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Septic Patients..Part 2..The 5 Pillars of management








Step 1: Early antibiotics- broad spectrum/tailored for source (if known)


Popular broad spectrum combo:
Tazocin or Zosyn (piperacillin/tazobactam)- 3.375 or 4.5 grams IV
Vancomycin- 15-20 mg/kg IV (usually capped at 1 gram per dose but latest guidelines recommend giving full weight based dose up to 2 grams IV for the first dose)


Antibiotics for other clinical situations

  • Healthcare associated pneumonia (patients at risk for drug resistant organsims- long term care facility resident, admitted to the hospital for 2 or more days in the past 3 months
  • dialysis patient
  • outpatient IV antibiotics or chemo in the past month

In any of these cases Please add Levofloxacin  or  levaquin to zosyn/vanc
Levaquin (levofloxacin)- 750mg IV “double covers pseudomonas”



Step 2: Aggressive fluid resuscitation


Start with a 2 liter normal saline bolus
Insert a central line above the diaphragm (subclavian, supraclavicular, internal jugular)
Measure central venous pressure (CVP)
If CVP <8 (or less than 12 in a ventilated patient)= more fluids
Give fluids until CVP goal is met, even if it means intubating the patient for pulmonary edema
PEARL- septic patients can get 13-14 liters in their first 24 hours!
PEARL- the actual act of breathing can take up to 30% of a critically ill patient’s metabolism so by intubating early you will improve their hemodynamics and their response to therapy


Step 3: Vasopressors


Once CVP above 8 or 12, if MAP is less than 65, start vasopressors
Will probably require an arterial line at this point
Levophed (norepinephrine)- 2-20 mcg/min- strong alpha and beta agonist (increased myocardial squeeze and increased vasoconstriction) central line, most clinician’s preferred 1st line pressor
Dopamine- 2-20 mcg/kg/min- can be given through a peripheral IV- gives more tachycardia than levophed



Step 4: Assess SCVO2 or SVO2


SCVO2- a measurement of oxygen saturation of the blood in the superior vena cava (as it returns to the heart)
SVO2-measurement of oxygen saturation of the blood in the pulmonary artery (the superior vena cava + IVC)....
SVO2 is not interchangeable with ScVO2
But since ScVO2 is less invasive (all what you need is central line..not Swan Ganz)..we will use ScVO2 for assessement .


ScVO2: 
Need a central line above the diaphragm to measure this
Two methods- Edwards catheter provides continuous SCVO2 readings (expensive) or draw serial VBGs from central line and look at O2 sat
If SCVO2 <70%- check hemoglobin/hematocrit and Check oxygenation parameters 
If H and H less than 10 and 30- transfuse pRBCs until its above 10/30
Once H and H is >10/30- if SCVO2 still <70%- start dobutamine
Dobutamine- strong B1 agonist
Dose- 2-20 mcg/kg/min


Step 5: Reassess response to therapy (also continuously)


It may take 6-12 hours or longer to reach this step. Once you are here, go back and reassess each step and make sure you have optimized each one. Follow serial lactates- if they are decreasing then you are doing something right. If they are staying the same or increasing- try something different


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