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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Sepsis: Antibiotic Choice
• Broad spectrum antibiotics recommended (e.g. piperacillin-tazobactam) and
consider individual risk of:
– MRSA coverage empirically if high risk
• High risk: known MRSA colonized, recurrent skin/soft tissue infxn, PWID, central lines, dialysis
– Multi-Drug Resistant (MDR) organism – **double (2 antibiotic) GN coverage if high risk
• High risk: previous abx within 3 months, known MDR colonization, local prevalence, travel to endemic
country or hospitalization abroad
**This is a weak recommendation with low quality evidence
– Fungal coverage if high risk
• High risk: neutropenia, immunocompromised, TPN, dialysis, chronic lines, PWID, HIV, Heme or solid organ
transplant, emergency GI surgery or anastomotic leak
• Daily assessment for de-escalation of antibiotics
• Rapidly identify if infection requires source control, remove source (including
vascular access device) as soon as possible
9
1. SSC 2021. Intensive Care Med (2021) 47:1181–1247.
doi.org/10.1007/s00134-021-06506-y
2. CCM (2021) 49:11. DOI: 10.1097/CCM.0000000000005357
GN = Gram Negative
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Sepsis: Guiding Resuscitation
• Use DYNAMIC VARIABLES over physical examination and static
parameters alone to guide resuscitation
– Response to fluid bolus
– Response to passive leg raise (45
o
raise x 30-90sec = 15% increase in stroke volume)
– Pulse pressure variation (PPV) (>10%)
– Echocardiography
• Stroke volume or Stroke volume variation (SVV)
• IVC
– Intubated, fully ventilated-Distensibility Index >15-20% likely to be fluid responsive
– Intubated breathing spontaneouslyà cannot use
– Spontaneously breathing not intubated IVC <2cm and respiratory variation>50%àlikely fluid responsive
• Lactate levels – if elevated aim to reduce with resuscitation
• Capillary refill à
Abnormal >3sec, Normal <3sec
DI=(Dmax-Dmin)/Dmean
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Sepsis: IV Fluids
WHICH ONE?
✓
Recommend Crystalloid first line
✓
Suggest using balanced crystalloid over
NS (SMART trial)
– Decreases major adverse kidney events at 30
days (death, new renal replacement,
Cr>200% above baseline)
? Suggest albumin in patients who received
large volumes of crystalloid over crystalloid
alone
- Costly, no mortality benefit, did not define
“large volume” – weak recommendation only
❌
Do not use starches (34 deaths per 1000)
❌
Do not use gelatin
HOW MUCH?
• Guidelines: insufficient evidence to make
recommendation
• Titrate to fluid responsiveness
• Judiciously give fluids to avoid excessive
fluid overload
• Restrictive Vs Liberal
– CLASSIC Trial (NEJM 2022) failed to show
difference in 90d mortality, but proof of
concept that less fluid can be safe
– CLOVERS (NEJM 2023): no 90d mortality
difference, more vasopressor use in
restrictive group
1. Semler, M. et al. NEJM 2018; DOI: 10.1056/NEJMoa1711584
2. PETAL Network and NHLBI. NEJM 2023; 388:499-510: DOI:
10.1056/NEJMoa2212663
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Hemodynamic Management and Vasopressors
12
Doses
Norepinephrine/Epinephrine
0.05-0.5mcg/kg/min
Vasopressin 2.4 units/hr
Dobutamine 2.5-10 mcg/kg/min
Add vasopressin when
Norepinephrine approx 0.25 –
0.5 mcg/kg/min
Consider MAP target 60-65 in
elderly patients.
Trend towards possible mortality
benefit with permissive
hypotension in age > 65 and
chronic hypertension.
Lamontagne F, et al. JAMA
2020: 323(10); 938-949
1. SSC 2021. Intensive Care Med (2021) 47:1181–1247.
doi.org/10.1007/s00134-021-06506-y
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Drug HR SVR CO PCWP
Phenylephrine
ê é ê é
Norepi
é é é/- é
Dopamine
é é é é
Epinephrine
é é é ê
Dobutamine
é ê é ê
Milrinone
é/- ê é ê
Vasopressin
ê/- é ê/-
é
BONUS: VASOPRESSOR PRIMER
BONUS
Read on own
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Steroid recommendations
Theory: may help immune dysregulation, relative adrenal insufficiency
• Consider for septic SHOCK with ongoing requirement for vasopressor
– Hydrocortisone 200mg/d (typically 50 mg IV q6h)
– Consider when norepinephrine 0.25mcg/kg/min for > 4hrs
– Not recommended in sepsis without shock
• Duration unclear (caution if prolonged àmay need to taper)
• No mortality benefit – considered a vasopressor sparing agent
• Risks include potential hyperglycemia, hypernatremia,
neuromuscular weakness
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“Don’t Try these at Home”:
Treatments to NOT give
• Immunoglobulins (IVIG)
• Polymyxin
• IV vitamin C (LOVIT trial – showed potential harm)
• Angiotensin II infusion
• Levosimendan
• Activated Protein C
• Liberal oxygen (target 94-96%, a sat >96% increases mortality in
critically ill)
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Best Practices in Sepsis: Summary of Guidelines
Screening
Hospitals to improve screening processes, SIRS/MEWS/NEWS >
qSOFA, admit to ICU < 6hrs
Resuscitation
30ml/kg balanced crystalloid, guide with dynamic measures, CRT, lactate
Infection
Abx in 1hr if probable or shock, cover resistant organisms if high risk, source control
Hemodynamics
MAP ≥65, Invasive BP monitoring, NE then Vaso, peripheral vasopressors for limited time
Steroids
Hydrocortisone 200mg/d when NE > 0.25mcg/kg/min for >4hrs
Ventilation
HFNC > NIV for Hypoxemic Resp Failure, LPV as per usual ARDS treatment (see slides on ARDS)
Best Practices
Restrictive Hb targets, VTE ppx, Stress ulcer prophylaxis, insulin for glucose > 10, Enteral
feeding early
Long term
outcomes
Address GOC early, integrate palliative care as needed, refer patient and family to support
groups, involve social work, arrange follow up at discharge
16
1. SSC 2021. Intensive Care Med (2021) 47:1181–1247.
doi.org/10.1007/s00134-021-06506-y
CRT = Capillary Refill Time, Abx = antibiotics, NE = norepinephrine, Vaso = Vasopressin, HFNC
= High flow nasal cannula, LPV = lung protective ventilation, ARDS = Acute Respiratory Distress
Syndrome, NIV = Non-invasive ventilation, GOC = Goals of care, Hb = haemoglobin, VTE
=Venous Thromboembolism
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MCQ 1
2024
A 45y patient presents to the emergency department with a 2 day history of right upper quadrant abdominal pain,
fever, rigors and vomiting.
Initial vitals BP 79/50, HR 110, RR 26, SpO2 96% on RA, Temp 39.5C. Weight 70kg.
Exam: abdominal tenderness in right upper quadrant but no signs of peritonitis, capillary refill time is prolonged.
Laboratory : Hb 95, WBC 21, Plt 46, ALT 80, ALP 500, Bilirubin 50, Lactate 5.
Abdominal ultrasound in the ED shows a hypoechoic structure in the common bile duct with biliary dilation, and a
distended gall bladder with edematous walls.
Two large bore antecubital fossa peripheral intravenous lines are inserted, broad spectrum antibiotics and 3L of
balanced crystalloid are administered.
Subsequent vital signs are BP 80/50 (MAP 60), HR 80, RR 24, SpO2 94% RA, POCUS shows a distended IVC without
respiratory variability, lactate is now 3.
What is the next best step in this patient’s management?
1. Consult Interventional Radiology for consideration of biliary drainage
2. Start hydrocortisone IV 200mg/day in divided doses
3. Start norepinephrine infusion via peripheral intravenous line
4. Transfuse platelets and insert a central venous catheter
5. Change MAP target to ≥ 60
17
C is correct.
Vasopressors should be started for patients with septic shock (sepsis + adequate
volume resuscitation + MAP < 65 + lactate > 2).
Not a: Source control should be achieved as soon as medically possible, whether that
be via consulting general surgery or interventional radiology. However, this process
may take hours and resuscitation should be optimixed first with vasopressors
Not b: Consider hydrocortisone once the patient is on norepinephrine at
0.25mcg/kg/min for > 4hrs. Vasopressors have not yet been started so this would not
be suggested yet.
Not D: Guidelines suggest vasopressors can be started peripherally if central access
is not available. Moreover, they suggest that you should not delay vasopressor
initiation to gain central venous access.
Not E: MAP targets in the initial resuscitation of sepsis should be >65. After initial
resuscitation 60-65 could be considered for elderly patients with ongoing vasodilation
(see Lamontagne study).
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OUTLINE
• Shock and Sepsis
• Respiratory failure
– HFNC, NIV, Invasive MV
– ARDS
– Covid-19 in the Critically Ill
• Weaning from Mechanical Ventilation
• ICU Delirium, Sedation, Analgesia, Sleep
• Targeted temperature management,
neuroprognostication, DNC, neuro ICU
• Tox icology
• Extra slides for your reference:
– Acute hypoxia in the ICU
– Gas trapping
– Maternal cardiac arrest
– Liver failure guidelines
– Hyperthermia & Hypothermia
– Toxi co lo gy Bo nus S li de s
– Bonus MCQs
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