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Management of  Adult Fever and Sepsis Management of  Adult Fever and Sepsis

Management of Adult Fever and Sepsis - PowerPoint Presentation

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Management of Adult Fever and Sepsis - PPT Presentation

MLP EM Education Curriculum Dave Markel September 15 2015 What will be covered Basic concepts and definitions Initial management Septic shock Pearls and pitfalls What will not be covered ID: 755075

sepsis fever septic shock fever sepsis shock septic patients definitions basic mmhg management initial inflammatory symptoms concepts 000 egdt

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Slide1

Management of Adult Fever and Sepsis

MLP EM Education Curriculum

Dave Markel

September 15, 2015Slide2

What will be covered

Basic concepts and definitions

Initial management

Septic shock

Pearls and pitfallsSlide3

What will not be covered

Pediatric fever (Scheduled for May 2017, Dr. Justice)

Febrile seizures

Hyperthermia

Environmental

Drug-inducedSlide4

Basic concepts and definitions

Fever: temp > 37.8 C = 100

F

(CDC definition)

Not “I’m usually at 96 degrees so 98.6 is a fever for me”

Not “It feels kinda warm in here”

Not “I had a chill the other day”

Most reliable way of checking the temperature?

No axillary temps, please!Slide5

Basic concepts and definitions

Systemic inflammatory response syndrome (SIRS)

At least 2 of the following:

Oral temperature > 38

or

< 35 C

Respiratory rate > 20

or

PaCO

2

< 32 mmHg (requires ABG)

Heart rate > 90

Leukocytes > 12,000

or

< 4,000

or

>10% bands

Sepsis

: + microbial source

Severe sepsis

: + organ dysfunction

Septic shock

: + hypotension unresponsive to fluids

Multiple organ dysfunction syndrome (MODS

)Slide6

Sick vs Not Sick

Patients with any of the following need IMMEDIATE intervention

Altered mental status

Respiratory distress

Cardiovascular instability

Prolonged temp > 41 C = 105.8 FSlide7

Most aren’t critically ill… take a history!

Localizing

symptoms

Atypical symptoms

Fever patterns

Tubes, lines, drains (incl. pacemakers, heart valves,

PICC lines, etc

)

Living situation (nursing home, dorm, jail, etc)

Recent hospitalizationsSlide8

Never trust the elderly

Symptoms are often atypical

May not even mount a fever response

Abdominal exam often deceptively benign

3 critical things to do when evaluating fever

in the elderly

Completely undress and examine skin

Chest x-ray (2-view if possible)

Urinalysis (straight cath if possible

)Slide9

Sepsis: a problem with perfusion

For MIS:

sepsis is caused by a complex disarray of pro-inflammatory and anti-inflammatory mediators which are triggered by infection, leading to tissue ischemia, direct tissue injury, alterations in apoptosis

For us:

sepsis = poor perfusion… fix it

Hypotension

Elevated lactate

Tachycardia

Decreased urine outputSlide10

How to fix the perfusion problem

IV fluids

Initial choice: 0.9% NS

Optimal volume unknown… usually will get 3-5 liters over first 6 hours

Watch for pulmonary edema

Vasopressors

Initial choice: norepinephrine (Levophed)

Consider phenylephrine if tachycardia or dysrhythmiasSlide11

Targets: first 6 hours

MAP ≥ 65 mmHg

UOP ≥ 0.5 mL/kg/hr (eg, 35 mL/hr in a 70 kg patient)

Central venous pressure (CVP) 8-12 mmHg

Central venous oxyhemoglobin saturation (ScvO

2

) ≥ 70%

 Slide12

ProCESS, 2014:

“In

a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes

.”

ARISE, 2014:

“In

critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days

.”

ProMISe, 2015:

“In

patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome

.”Slide13

Bonus: empiric abx (if source unknown)

Gram-positives and MRSA:

vancomycin

Gram-negatives:

3

rd

- or 4

th

generation cephalosporin (eg, ceftriaxone)

Pseudomonas:

zosyn, ceftazidimeSlide14

Bonus: Vasopressors