early goal directed therapy in the treatment of sepsis nouf y.akeel general surgery demonstrator...
TRANSCRIPT
Early goal directed therapy in the treatment of sepsis
Nouf Y.AkeelGeneral surgery demonstratorSaudi board trainee R3
•Introduction •Case presentation•EGDT•Review •Summery
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•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.
•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 : )
