Skip to main content

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


Labels

Labels:

Comments

Post a Comment

Popular posts from this blog

Driving Pressure in ARDS: A new concept!

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome Marcelo B.P. Amato, M.D., Maureen O. Meade, M.D., Arthur S. Slutsky, M.D., Laurent Brochard, M.D., Eduardo L.V. Costa, M.D., David A. Schoenfeld, Ph.D., Thomas E. Stewart, M.D., Matthias Briel, M.D., Daniel Talmor, M.D., M.P.H., Alain Mercat, M.D., Jean-Christophe M. Richard, M.D., Carlos R.R. Carvalho, M.D., and Roy G. Brower, M.D. N Engl J Med 2015; 372:747-755 February 19, 2015 DOI: 10.1056/NEJMsa1410639 BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V T ), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (C RS ) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size)...
5 comments
Read more

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
Post a Comment
Read more

Epidural catheter tests...not only the test dose

Siphon test The catheter is held upright and a fluid level sought. If the catheter is then elevated, the fluid level should fall (see inset) as the fluid siphons in to the epidural space, which is usually under negative pressure compared with atmospheric. If the fluid column continues to rise, this may suggest subarachnoid placement. The siphon test can be reassuring, but is not mandatory. Aspiration  This should be considered mandatory. The Luer connector is attached to the catheter and a syringe is used to apply negative pressure. Free and continued aspiration of clear fluid can indicate subarachnoid placement of the catheter. However, if saline has been used for loss of resistance, it is not unusual for a small amount of this to be aspirated. If there is doubt, the aspirated fluid can be tested for glucose (cerebrospinal fluid will generally test positive) or mixed with thiopentone (cerebrospinal fluid forms a precipitate). If blood is freely and continuously aspirated, this sug...
Post a Comment
Read more