / LRTI / nursing home resident / mental status; predicts mortality at 28/7; >16 = 45%, 0-4 = 1%00History: contacts, immunosuppression, prosthetic devicesMEDS score: based on terminal illness / RR or sats / septic shcok / platelets / 10% bands / age / LRTI / nursing home resident / mental status; predicts mortality at 28/7; >16 = 45%, 0-4 = 1%15506705285740Elderly, infants, immunosuppresion, adolescents, indigenous populations00Elderly, infants, immunosuppresion, adolescents, indigenous populations2457455285740Risk Factors00Risk Factors2374901437640Definitions00Definitions156718014370050015671804790440Septic shock00Septic shock25501604791075Severe sepsis + hypotension not reversed by fluid resus, with associated hypoperfusion00Severe sepsis + hypotension not reversed by fluid resus, with associated hypoperfusion15690851437005Bacteraemia00Bacteraemia15690851768475Infection00Infection15697204166235Sepsis00Sepsis15690854482465Severe sepsis00Severe sepsis25501604482465 Sepsis + organ dysfunction / ARDS00 Sepsis + organ dysfunction / ARDS25501604166235 SIRS + infection00 SIRS + infection15671802915285Organ Dysfunction00Organ Dysfunction25501602915286Any of:SBP <90 / SBP 40mmHg less than normal / MAP <60 (<65 in infants, <75 in children)Base excess < -5Lactate >2Urine output <30ml/hrToxic confusional stateFiO2 >0.4 and PEEP >5 for oxygenationCreatinine >0.1600Any of:SBP <90 / SBP 40mmHg less than normal / MAP <60 (<65 in infants, <75 in children)Base excess < -5Lactate >2Urine output <30ml/hrToxic confusional stateFiO2 >0.4 and PEEP >5 for oxygenationCreatinine >0.1615671802107565SIRS00SIRS25501602107565≥2 of: T >38°C / <35°C (>38.5°C in children) HR >90 (>160 in infants, >150 in children, bradycardia in <1yr) RR >20 / PaCO2 <32 WCC >12 / <4 / >10% immature bands00≥2 of: T >38°C / <35°C (>38.5°C in children) HR >90 (>160 in infants, >150 in children, bradycardia in <1yr) RR >20 / PaCO2 <32 WCC >12 / <4 / >10% immature bands25501601775460Bacteraemia / fungus / protozoa / virus or septic focus / infected cavity / tissue mass00Bacteraemia / fungus / protozoa / virus or septic focus / infected cavity / tissue mass25501601437640Presence of viable baceria in blood; G+ive > G=ive00Presence of viable baceria in blood; G+ive > G=ive243840963930Epidemiology00Epidemiology1551305962026Presents to ED with T >38°C = mortality rate 3%, 6% ICU admission; 27% mortality if admitted ICU; septic shock mortality rate 23-46%; 95% bacteria, 5% fungal00Presents to ED with T >38°C = mortality rate 3%, 6% ICU admission; 27% mortality if admitted ICU; septic shock mortality rate 23-46%; 95% bacteria, 5% fungal246380330200Sepsis00Sepsis3181359317990CORTICUS00CORTICUS16344909317990Hydrocortisone in septic shock; NEJM, 2008; no improved survival or reversal of shock; however, did speed up reversal of shock in patients who did survive00Hydrocortisone in septic shock; NEJM, 2008; no improved survival or reversal of shock; however, did speed up reversal of shock in patients who did survive16344908579485Lancet, 2007; no difference in efficacy or safety00Lancet, 2007; no difference in efficacy or safety3181358579485Noradrenaline + Dobutamine vs Adrenaline Alone in Septic Shock00Noradrenaline + Dobutamine vs Adrenaline Alone in Septic Shock16344907946390Lancet, 2000; no significant renal protection provided; do not use low dose dopamine00Lancet, 2000; no significant renal protection provided; do not use low dose dopamine3181357946390Low dose Dopamine for Renal 00Low dose Dopamine for Renal 16344907323455NEJM, 2010; no significant difference in outcome, but dopamine associated with ? adverse events (arrhythmia); dopamine causes ? mortality in patients in cardiogenic shock00NEJM, 2010; no significant difference in outcome, but dopamine associated with ? adverse events (arrhythmia); dopamine causes ? mortality in patients in cardiogenic shock3181357323455Dopamine vs Noradrenaline in Shock00Dopamine vs Noradrenaline in Shock16344906543040Saline vs albumin in critically ill patients in ICU, randomised double-blinded NEJM, 2004; showed no significant difference in mortality, survival time, organ dysfunction, duration of mechanical ventilation, duration of dialysis, LOS in ICU and hospital at 28 days; albumin ? mortality in severe sepsis; ? mortality in trauma00Saline vs albumin in critically ill patients in ICU, randomised double-blinded NEJM, 2004; showed no significant difference in mortality, survival time, organ dysfunction, duration of mechanical ventilation, duration of dialysis, LOS in ICU and hospital at 28 days; albumin ? mortality in severe sepsis; ? mortality in trauma3181356536055SAFE Study00SAFE Study318135513080Management(cntd)00Management(cntd)16344905118112) Vasopressors: if IV fluid fails to restore adequate BP or shows signs of pulmonary oedema; if using these, give steroids also (controverisal) Therapeutic aims: PWP 15-18, MAP 90-110, HR 80-120 Noradrenaline 2.5-20mcg/kg/min + insert CVL +/- arterial line3) Inotropes: if IV fluids fails to restore adequate CO (ie. ? Lactate, ? urine output, CV sats <70%) Dobutamine (but book said it was unhelpful due to hypotension and tachycardia); use in combination with vasioressor if hypotensive; infants may be resistant to dobutamineAdditional measures:Antibiotics: start within 1 hour; reassess at 48-72 hours and narrow spectrum down; in 1st 6 hours, ? mortality by 8%/hour for delay in giving antibioticsUnknown sourceFlucloxacillin+Gentamicin / cephalothinRespiratoryCeftriaxone+AzithromycinGastrointestinalAmpicillin / cef+Gentamicin+ MetronidazoleUrinaryAmpicillin+GentamicinSkinFlucloxacillinPerform source control: debride, incision and drainage, remove lines etc…Intubate: if shock resistant to fluids and pressors In ARDS: TV 6ml/kg (? mortality rate from 40% to 30%), RR 18-22, PIP <30, allow moderate hypercapnia, PEEP (level depends on FiO2 required – ? PEEP if ? FiO2 needed), semi-recumbent position, head of bed elevated 45°; avoid neuromuscular blockade if possibleBSL: aim <8-9; continuous insulin infusion recommendedSteroids: controversial; recommended if septic shock requiring vasopressors; 200-300mg hydrocortisone per dayRecombinant activated protein C: use if severe sepsis with dysfunction of >2 organ systems / APACHE >25; unclear if has any effect on mortality; give 24mcg/kg/hr INF for 96 hours Side effects: prolonged APTT, ? risk haemorrhage Contraindications: active haemorrhage, recent trauma, CVA, surgery, ? INR and APTT, ? platelets, anticoagulatedImmunoglobulin: Cochrane review showed promising results in ? mortalitySevere acidosis: THAM only if CVS failing and pH <7.2Renal protection: MAP 90-110; urine output >2ml/kg/hrDopamine – can provide additional chronotropy; proportionally greater ? in splanchnic and renal perfusion; Help ? in lung oedema; Immunosuppression; no renal benefit Adrenaline – may cause splanchnic ischaemia Digoxin – may help, even in sinus rhythmOthers: avoid bicarbonate, DVT prophylaxis, stress ulcer prophylaxis, beware of amiodarone002) Vasopressors: if IV fluid fails to restore adequate BP or shows signs of pulmonary oedema; if using these, give steroids also (controverisal) Therapeutic aims: PWP 15-18, MAP 90-110, HR 80-120 Noradrenaline 2.5-20mcg/kg/min + insert CVL +/- arterial line3) Inotropes: if IV fluids fails to restore adequate CO (ie. ? Lactate, ? urine output, CV sats <70%) Dobutamine (but book said it was unhelpful due to hypotension and tachycardia); use in combination with vasioressor if hypotensive; infants may be resistant to dobutamineAdditional measures:Antibiotics: start within 1 hour; reassess at 48-72 hours and narrow spectrum down; in 1st 6 hours, ? mortality by 8%/hour for delay in giving antibioticsUnknown sourceFlucloxacillin+Gentamicin / cephalothinRespiratoryCeftriaxone+AzithromycinGastrointestinalAmpicillin / cef+Gentamicin+ MetronidazoleUrinaryAmpicillin+GentamicinSkinFlucloxacillinPerform source control: debride, incision and drainage, remove lines etc…Intubate: if shock resistant to fluids and pressors In ARDS: TV 6ml/kg (? mortality rate from 40% to 30%), RR 18-22, PIP <30, allow moderate hypercapnia, PEEP (level depends on FiO2 required – ? PEEP if ? FiO2 needed), semi-recumbent position, head of bed elevated 45°; avoid neuromuscular blockade if possibleBSL: aim <8-9; continuous insulin infusion recommendedSteroids: controversial; recommended if septic shock requiring vasopressors; 200-300mg hydrocortisone per dayRecombinant activated protein C: use if severe sepsis with dysfunction of >2 organ systems / APACHE >25; unclear if has any effect on mortality; give 24mcg/kg/hr INF for 96 hours Side effects: prolonged APTT, ? risk haemorrhage Contraindications: active haemorrhage, recent trauma, CVA, surgery, ? INR and APTT, ? platelets, anticoagulatedImmunoglobulin: Cochrane review showed promising results in ? mortalitySevere acidosis: THAM only if CVS failing and pH <7.2Renal protection: MAP 90-110; urine output >2ml/kg/hrDopamine – can provide additional chronotropy; proportionally greater ? in splanchnic and renal perfusion; Help ? in lung oedema; Immunosuppression; no renal benefit Adrenaline – may cause splanchnic ischaemia Digoxin – may help, even in sinus rhythmOthers: avoid bicarbonate, DVT prophylaxis, stress ulcer prophylaxis, beware of amiodarone18224546291490018224543243400 ................
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