early goal directed therapy in the treatment of sepsis

Early goal directed therapy in the treatment of sepsisNouf Y.AkeelGeneral surgery demonstratorSaudi board trainee R3

•Introduction •Case presentation•EGDT•Review •Summery

صلوا على الحبيب

•13 y/o male patient known to have IDDM presented to ER with 3-day history of abdominal pain. Hx of vomiting and fever.

•He was confused

•T. 39.4 HR 130 RR 24 BP 77/50

•Abdomen on examination was distended and rigid

•WBC 17,OOO Hb 11 HCT 31 PLT 251

•Na 134 K 4.1 Ur 7 Cr 119

How to manage this patient?

EGDT•This approach involves adjustments of

cardiac preload, afterload, and contractility to balance oxygen delivery with an increased oxygen demand

I. Fluid therapy •Crystalloids vs colloids (no difference in the

mortality)•CVP 8-12 mmHg•Fluid challenge: *infusion of crystalloids boluses of 20ml/kg

over5-10 min (up to 3 boluses) *1L of crystalloids or 300-500ml of

colloids over 30min

I. Fluid therapy •Reduce the rate of fluid administration if

there is sign of adequate cardiac filling with no hemodynamic improvement

II. Vasopressors•MAP 65-90 mmHg•Start with Dopamine or nor epinephrine

(centrally)•Insert A-line for continues monitoring•Low-dose dopamine doesn’t protect the

kidneys!

III. ScvO2 monitoring •ScvO2 > 70%

DO2=CO X 1.34 X Hb X SaO2 X 10

•These benefits arise from the early identification of patients at high risk for cardiovascular collapse and from early therapeutic intervention to restore a balance between oxygen delivery and oxygen demand.

Review

•EGDT results in significant reductions in morbidity, mortality, vasopressor use, and health-care resource consumption

•Mortality reduction at 28-d is 16%

49.2%

33.3%

0

10

20

30

40

50

60

Standard Therapy N=133

EGDTN=130

P = 0.01*

Early Goal-Directed Therapy Results:28 Day Mortality

NEJM 2001;345:1368-77.

Mortality

• Initial resuscitation

• Diagnosis

• Antibiotic therapy

• Source control

• Fluid therapy

• Vasopressors

• Inotropic therapy

• Corticosteroids

• rhAPC• Blood products

administration

• Mechanical ventilation (ARDS/ALI)

• Sedation, analgesia, and neuromuscular blockade

• Glucose control

• Renal replacement

• Bicarbonate therapy

• DVT prophylaxis

• Stress ulcer prophylaxix

• Consideration for limitation of support

Summery • Approach targeted on the first 6 hours of

care in the emergency department and ICU.

• Focuses on 1.adequate fluid replacement 2.vasopressors3.optimizing oxygen delivery

Thank You : )