1. Case Presentation Presented by: Dr.Safaa fadhl Supervised by: Dr.Kamal Marghani

2. 29 yrs male presented to ED at 1:40pm complaining of cough, S OB, and fever. At triage : RRPulse rate tempBpOxygen saturati on 2216640.2-86

3. Pt was admitted to room A at 2:00pm 29 yrs old male whose known to be DM for 7yrs on mixtard insuline presented with cough, SOB, and fever for 7days prior to the presentation for which he received amoxicillin \clavunate tabs without any significant improvement. OE: pt looks ill tachypnic vitals signs : - Pulse 144 - Bp 160\80 - SPO 2 65% on room air - RBS 257 - Chest : bronchial breathing,and decrease air entery on the RT side.

4. Plane : - Give oxygen via NRM rate 15 L\min. - Normal saline 1000ml. - Samixon 1g BD - Clarithromycin 500 BD - insulin mixtard - Take investigation, ABG,CXR

5. ABG on NRM: PHPaCO 2 PaO 2 HCO 3 PSO 2 7.4522.26315.580.3 HGTWB CS PLTPTPTTINRURE A CRE ATI NIN KNA 11.510.211624.729.21.826.00.93.6135

7. SO, the pt was diagnose as pneumonia At 9:30 pm pt was admitted to CCR. On admission he was looking ill,tachypnic on NRM. A : his airway was patent, on NRM B : RR 39, SPO 2 85, both sides of the chest moving equally, there was bronchial breathing and decrease breath sounds on Rt side. C : pulse 130, BP 119\80 D : GCS 15\15, RBS 296 E : examination of all other systems were unremarkable.

8. ABG on arrival: The diagnose was sever sepsis( type I respiratory failure) Plan : -NPO. -add DVT prophylaxis. -add peptic ulcer prophylaxis. -DNS 125 ml\hr. -RBS\4hr + sliding scale. -ABG \4hrs + when ever indicated PHPCO 2 PO 2 HCO 3 SPO 2 7.4726.55119.386

9. A : airways patent B : distress using accessory muscle, RR 40, SPO 2 87 C :pulse 128, BP 114\79 MAP 88, good UOP. D : GCS 15\15, RBS 98 PHPaCO 2 PaO 2 HCO 3 SPO 2 7.4522.05215.583.1

10. At 12:45pm, pt became more distress and not responsive, he was intubated and connected to MV. Initial settings were : modeTVRRPSPEEPFIO2Platue SIMV4001815510019

12. 1hr after the intubation his ABG: MV setting : PHPaO2PaCO2HCO3SPO2 7.247847.920.992.9 modeTVRRPSPEEPFIO2 SIMV40024155100

13. The plan was to keep the pt MASS zero. 1 hr later the pt became hypotensive, he received 2 L of nomal saline without improvement, so noreadrenaline was added, then the BP was maintain on max dose of inotropse..

14. A clinical response arising from a nonspecific insult, with  2 of the following: A clinical response arising from a nonspecific insult, with  2 of the following:  HR >90 beats/min  RR >20/min  WBC >12,000/mm 3 or 10% bands  T >38 o C or 38 o C or <36 o C SIRS = systemic inflammatory response syndrome SIRS with a presumed or confirmed infectious process Chest 1992;101:1644. SepsisSIRS Severe Sepsis Septic Shock Sepsis with organ dysfunction Refractory hypotension

15. Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis Tachycardia Hypotension  CVP  PAOP Jaundice  Enzymes  Albumin  PT Altered Consciousness Confusion Psychosis Tachypnea PaO 2 <70 mm Hg SaO 2 <90% PaO 2 /FiO 2  300 Oliguria Anuria  Creatinine  Platelets  PT/APTT  Protein C  D-dimer

16. Early Goal-directed Therapy in the Treatment of Severe Sepsis and Septic Shock To Examine whether Early Goal Directed Therapy (EGDT) before admission to the ICU is superior to standard hemodynamic therapy in patients with sever sepsis and septic shock

19. N = 1004 patients Every one-hour delay… you drop survival by 7.5%

20. Recommend early goal-directed therapy Give early appropriate antibiotics Give early appropriate fluids Give appropriate inotropic support Take early cultures Take early lactate level Take early central venous oxygen saturation(SVO2)

21.  Noradrenaline  Adrenaline  Vasopressin  Dopamine( selected cases) NO RENAL DOSE DOPAMINE

30. Intensive insulin therapy  Target glucose 140 -200 mg  Improved survival  Decreased infections  Decreased organ failure

32. At this stage the pt went from sever sepsis to septic shock. Plane : - NPO - N.S 125 ml\hr - Meropenum 1g TDS (given within 1hr of diagnosis) - Noreadrenaline infusion titrated to keep map more than 65mmhg - For septic screening. - VBG - RBS\4hrs + give insulin according to sliding scale( Target 140-200)

33. 2hr later the ABG: PHPaO2PaCO2HCO3SPO2 7.348335.119.295.7

34. Day 3 - As the pt had a refractory hypoxymia,he was kept MASS zero for another 48hrs. -Noreadrenaline : weaned to off But the pt still febrile so vancomycine was added PHPaO2PaCO2HCOSPO2 7.525135.428.989.5

35. Day 4 Off Noreadrenaline. Sedation vacation done, GCS 11\15

36. MV setting : DAYMODETVRRPSPEEPFIO2 5SIMV50015 8100 6SIMV380181510100 7SIMV380121510-5.590-55 8SPONT40018155.555

37. Day 9 CCR: -Pt on spont for more than 24 hrs on minimal ps - fully conscious communicating in tube. -Good cough reflex. - NPO. EXTUBATED AT 11:00 am and put on simple mask

40. THE Message Time is life

41. Thank you for your attention