Watcharin Chayakul Critical Care Medicine - PowerPoint Presentation

Slide1

Watcharin ChayakulCritical Care Medicine

SEPSIS & SEPTIC SHOCK

Slide2

68/52

What kind of shock

is this

?

Slide3

SEPTIC SHOCK

Slide4

Infection

Pathogen

Cytokines

Mediators

Myocardial depression

Vasodilate

Leakage

Organ

Dysfunction

Intravascular

volume

Tissue Perfusion

Hypotension

Inflammation

Pathology

Vessel

DEATH

Lactic acidosis

& MA

RBC

DIC

Slide5

Sepsis DefinitionSurviving Sepsis Campaign 2012

Infection + SIRS

2. Inflammatory variables

-WBC > 12,000, < 4,000 or Band > 10%

-CRP > 2 times

-

Procalcitonin

> 2 times

1. General variables

-BT > 38 °

-HR > 90

bpm

, Tachycardia-Alteration of consciousness-Positive fluid balance > 20 ml/kg/24hrs

-BS > 140 mg% without DM5. Tissue perfusion variables

-Lactate > 1 mmol/L-Capillary refill prolong, skin mott

4. Organ dysfunction variables-PaO2/FiO2 < 300 -Urine < 0.5 ml/kg/

hr x 2 hrs-Cr rising > 0.5 mg/dl-INR > 1.5,

aPTT > 60 second-Absent bowel sound-Platelet < 100,000-TB > 4 mg/dl

3. Hemodynamic variables

-Hypotension-SBP < 90 or Drop > 40 mmHg-MAP < 70

Slide6

SIRS negative Severe SepsisElderly patientsESRDDM

CirrhosisImmunocompromised Corticosteroid used

Beta-blocker use

Heart rate

Immune

responsive

SIRS

Slide7

Severe Sepsis -Sepsis induced hypotension-Lactate > 4 mmol/L

-Urine < 0.5ml/kg/hr x 2 hrs-Creatinine

> 2 mg/dl

-TB > 2

mg/dl

-Platelet < 100,000/mm

3

-ARDS

: No pneumonia PaO2/FiO2 < 250

: Pneumonia

PaO2/FiO2 < 200

Sepsis

induced organ dysfunction

Sepsis Induced tissue hypoperfusion

Slide8

Sepsis induced hypotension

Septic shock

Sepsis induced hypotension

Hypotension

despite

fluid resuscitation

-SBP <

90 mmHg

-SBP drop

> 40 mmHg

-MAP <

70 mmHg

Fluid

IMPROVED

Slide9

Sepsis induced tissue hypoperfusion Infection

Hypotension

Lactate

> 4

mmol

/L

Urine

< 0.5 ml/kg/

hr

Micro

circulation

Macro

circulation

Slide10

Revised DefinitionSEPSISSEPTIC SHOCKqSOFA Score

SOFA Score

Slide11

Two or more of:-Temperature >38°C or <36°C-Heart rate >90/min-Respiratory

rate >20/min or PaCO2 <32mmHg

-

White

blood cell count

>

12 000/mm3 or

<4000/mm3 or

>

10% immature bands

SIRS

?? (

Systemic Inflammatory Response Syndrome)

Specificity and Sensitivity

Definition of Sepsis 2012

Definition of Sepsis 2016

Sepsis, Septic Shock and

Organ

dysfunction

?

Slide12

SEPSIS 2016

Septic Shock

SERVERE SEPSIS

Slide13

New Definition of Sepsis 2016StrangeMortality 10%

Mortality 40%

SEPSIS

SEPTIC SHOCK

Lactate

Micro

circulation

Indicators

?

Metabolic

acidosis

Tissue

hypoperfusion

Slide14

qSOFA : Clinical Dx. qSOFA (Quick SOFA)

Criteria1. Respiratory rate ≥ 22/min2. Altered mentation3. Systolic BP ≤100mmHg

qSOFA

Variables

-Respiratory rate

-Mental status

-

Systolic BP

Altered mentation

Cerebral tissue

hypoperfusion

Early Detection and Management

2/3

Slide15

SOFASOFA Variables-PaO2/FiO2 ratio-Glasgow

Coma Scale score-Mean arterial pressure-Administration of vasopressorswith type and dose rate of infusion-Serum

creatinine

or urine output

-Bilirubin

-Platelet

count

PaO2/FiO2 = P/F ratio: Normal = 100/0.21 = 476

ARDS

Mild < 300

Moderate < 200

Severe < 100

Clinical

Lab

Treatment

6 variables

30 Scores

CNS

CVS

ReS

HeP

ReN

HeM

Slide16

Sequential [Sepsis-Related] Organ Failure Assessment Scorea: SOFA

SystemScore1

2

3

4

5

Respiration

-PaO2/FIO2

≥400

<400

<300

<200

<100

Coagulation

-Platelets

≥150,000

<150,000

<100,000

<50,000

<20,000Liver-Bilirubin,

mg/dl

<1.2

1.2-1.9

2.0-5.9

6.0-11.9>12.0

Cardiovascular

-Vasoactive drugs ≥1 hr

mcg/kg/minMAP ≥70

MAP <70Dopa

<5or

Dobu

Dopa 5.1-15

OrEpine ≤ 0.1

or NorE ≤ 0.1

Dopa

>15 orEpine >0.1

or NorE

>0.1Central nervous

-GCS Score

15

13-14

10-126-9

<6

Renal-Cr., mg/

dL-

Urine output, mL/d

<1.21.2-1.9

2.0-3.4

3.5-4.9<500

>5.0<200

Slide17

Operationalization of Clinical Criteria Identifying Patients With Sepsis and Septic ShockPatient with suspected infection

qSOFA ≥

2

?

Sepsis still

suspected

?

Monitor clinical condition;

reevaluate for possible sepsis

if clinically indicated

Assess for evidence

of organ dysfunction

Despite

adequate fluid resuscitation,

1. Vasopressors required to maintainMAP ≥65 mm Hg

AND2. Serum lactate level >2 mmol/L

?

Sepsis

SOFA ≥

2

?

Septic Shock

No

Yes

Monitor clinical condition;reevaluate for possible sepsis

if clinically indicated

YesNo

No

No

Yes

Yes

Slide18

100/46

RR 24

142

Good Consciousness

Well co operated

BT 38.9 C

Septic Shock

?

BP Ok

1

/3

qSOFA

SOFA

Slide19

Symptoms and SignsEvidence of Infection

Organ dysfunction

SIRS

?

Slide20

Shock = Tissue Hypoperfusion

Brain

-Cerebral

hypoperfusion

-Alteration of conscious

Renal and Metabolism

-AKI

-Metabolic acidosis

Heart

-Myocardial depression

-2

nd

MI

Endocrine

-Hypo& Hyperglycemia

Hematology

-DIC

Lung-ARDS

GI and Liver- Shock liver

Skin

-Cool

 Late

-

C

apillary refill

MODS

Slide21

Normotensive SHOCKBP, MAP normal range Tachycardia

( Brady or normal heart rate if on Beta blocker) - Hypertension PatientsSBP drop > 40 mmHg

Tissue

Hypoperfusion

Organ dysfunction

Slide22

Hemodynamic change in Septic Shock

Slide23

Blood Pressure (BP) CO = SV x HRSV = EDV-ESV = (EDV-ESV)EDV EDV

BP = Preload x Contractility x HR x SVRBP = Preload x Contractility x HR x Afterload

CO

: Cardiac output

SVR

: Systemic Vascular Resistance

SV

: Stroke volume

HR

: Heart rate

EDV

= Preload

(EDV-ESV)/EDV

= Contractility (EF)

BP = CO x SVR

Slide24

BP and Septic Shock

BP

HR

CO

SVR

Preload

EF

Vasodilate

BP = CO x SVR

CO = SV x

HR

BP

Relative hypovolemia

Slide25

Hemodynamic change in Septic ShockBP = Contractility x Preload x HR x SVR

Blood Pressure-MAP < 70 mmHg-SBP drop > 40 mmHg-DBP drop > 20 mmHgPulse pressure

-Wide pulse pressure

Heart rate

-Tachycardia

Cardiac

function

EF

Preload

-Decrease Contractility (RV and

LV)

-Decrease Preload

Systemic vascular Resistance (SVR)

-Decrease SVR (Vasodilate)

Slide26

Principle Shock Management Physiology

BP = Preload x Contractility x HR x SVR

Pathology

Infection

BP

BP

Fluid

NorE

Dopa

BB

Dobu

Treatment

Slide27

68/52

RR 28

164

15 minutes later

How to manage

this

?

BP!

Slide28

ManagementEGDTBundle 1Bundle 2Bundle 3

OK

What time is

it

?

Slide29

Surviving Sepsis Campaign Care Bundles 2012BundleWithin 3

hrsLactate level

Blood cultures

& Antibiotic

Crystalloid 30 ml/kg

-Hypotension

-Lactate ≥ 4

mmol

/L

Tissue perfusion

ATB Full dose normal GFR

x 24

hrs

Slide30

Surviving Sepsis Campaign Care Bundles 2012Bundle Within 6

hrs

Remeasure

lactate level

Goal < 2

Vasopressors

-Hypotension

-Goal MAP ≥ 65

Persistent

hypotension or initial

lactate ≥ 4

-

CVP: Goal 8-12 cmH20-ScvO2: Goal ≥ 70%

Reassess volume status and tissue perfusion

Urine Goal > 0.5ml/kg

Slide31

Early Goal Directed Therapy Supplemental Oxygen ± ET tube

Central venous and Arterial catheterization

Sedation, Paralysis (if intubated) or Both

CVP

MAP

ScVO2

Goal achieved

Crystalloid

Colloid

Vasoactive agents

Transfusion of Red Cells



Hct

>30%

Inotropic agents

Hospital admission

No

Yes

< 8-12

< 65

>

90

≥ 65 + ≤ 90

< 70%

≥ 70%

8-12

< 70%

E

G

T

D

Slide32

Septic Shock clinical trialEGDT 2000

ProCESS 2014Pittsburgh

ARISE

2014

Australia or New Zealand

ProMISe

2015

London,

UK

-EGDT

-Protocol

based EGDT-Usual care

-Protocol based EGDT-Usual care

-Protocol based EGDT-Usual care

Protocol EGDT-CVP-ScVO2Protocol EGDT-CVP

-ScVO2Usual care

-Serum Lactate

± CVP & ScVO2Protocol EGDT

-CVP-ScVO2

Usual care

-Serum Lactate

-No need CVP & ScVO2Protocol EGDT-CVP

-ScVO2

Usual care-

Serum Lactate -No need CVP & ScVO2

Improved mortality

No differences

Slide33

Surviving Sepsis Campaign Care Bundles 2012Bundle Within

12 hrs

Source Control

Reassess volume status and tissue perfusion

Slide34

Management of Severe Sepsis & Septic shock

EGDTBundle 1Bundle 2Bundle 3

Initial Resuscitation

Antibiotic

Source Control

Fluid Therapy

Vasopressors

Other therapy

-Corticosteroid

-Blood Product

-Glucose Control

-

Bicarbonate therapy

Slide35

SEVERE SEPSISAntibiotic

1. Respiratory tract (CAP)

-Ceftriaxone

+

Clarythromycine

2

. Intra abdominal infection

-

Ceftriaxone

+

Metronidasone 3

. Urinary tract infection -Ceftriaxone

Antibiotic and Source Control

Source of infection

Within 1 hour

Within

12 hours

4. CNS infection

-

Ceftriaxone

-Dexamethasone

(S.suis,

S.pneumoniae) 5. Systemic infection -

Ceftriaxone -Doxycycline (Scrub, Murine typhus)

Slide36

Initial Resuscitation & Fluid therapy

Slide37

What type of fluid?

Glucose

?

Colloid

?

Crystalloid

Slide38

Type of FluidCrystalloid (Isotonic solution, Balance salt isotonic solution)Hydroxyethyl starches Albumin  Alternative choice

HES

AKI

Albumin

Decrease Fluid accumulated

If Crystalloid

no response

Positive fluid balance

Mortality

ALBIOS

Study 2014

Slide39

Initial Resuscitation & Fluid therapy

TypeCrystalloid: Isotonic -Balance salt isotonic solution

Dose

30

ml/kg Rapid Bolus

Re-Evaluation

Hypotension

500-1000ml in 30 min

500-1000

ml/

hr

Improved

Yes

No

Sepsis induced hypotension

Septic Shock

Slide40

Phase 1: Fluid resuscitationSalvage Time: 30-60 minutes

Type: Crystalloid Isotonic solution

Rate: Rapid bolus

Goal: Correct Shock

T

R

O

Limit: Pulmonary edema

L

Slide41

Is the patient’s condition optimized?

98/54 (62)

110

CVP 16

RR 24

Volume overload

?

How to

evaluate it

?

JVP

NSS 4,500 ml

Lung: Crepitation

CXR: Congestion

Slide42

How much fluid?

Fluid

Slide43

OptimizationUrine

CVP

USG

HR

BP

?

Slide44

Time: 60 minutes-6hoursType: Crystalloid

Isotonic solutionRate: Fluid Challenge test

Goal: Maintenance tissue

perfusion

T

R

O

Limit: Pulmonary edema

L

Phase 2: Optimization

Slide45

Total Body Water and MortalityFluid

TBW

Volume overload

TWB = (TBW After) – (TBW Before)

TBW Before

Increase TBW

≥ 20%

Increase

Mortality Rate

Slide46

Volume Status Monitoring

Slide47

Fluid Responsive TestStatic-CVP-

PCWP-RV/LV EDV-RV/LV EDA-LVEDV, LVEDA

Dynamic

-Fluid Challenge test

-Passive leg

rising

Heart lung interaction

-PPV, SVV-IVCDI

Limitation

Cardiac arrhythmia

Tidal volume < 8 ml/kg

Open Chest condition

RV failure

Slide48

Central Venous Pressure (CVP) Monitoring

Indications_SSC

2012

Bundle 2 (within 6hrs)

Persistent

arterial hypotension

despite volume

resuscitation (MAP < 65 mmHg)

I

nitial lactate ≥

4

mmol

/L

Slide49

Central Venous Pressure (CVP)CVP MeasurementScVO2 (EGDT)

CVP = Distal tail

Slide50

CVP Measurement

Phlebostatic

axis

RA

4

th

ICS

1. Position

??

2. Ventilator disconnect

??

-

Level & Zero

- End of Expiratory phase

Slide51

Spontaneous Breathing

Lung

Lung

RA

LA

RV

LV

PA

PV

Pleural space

Aorta

SVC

Inspiration

CVP

Expiration

CVP

Thoracic pressure

End of Expiratory = Maximum

Slide52

ITP

CVP

I

E

I

E

End of Expiratory

CVP Measurement & Spontaneous

Breathing

Slide53

Lung

Lung

RA

LA

RV

LV

PA

PV

Pleural space

Aorta

SVC

Inspiration

CVP

Expiration

CVP

Positive Pressure Ventilation

Thoracic pressure

End of Expiratory = Minimum

Slide54

CVP

Measurement &

Positive

Pressure Ventilation

ITP

CVP

I

E

I

E

End of Expiratory

Slide55

Fluid Challenge testBP = CO x SVR

BP

(2 CVP) + 2 = LVEDP

Fluid

CVP

Slide56

Stroke Volume and LVEDP

LVEDP

LVEDP or

PCWP

LVEDV

S

V

A

A

B

B

Fluid

Fluid

SV

CVP

Slide57

Rate of Fluid Challenge testCVP (cmH2O)

Fluid Therapy(Crystalloid, Colloid)< 8

200

ml in 10 min (1,200ml/

hr

)

8-12

100 ml in 10 min (600 ml/

hr

)

> 12

50 ml in 10 min (300 ml/hr)

Colloid: Albumin100 ml in 1 min

Minimal Fluid challenge

Volume Overload

Slide58

Fluid Challenge testInitial CVP

Decrease rate of fluid Tx

CVP increase ≤ 2

CVP increase 2-3

Continuous fluid

Tx

(Same dose)

CVP increase > 5

Repeat CVP

Wait 10

mins

Stop fluid

Tx

CVP increase > 5

Stop fluid

Tx

Start Vasopressor

Response

Continuous fluid

Tx

(Same dose)

CVP increase < 5 cmH2O

CVP increase > 5

Decrease rate

of fluid

Tx

Start Vasopressor or inotrope

Yes

Yes

No

No

Slide59

Heart Lung Interaction

Slide60

Heart Lung Interaction

Slide61

Pleural pressure

Transpulmonary pressure

RV preload

LV preload

RV afterload

LV afterload

RV SV

LV SV

LV preload

LV SV

Inspiratory

Expiratory

Slide62

Pulse Pressure Variation (PPV)

Indications

Ventilator with

PEEP

V

T

> 8 ml/kg

No Cardiac arrhythmia

PPV > 13%

Fluid

Responsive

Inspire

Expire

(PPV Max-PPV Min)x 100

(

PPV

Max+PPV

Min

)/2

Slide63

Inferior vena cava distensibility index (IVCD)

IVCD index

= (IVC Max – IVC Min) x 100

IVC Min

IVCD ≥ 18% = Fluid Responsive

IVC

Max

IVC

Min

Indications

Ventilator with

PEEP

(Positive Pressure)

Slide64

Passive Leg Rising Test (PLR)

Head elevated 45

°

Increase Venous Return

CO

Leg elevated 45 ° 60-90 sec

CO (ABF) Increase > 10%

= Fluid

Responsive

NO Positive Pressure

= 300 ml

Slide65

6 hrs later

Macrocirculation

Microcirculation

?

Urine:

30

ml/

hr

Lactate

=

2.5

mmol

/LScVO2 = 65%Hct 28%

118/80 (96)

150

How to manage this

?

CVP 12

Slide66

Time: 6 hours – 72 hoursType: Crystalloid, Colloid

Rate: Maintenance fluid

Goal: Balance tissue fluid

T

R

O

Limit: Pulmonary & tissue edema

L

Phase 3: Stabilize

Slide67

Microcirculation- ScVO2 70-80%- Lactate < 2 mmol/L

- Urine output ≥ 0.5ml/kg/hr

GOAL

6

hrs

Macrocirculation

- MAP ≥ 65

mmHg

Lactate clearance = (Lactate After –Before)

Lactate Before

Lactate

clearance

≥

20% after 2 hour

Decrease Mortality

Slide68

Microcirculation ManagementLactateScVO2**

Tissue perfusionMAP > 65 mmHg

Urine output

Increase CO

= Preload

***

: Fluid resuscitate

= Contractility

:

Dobutamine

Increase O2

= O2 supplement

= Red blood cell

Keep

Hct

≥ 30%

O2 delivery = CO x CaO2

Slide69

Microcirculation ManagementScVO2 < 70% Lactate > 4 mmol/L

CVP measure

CVP < 8-12

(10-15)

CVP > 8-12

(10-15)

Fluid challenge

test

Hct

< 30%

Hct

> 30%

Dobutamine

PRC transfusion

NTG

MicroCIR

?

Levosimendan

Vasopressin

-Mortality

-

MicroCIR

?

Thiamine

?

Slide70

Thiamine

TCA

AcetylCoA

Pyruvate

PDH

Lipoic

acid

Ketogenic

diet

Thiamine

Glucose

Gluconeogenesis

Glycolysis

Lactic

acidosis

Lactate

ThiamineInjection

Slide71

118/80 (96)

150

CVP 12

Tachycardia

Heart Rate Control

??

Heart Rate Control

Short acting Beta blocker

Esmolol

Lactecemia

,

NorE

, Mortality

HR, SV

Slide72

72 hrs later

Lactate

=

1.2

mmol

/L

ScVO2

=

75%

I/O : 2,300/300

ml/d

Total I/O (72 hrs) : 7,200/2,000 ml

128/84 (94)

72How to manage

this?

CVP 2437.2

Slide73

Time: ≥ 72 hoursType: Diuretic (Furosemide)

Rate: Keep negative I/O

Goal:

Remove accumulated

fluid

T

R

O

Limit:

Maintain

tissue

perfusion

L

Phase 4: De-escalate

Slide74

Timing Type Side effect Vasoactive Drugs

Ok. That’s a good time to start!

Slide75

Vasoactive DrugsDrugs

Dose(mcg/kg/m)CO

SVR

MAP

HR

Norepinephrine

(

Levophred

)

0.1-1.0

0

++

++

0

Epinephrine(Adrenaline)0.05-1.0

+++

++++Dopamine<

55-10> 10 0

++-0++

0/-+++0

+++Dobutamine*

1-20

++-0/+

0/+

Dosage calculation

(mcg/kg/min) = (Concentration x Rate x 1,000) ÷BW x 60

Slide76

How to manage this ?

Norepinephrine

0.5 mcg/kg/min

Total fluid

4

,800 ml in 2 hours

94/46

(62)

CVP 14

102

ABG:

pH 7.10

PaCO2 25

PaO2 98

HCO3 12

Electrolyte

Na 148

, K 4.5, Cl 118, HCO3 10 BUN/Cr

36/1.60RR 28

Wide +

Normal GAP MA

+ R-Alk

Adrenaline

Dopamine

Hydrocortisone

Slide77

BPpH

Bicarbonate

F

luid

Norepinephrine

1 mcg/kg/min

Hydrocortisone

HCO3

Adrenaline

Dopamine

Dobutamine

Slide78

Vasoactive DrugsDrugsIndications

Norepinephrine-First choice

Dopamine

-Alternative drug

Epinephrine

-Increase BP

-Decrease internal organ perfusion

-

Additional agent is needed to maintain adequate blood pressure

-Moderate dose of

NorE

+ MAP < 65

-Severe Metabolic acidosis (

vasoplegia

) no response to

NorE

Dobutamine MAP ≥ 65 mmHg

-ScVO2 < 70%

-Lactate > 4 mmol/L

-

Hct > 30%

Slide79

What happened?

How to manage this ?

Norepinephrine 0.5 mcg/kg/min

180/98 (110)

MAP 65-70

vs

80-85

Slide80

Side effects

DrugsSide effect

Prevention

Norepinephrin

e

Limb ischemia

Gangrene

Lactic acidosis***

-Concentration

-Route (C-line)

-Dose

-Correct cause

Epinephrine

Tachycardia

Limb ischemiaLactic acidosis***-Optimal indication-Dose

-Correct causeDopamine

-Tachycardia-Optimal

indication-Dose-Correct cause

Dobutamine

-Vasodilate

-Hypotension

-Optimal

indication-Alternative drug

: Dopamine

Slide81

Corticosteroids

102

That’s a

good time to start.

Norepinephrine 0.5 mcg/kg/min

Total fluid 4,800 ml in 2 hours

94/46

(62)

CVP 14

Hydrocortisone

Potent vasoactive agent

Slide82

CorticosteroidsIndications-Vasopressor-unresponsive

-Hypotension despite fluid resuscitation & vasopressors Timing > 60 minutes

No ACTH stimulation test

Dose 100 mg bolus, 200 mg

iv in 24

hrs

Taper off after

vasopressors

CIRCI

Cortisol

Hydrocortisone

> 35

No

15-34

No & Yes

<

15

Yes

Slide83

Blood Product Administration No Tissue hypoperfusion

Tissue hypoperfusion

Hct

< 30%

ScvO2 < 70%

Blood

Transfuse

Myocardial ischemia

Severe hypoxemia

Acute hemorrhage

-

Hct

< 30%

Platelet

P

rophylactic < 10,000

High Risk bleeding

< 20,000

3. Active bleed or

Sx < 50,000

Hb

< 7mg%Keep Hb 7-9

Slide84

Mechanical Ventilation of Sepsis Induced ARDS -VT6 ml/kg-PBW

-Keep Pplat < 30 mmHg-PEEP prevent atelectrauma-High PEEP > low PEEP

-

R

ecruitment

maneuvers

for refractory hypoxemia

-Prone position for P/F < 100

-Head elevated 30-45 °

-Weaning protocol with SBT

C

onservative

fluid

Strategies (CVP ≤ 4cmH2O)

No Tissue Hypoperfusion

Slide85

Sedation, Analgesia and Neuromuscular Blockade

NMBs agent in ARDS-PaO2/FiO2 < 150-Duration ≤ 48 hours

-Low dose

: Bolus or continuous

AVOID

NMBs agent in non-ARDS

Slide86

Glucose ControlBlood sugar > 180 mg% x 2 times

Start Insulin

Serial BS q 1-2 hours

How much blood sugar should you keep

?

< 110

mg%

Keep BS

≤ 180 mg%

(140-180)

Slide87

Bicarbonate TherapyCase 1AGB: pH 7.14PaCO2 50

PaO2 88HCO3 18 (V)(CO2 37)

Metabolic

acidosis

When should

i

give

it

?

pH < 7.15

Case 2

ABG: pH 7.14

PaCO2 28

PaO2 90

HCO3 12 (V)

(CO2 28)

MA + R-

alk

C

ompensated

MA + RA

Hypocalcemia with cardiac arrhythmia (QTC prolonged)

Slide88

Stress Ulcer Prophylaxis Proton pump inhibitor (omeprazole)

Stress ulcer prophylaxis

High risk

-Coagulopathy

-Head injury

-On Ventilator

-Liver cirrhosis

-

Hx

. GIB

H2 blocker (Ranitidine)

Slide89

NutritionOral Or Enteral nutrition

Start low dose feeding

When should i start it

?

Start

-

24-48 hours

-Parenteral + Enteral

(Glucose IV + Oral feeding)

Slide90

When to Refer ?

Unresponsive to vasopressor

AKI stage III with volume overload

Acute

respiratory

failure

Organ support

Advance

I

nvestigation

Advance Treatment

Respiratory failure

Type 1. Hypoxic RF

Type 2.

Hypercapnic

RF

Type

3

. Perioperative RF

Type

4.

Shock

Slide91

Conclusion

Slide92

ShockTherapy

Preload Fluid replacement : Crystalloid : Colloid

: Blood product

SVR

Vasopressors

: Norepinephrine

: Dopamine

: Epinephrine***

Contractility

Inotropes

:

Dobutamine

: Epinephrine***

Heart rate Rate

control : Esmolol

ATB

Adjunct Therapy

Slide93

Hemodynamic supportIf MAP < 65 mmHgBaseline serum lactate

Acceptable BP Tim……..

Date……………….

Organ + Metabolic support

+ Intubation & Ventilator

+ Renal replacement

Tx

.

Name………………………........

Time of Diagnosis…..…

am,pm

Invasive monitoring

__

Urine > 0,5 ml/kg/

hr

or

__Serum Lactate or ScVO2

Adequate volume

Surgical drainage

if indicated

Source identification

+ Control

+ AntibioticAt................am, pm

-Give fluid rate 500-1,000 ml in 30 min-Intravascular volume evaluation

Adequate perfusion

CVP 10-15 cmH2O

2

.Vasopressor

-NorE 0.02-2 mcg/kg/min-Dopa

5-15 mcg/kg/min3.If MAP < 65 +Vasopressor

-Hydrocortisone 200 mg/24hr4. Intravascular volume status evaluation5.If MAP < 65 mmHg

-Adrenaline iv drip

-If MAP >90 mmHg decrease dose of vasopressor

goal 65-90 mmHg-PRC If Hct < 30%-

Dobutamine if Hct > 30%

-Goal achieved adequate tissue perfusion within 6

hrs-

Freqeunt assessment

1.CVP monitoring + give fluidGoal CVP 10-15 cmH2O

No

Yes

No

Yes

Yes

No

Yes

No

Unc

Slide94

Septic Shock MonitoringParameters

Mean arterial pressure MAP < 65 mmHg-กรณีได้รับยา Norepinephrine หรือ Dopamine หรือ

Adrenaline

ถ้าปรับยาเพิ่มทุก

15

นาที

x 2

ครั้ง

แล้ว

MAP

ยังต่ำกว่า 65 mmHgHeart rate

HR ≥ 150 bpm หรือ < 50 bpm หรือ

Abnormal ECGRespiratory rate

หายใจหอบเหนื่อย Urine output

Urine < 30 ml/hr CVP (ถ้ามี)

CVP < 8 cmH2O ร่วมกับ MAP < 65 หรือ

HR ≥ 150 bpmLaboratory

ABG pH < 7.20Serum HCO3 ≤ 10

Slide95

Conclusion: 6Es

Slide96

Slide97

Tel. 094-7833454

Line 083-0886140veeragum@gmail.com