Sepsis

Thank you Dr Erin Narewski for a shocking lecture!

  • Start antibiotics within one hour of recognition of severe sepsis or septic shock. Remove any lines or debride any tissue which may serve as a source.
  • Initial resuscitation efforts
    • CVP 8-12mmHg, MAP >65, Urine output >0.5 mL/kg/hr, Central venous or mixed venous oxygen sat 70 or 65%, respectively.
  • Patients with elevated lactate levels targeting resuscitation to normalize lactate
  • Transfusion goal of >7 g/dL in those without other circumstances (MI, severe hypoxemia, acute hemorrhage, ischemic heart disease).
  • Transfuse platelets with counts <10,000 in absence of bleeding. Prophylactic platelets when counts <20,000 with significant risk of bleeding. Counts greater than 50,000 when active bleeding is occurring, surgery or invasive procedure are planned.
  • Glucose goal <180 mg/dL. Be wary of point-of-care testing of capillary blood (maybe falsely low)
  • Do not use sodium bicarbonate in patients with hypoperfusion induced lactic academia with pH >7.15
  • Vasopressor therapy is to target a MAP of 65mmHg. Norepinephrine is the first choice, followed by epinerphine.
  • Discuss goals of care and prognosis with patients as early as is feasible.

DKA/ HHS

Lecture audio: DKA-HHS – McNellis.mp3

Many thanks to Dr McNellis for another amazing lecture!

Key Points:

Definitions

  • DKA
  • BG >200
  • pH<7.3
  • Bicarb<15
  • Serum/urine ketones

Precipitating Causes

  • Noncompliance
  • Infection
  • Ischemia (cerebral, myocardial, etc)
  • Pregnancy
  • Catecholamine surge (trauma, surgery, medications: steroids, pseudoephedrine)
  • Thyrotoxicosis

Treatment

  1. Volume status
  2. Acidosis
  3. Electrolytes
  4. Precipitating causes