Septic patient..Part1..Basic definitions

Systemic Inflammatory Response Syndrome (SIRS)
A screening tool to identify patients who are having a systemic response to a stressor (usually an infection)

WBC count <4 or >12
Temperature <36 C or >38C (<96.8 F or >100.4 F)
Respiratory rate >22 or PaCO2 <30
Heart rate >90

PEARL- just because someone meets SIRS doesn’t mean its sepsis or worse. A patient with a broken ankle could have most of those SIRS criteria but they don’t have an infection- it’s a screening tool

Sepsis = 2 out of 4 SIRS criteria + known or suspected source of infection

PEARL- Again, just because you meet criteria for sepsis doesn’t mean you get a central line and get admitted to the MICU. Technically if you are febrile and tachycardic from strep pharyngitis then you are septic.

Severe Sepsis- Sepsis + signs of end organ damage

Lactate >4 (byproduct of anaerobic metabolism and a marker of global hypoperfusion)
Systolic BP <90 after 2 liters of normal saline bolus (OR more than 40 points below the patient’s established outpatient baseline)
New onset (or worsening) renal failure
Altered mental status
Hyperglycemia in a patient who is not diabetic

Septic Shock- Severe sepsis requiring vasopressors

Early Goal Directed Therapy for Severe Sepsis and Septic Shock
Rivers, et al. New England Journal of Medicine. 2001; 345:1368-137
(Full text available for free- google search “rivers sepsis”- read it!)
Criteria: Patients with severe sepsis or septic shock
Main points of protocol- very aggressive fluid resuscitation- intubate if necessary, early initiation of antibiotics

Comments

The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by: the area of the curve the slope of the line from points C to D the distance of the line from points C to D the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by: the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body

Steroids In Perioperative period...The Multi-purpose Drugs

1-Steroids are not Bronchodilator ,but have well established usefulness in hyper-reactive airway. They are also said to have a permissive role for bronchodilator medication. They can be administered orally, parenterally or in aerosol form 2- Steroids have been commonly used in chemotherapy for prevention of nausea along with other anti-emetic agents . Dexamethasone was found to be highly effective when given immediately before induction rather than at the end of anesthesia . 3- Steroids do exert analgesic effects. Various routes of administration of steroids include parentral, local infiltration at operated site , as an adjuvant in nerve blocks and central-neuraxial blockade. 4 - Steroids cannot be the mainstay of therapy in anaphylaxis because of the delayed onset of action, so they are used as adjunct after initial treatment with epinephrine. 5- Steroids (Dexamethsone) are of value in reduction or prevention of cerebral edema associated with parasitic infections and neopla...

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