Sepsis
Considerations
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Critically ill patient, high mortality
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Emergency surgery, possible full stomach
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Distributive shock with severe hypovolemia:
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Early goal-directed therapy & early antibiotics/source control required
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Potential for cardiovascular collapse on induction
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Need for invasive monitoring
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Need for critical care monitoring/ICU postop
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Multi-organ failure:
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ARDS
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AKI
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DIC
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Goals
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Follow Surviving Sepsis Guidelines:
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Broad spectrum antibiotics within 1 hour
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Goal directed resuscitation within 6 hours:
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MAP ≥ 65
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Fluid therapy:
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Use crystalloids as first line, avoid synthetic colloids, consider albumin if substantial amounts of crystalloids used
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Initial fluid bolus = 30cc/kg, use dynamic or static variables to guide further fluid therapy
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Vasopressors/inotropes:
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Norepinehprine = 1st line
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Epinephrine can be added as second vasopressor
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Vasopressin NOT recommened alone, may be added as second or third agent
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Dopamine not routinely recommended
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Phenylephrine can be useful if excessive arrythmia from other vasopressor, very high cardiac output states, or as an adjunct vasopressor
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Dobutamine as first line inotropic agent in settings of reduced cardiac output/low mixed venous/myocardial dysfunction
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Urine output > 0.5 mL/kg/hr
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Lactate < 2 mmol/L, clearance of lactate
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Lung protective ventilation (Tidal volumes ~6cc/kg, plateau pressure <30cm H20, PEEP)
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Corticosteriods:
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NOT indicated if fluids/vasopressors have restored hemodynamics
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Consider IV hydrocortisone 200mg daily if refractory shock
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Hemoglobin: in absence of myocardial ischemia/ischemic heart disease, goal Hgb ≥70
*Note that routine monitoring of central venous pressure (CVP) or central venous oxygen saturation (ScvO2) are no longer recommended