Sepsis | Ventilation

This is v. good to evaluate SIRS/SEPSIS patient:

Resuscitation Goals in shock / sepsis:
- MAP 65-70
- Urine Output 0.5 ml/kg/hr
- Central Venous O2 > 70%
- ABX: Broad spectrum, Pseudomonal coverage, MRSA / Neutropenia
- Fluids: 20 ml/kg up to 1000.  Repeat PRN
- Steroids: 100 mg Hydrocortisone
- Blood Products
- Glucose: 150
- Bicarb: 7.1
- Measure Lactic Acid - if high treat more aggressively - fluids until it returns to NL LA < 2.
- Prophylaxis: DVT/GI
- Cap refill < 3s
- CVP > 12
- Pressor support is required when the MAP < 65 despite aggressive fluid resuscitation.
- 1. Levophed - start 2 mcg / min up to 20 mcg/min when MAP < 65 despite fluid resuscitation.
- 2. Vasopressin - start .03 U/min when Levo is at 8 mcg/min, D/C when Levo < 8 mcg/min
- 3. Dobutamine: (Used in cardiogenic shock)
         < 2    ug/kg/min -  increases contractility by stimulating beta adrenergic receptors
         2-5   ug/kg/min -   increases contractility and increases renal blood 
         > 10 ug/kg/min -   increases blood pressure primarily via alpha adrenergic receptor

Dobutamine Facts -  (Reference) - In sepsis, dobutamine, although a vasodilator, increases oxygen delivery and consumption. Dobutamine appears particularly effective at splanchnic resuscitation, increasing pHi (gastric mucosal pH) and improving mucosal perfusion in comparison with dopamine. It appears that dobutamine is a useful second line agent to add in septic shock, to improve cardiac performance and to improve splanchnic perfusion. The combination with nor-epinephrine would appear appropriate.

Stages of Shock:
1. Compensated
2. Decompensated
3. Irreversible

Criteria for extubation: (see the .png file attached below).
- PEEP < 5 cm H20
- Vital capacity > 10-15 ml/Kg
- TV 4-5 mL/kg
- FiO2 < 40%
- P(A-a) O2 at an FiO2 of 100% less than 350 mmHg

Dehydration assessment in a child: 

The 3 most useful physical findings to identify hypovolemia in a child are are:

1. prolonged capillary refill time
2. abnormal skin turgor
3. abnormal respiratory pattern (SOR C).

NB: Capillary refill time is not affected by fever and should be less than 2 seconds. Skin recoil is normally instantaneous, but recoil time increases linearly with the degree of dehydration. The respiratory pattern should be compared with age-specific normal values, but will be increased and sometimes labored, depending on the degree of dehydration. Unlike in adults, calculation of the BUN/creatinine ratio is not useful in children. Although the normal BUN level is the same for children and adults, the normal serum creatinine level changes with age in children. In combination with other clinical indicators, a low serum bicarbonate level (<17 mmol/L) is helpful in identifying children who are dehydrated, and a level <13 mmol/L is associated with an increased risk of failure of outpatient rehydration efforts. (Reference)

NOW - A relevant historical board question: 

Which one of the following serum proteins is typically DECREASED in a hospitalized patient with sepsis?   (check one)

A. Complement C3
B. Ferritin
C. C-reactive protein (CRP)
D. Albumin  
E. Fibrinogen

The acute phase response refers to the multiple physiologic changes that occur with tissue injury. The synthesis of acute-phase proteins by hepatocytes is altered, leading to decreased serum levels of several of these proteins, including albumin and transferrin. Serum levels rise for other proteins, such as ceruloplasmin, complement proteins, haptoglobin, fibrinogen, and C-reactive protein. Serum levels of ferritin may be extremely high in certain conditions, but are also influenced by total-body iron stores.
The answer is D. Albumin. Ref: Firestein GS, Budd RC, Harris ED Jr, et al (eds): Kelley’s Textbook of Rheumatology, ed 8. Saunders, 2008, chap 52.

Marc Curvin,
May 5, 2013, 12:15 PM