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Idea Transcript
10/11/17
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Sepsis & Septic Shock Joshua Farkas MD MS Pulmonary & Critical Care Medicine UVM Medical Center @PulmCrit www.PulmCrit.org
Ten things I’ve learned about sepsis
1/ send ’em to the ICU
´ Send ’em to the ICU ´ Early pressors ´ Peripheral pressors ´ Ignore CVP & mixed venous O2% ´ There’s more to volume overload than pulmonary edema ´ Small IVC & hyperkinetic heart doesn’t prove volume deficiency ´ Volume responsive doesn’t mean volume will help ´ Lactate isn’t an indicator of perfusion or anaerobiasis ´ Consider epinephrine as a 2nd-line pressor ´ Maybe vitamin C can help
ICU admission criteria? ´ Lactate >4 without alternative cause Troponin = 5
´ Hypotension not promptly responsive to fluid ´ Organ failure or impending failure (e.g. delirium) ´ Anticipated course, e.g.: ´ Pneumonia with significant tachypnea ´ Ascending cholangitis
´ Spidey-sense
Lactate = 5
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2/ early pressors
do we need to fill the tank first?
3/ peripheral administration of pressors
Lehman LW et al. 2010 PMID 21158679
Administration of peripheral pressors?
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FDA approved for SQ injection! ´ Epinephrine ´ Phenylephrine ´ (no longer)
4/ ignore CVP & mvO2%
Marik PE et al. 2008 PMID 18628220
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What if we calculated cardiac output?
pulmcrit.org/central-venous-saturation/
pulmcrit.org/central-venous-saturation/
5/ there’s more to volume overload than pulmonary edema
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´ If it stays in the vasculature: ´ Perfusion pressure = MAP – CVP ´ If it leaves the vasculature ´ Perfusion pressure = MAP - IAP
Marik PE et al. 2017 PMID 28130687
6/ small IVC & hyperkinetic heart doesn’t prove volume depletion
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7/ volume responsiveness doesn’t mean that volume will help
Patient hypotensive Volume responsive
3rd spacing
Volume given
Clinical Improvement
8/ lactate isn’t an indicator of perfusion or anaerobiasis
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being held together by a hyper-active sympathetic drive!
´ GREAT sympathetic drive.
´ BROKEN autonomic system.
´ SBP 120 mm, Heart rate 150 b/m
´ SBP 70 mm, Heart rate 80 b/m
´ Lactate 9 mM
´ Lactate 2 mM
´ Lactate is a measurement of the patient’s endogenous epinephrine level.
Marik Cocktail ´ 1.5 grams IV ascorbic acid Q6hr x4 days ´ 200 mg IV thiamine Q12 hr x4 days ´ 50 mg IV hydrocortisone Q6hr (gradual taper per usual) ´ Probably works at least somewhat without the hydrocortisone (especially for weaning pressors)
Marik PE et al. 2017 PMID 27940189
Contraindications?
Marik PE et al. 2017 PMID 27940189
Problems with the Marik Cocktail
´ History of oxalate renal stones.
´ Your partners may think you’re insane.
´ History of oxalate nephropathy.
´ Any complication will be blamed on it.
´ Chronic renal failure?
´ Complacency. ´ Can reduce vasopressor doses (“stealth vasopressor”). ´ Lowers ICU census – bad for billing.
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Bottom line on Marik Cocktail ??
Ten things I’ve learned about sepsis
´ Reasonable to do it. ´ Reasonable not to do it. ´ Reasonable to omit steroid (Nathens et al.).
´ Send ’em to the ICU
´ More evidence should be coming soon.
´ Early pressors ´ Peripheral pressors ´ Ignore CVP & mixed venous O2% ´ There’s more to volume overload than pulmonary edema ´ Small IVC & hyperkinetic heart doesn’t prove volume deficiency ´ Volume responsive doesn’t mean volume will help ´ Lactate isn’t an indicator of perfusion or anaerobiasis ´ Consider epinephrine as a 2nd-line pressor ´ Maybe vitamin C can help