Early goal directed therapy in the treatment of sepsis

1. Early goal directed therapy in the treatment of sepsis Nouf Y.Akeel General surgery demonstrator Saudi board trainee R3

2. Introduction • Case presentation • EGDT • Review • Summery

3. صلوا على الحبيب

5. 13 y/o male patient known to have IDDM presented to ER with 3-day history of abdominal pain. Hx of vomiting and fever.

6. He was confused • T. 39.4 HR 130 RR 24 BP 77/50 • Abdomen on examination was distended and rigid • WBC 17,OOOHb11 HCT 31 PLT 251 • Na 134 K 4.1 Ur 7 Cr 119

7. How to manage this patient?

9. EGDT • This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with an increased oxygen demand

10. 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

11. I. Fluid therapy • Reduce the rate of fluid administration if there is sign of adequate cardiac filling with no hemodynamic improvement

12. 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!

13. III. ScvO2 monitoring • ScvO2 > 70% DO2=CO X 1.34 X Hb X SaO2 X 10

15. 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.

16. Review

19. EGDT results in significant reductions in morbidity, mortality, vasopressor use, and health-care resource consumption • Mortality reduction at 28-d is 16%

20. Early Goal-Directed Therapy Results:28 Day Mortality 60 49.2% P = 0.01* 50 40 33.3% 30 Mortality 20 10 0 Standard Therapy N=133 EGDT N=130 NEJM 2001;345:1368-77.

22. 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

23. Summery • Approach targeted on the first 6 hours of care in the emergency department and ICU. • Focuses on 1.adequate fluid replacement 2.vasopressors 3.optimizing oxygen delivery

24. Thank You : )