Case admit 17..56

History 64 . .CC: 3 .PI: Relevant history: Cellulitis left leg 5 d.PTA on Ceftriaxone, Clindamycin 6 day

Past history. Dyslipidemia on Simvastatin(20) 1 tab o hsHT 2 on Amdipine(5) 1x2 o pc, Enalapril(5) 2x1 o pc FBS 2 / 2 (4 ..55 BUN 10.9, Cr 0.53) Family history :

Physical examinationV/S BT40 c PR 132 bpm RR 22 tpm BP 90/48 mmHgBW 75 kg HT 150 cm.GA: an obese woman, looked fatigue, moon faceHEENT: dry lips and tongue, pink conjunctiva, anicteric sclera, impalpable SCLN&CLN CVS : normal S1S2, no murmurRS: normal breath sound, no adventitious sound Abdomen: obese abdomen, cannot evaluate liver and spleen, generalized mild tender, no guarding, no reboud tendernessCVA: not tenderEXT: pitting edema 1+ at left leg, no redness, not tender, no warm

Problem list FeverDiarrheaHypotensionDehydrationHx Oliguria Hx herbU/D HTU/D Dyslipidemia

ImpressionInfective diarrheaHypovolumic shockSeptic shockChronic renal failure

Investigation

shock

Classification of shockHypovolemic shockObstructive shock - Pulmonary embolism and pericardial tamponade Distributive shock - septic shock Cardiogenic shock - primary myocardial dysfunction

Systemic inflammatory response syndrome (SIRS)systemic response to infection2/4BT >38C or 90 bpmRR >20 bpm or PaCO 2 12,000/L or < 4000/L, or band 10%

Sepsis = infection + SIRS Severe sepsis = sepsis + end-organ dysfunction (altered mental status, an episode of hypotension, elevated creatinine concentration, DIC) Septic shock = acute circulatory failure (hypotension+adequate fluid resuscitation)

Management Early recognitionEarly and adequate antibiotic therapySource controlEarly hemodynamic resuscitation and continued supportCorticosteroids (refractory vasopressor-dependent shock)Tight glycemic control

Antimicrobial therapyfirst hour of recognition of septic shockbroad spectrum

Hemodynamic resuscitation0.9% NaCl 30 mL/kg in 15 60 mincentral venous catheter 8 -12 cmH2O (no ventilator) 12-15 cmH2O (ventilator)MAP 65 mmHgUo 0.5 ml/kg/hrCentral venous 70% mixed venous oxygen saturation 65%

fluid challenge

Guided byCVP ( cmH20 )PCWP ( mmHg )InfusionStart< 8< 10200 ml/10 min< 12< 14100 ml /10 min 12 1450 ml /10 minDuring infusion>5 >7StopAfter 10 min 7Stop > 2 >3Stop < 2

Vasopressure & Inotrope

DrugDose(g/kg/minor g/min)CardiacStimulation(1)VasoconstrictionVasodilatation(2)DopaminergicDopamine1-1010-20+++++++++++++++0Norepinephrine2-10+++++++00

Epinephrine1-8++++++++00Dobutamine 1-10+++++00

dose

ConcentrationDrip rate (ml/hr) rateMax rate(ml/hr)Levophed4:2504:1258:12510532-51608040Dopamine2:14:15-303-15230Adrenaline1:10102-5-Dobutamine 4:12:15-155521520

Ventilator managementAssist control mode - volume ventilationtidal volume 6 mL/kgSao2/Spo2 88-95%PEEP - Fi02

Adrenal insufficiencyhydrocortisone 200 mg/day 3-4 x 7 dayCortisol < 10 mcg/dl

Glucose controlKeep < 150 mg/dlInsulin anti-inflammation, endothelium

Blood product administrationPRC transfusion oxygen deliveryKeep Hct > 30

Bicarbonate therapyarterial PH < 7.15

referencehttp://www.survivingsepsis.org/Guidelines/Pages/default.aspx