Adam Manko, M.D. PGY-3 Internal Medicine University Hospitals Case Medical Center

 Sepsis – Definition  Initial Management  Medications  Mechanical Ventilation - Briefly  What Your Senior Expects From You  Summary

 69 y/o Male presented to ER with shortness of breath.  VS / %  He is placed onto 50% ventimask, but continues to have low oxygen saturation and is intubated in the ER.  He is given 2L of NS and repeat BP is 92/44

 The Patient arrives in the MICU…..what do you do next?

 Sepsis is a continuum…..  SIRS  Sepsis  Severe Sepsis  Septic Shock  Refractory Septic Shock  Multi-Organ Dysfunction Syndrome (MODS)

 SIRS Criteria ◦ Temperature >38.3 (or >38.0 for 1 hour) or <36.0 ◦ WBC >12k or 10% bandemia ◦ RR >20, or paCO2 <32mmHg ◦ HR >90

 Sepsis = SIRS + suspected infection ◦ Does not have to be culture proven infection to begin treatment for Sepsis

 Severe sepsis = sepsis + and signs of at least one organ dysfunction thought to be from tissue hypoperfusion ◦ Hypotension ◦ Elevated lactate ◦ Urine output <0.5ml/kg ◦ Acute Lung Injury with PaO2/FiO2 ratio of <250 ◦ ARDS ◦ Acute Renal Failure ◦ Elevated bilirubin ◦ Platelet Count <100,000 ◦ Coagulopathy with INR >1.5 ◦ Altered Mental Status ◦ Abnormal EEG findings ◦ Cardiac Dysfunction

 “Early Goal Directed Therapy” ◦ Goal SBP >90 ◦ Goal MAP >65 ◦ Goal Hemoglobin 7-9 ◦ Goal urine output >0.5ml/kg/hr ◦ Goal normalized serum lactate ◦ Goal Mixed Venous >70% ◦ Central Venous >65%

 Goal SBP >90, MAP >65, Hgb 7-9  IVF bolus with NS  What if you give IVF and remains hypotensive? ◦ Need to check a CVP!!!

 CVP ◦ = Central Venous Pressure  What is the utility of a CVP ◦ Estimates the Right Atrial Pressure ◦ What is a Normal Right Atrial Pressure  <6

 Place a CVC = Central Venous Catheter  Locations include ◦ Internal Jugular ◦ Subclavian

 CVP >8  If intubated, CVP >12  What if still hypotensive but at goal CVP?

 Norepinephrine ◦ First Line pressor (preferred agent over dopamine  (NEJM 2010 Comparison of Dopamine and Norepinephrine in the Treatment of Shock) ◦ Mainly A1, some B1 ◦ Dosing in mcg/min  Typically uptitrate to max of ~30 mcg/min  Vasopressin ◦ Second line pressor ◦ Entirely V1  Can be titrated, however we typically turn it “on or off” at dose of 0.04 U/min

 Phenylephrine ◦ Weaker pressor, A1 activity ◦ Less arrhythmogenic  Dopamine ◦ Dose dependent ◦ Low dose 1-3mcg/kg/min = “renal” dosing, almost all D1 ◦ Medium dose 3-10mcg/kg/min = B1 and D1 ◦ High Dose >10mcg/kg/min = “pressor” dosing

 Epinephrine ◦ “king of pressors” ◦ Used as last line pressor at our institution ◦ Side effect includes increased risk of intestinal ischemia

 Pressor photo

 Mixed Venous >70 ◦ Mixed venous taken from a swan-ganz catheter  Central Venous >65% ◦ Taken from Central Line in the SVC

 High Venous saturation with unclear utility  Low Venous saturation means increased extraction peripherally  How to increase mixed venous saturation, you have 2 option ◦ Increase hematocrit ◦ Increase cardiac output  Dobutamine

 Consider when refractory hypotension ◦ when you are adding 2 nd pressor, think of adding steroids!!  No longer recommended to do ACTH stim or random cortisol  Empirically add hydrocortisone, dose 50mg q6h

 Antibiotics within 1 hour  Typically vancomycin and zosyn are first line agents if unclear of source  Start broad and narrow when source identified

 ABX photo from UH guide

 Maintain tight blood glucose control with goal  If unable to manage easily (you get 2 tries with SQ insulin) then start on insulin gtt  Protocol driven by nursing ◦ FYI this is different than the DKA protocol ◦ (2010 NEJM – Glycemic Control in the ICU)

 DVT ◦ If no contra-indications….  Heparin SQ preferred agent ◦ If contraindications  SCDs and TED hose  Stress Ulcer ◦ PPI or H2 blocker

 Protective Lung Ventilation Strategy  ARDSnet protocol ◦ Low tidal volumes  6ml/kg of IBW ◦ PEEP ◦ Goal plateau pressure <30  (2007 NEJM - Low Tidal Volume Ventilation in the Acute Respiratory Distress Syndrome)  (2000 NEJM – Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome)

 ARDS NET photo

 RRT = Renal Replacement Therapy ◦ HD = Hemodialysis ◦ UF = Ultrafiltration  CRRT = Continuous Renal Replacement Therapy ◦ CVVH = Continuous veno-venous hemofiltration ◦ CVVHD = Continuous veno-venous hemodialysis

AA ◦ Acidosis EE ◦ Electrolyte imbalance II ◦ Intoxication OO ◦ Fluid Overload UU ◦ Uremia

 Sedation ◦ Versed for anxiety ◦ Fentanyl for pain ◦ Haldol for agitation ◦ Propofyl ◦ Precedex

 Assess the patient!! (Go into room, not look in EMR first)  Labs ◦ CBC ◦ RFP ◦ LFTs ◦ Coag ◦ Type and Screen ◦ Lactate!!! ◦ In the right setting  Troponin, amylase, lipase, etc  Microbiology ◦ Blood cultures x2 ◦ UA and culture ◦ +/- sputum culture  Imaging ◦ CXR, +/- KUB ◦ CT in right setting

 Check for Access ◦ Prep for CVC  If hypotensive, need invasive hemodynamic monitoring ◦ Central Line (CVC) ◦ Arterial Line  Other ◦ HD Catheter? ◦ Introducer (Cordis)?

 Get us if you are uncomfortable in a situation, aka the patient is very sick and crashing!!  STAY CALM!!!  Nurses are your friend or worst enemy, the choice is yours!! ◦ They have taken care of more patients than you, they often know what the next step is, use them as a resource!!

 In Summary, the Goals of Sepsis are……

 69 y/o Male presented to ER with shortness of breath.  VS / %  He is placed onto 50% ventimask, but continues to have low oxygen saturation and is intubated in the ER.  He is given 2L of NS and repeat BP is 92/44

 The Patient arrives in the MICU…..what do you do next?

 Identify Severe Sepsis and Septic Shock Early  IVF  Early invasive hemodynamic monitoring  Goal endpoints ◦ Urine output, SBP, MAP, lactate, central venous sat, CVP <8 or 12 ◦ Pressors and Steroids  Cultures and ABX

 Thank you!!!