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M+M 25/07/2017 Dr. Patrick Abbott Recognition and Management of Sepsis and Shock M+M 25/07/2017 Dr. Patrick Abbott Recognition and Management of Sepsis and Shock

 KC – 62 yo female Background of Hypertension Cholelithiasis Obesity Breast cancer and KC – 62 yo female Background of Hypertension Cholelithiasis Obesity Breast cancer and axillary clearance 2006 Bilateral TKRs KC RK 336011

 3/52 hx of post-prandial upper abdominal pain and subjective fevers Gallstones on USS 3/52 hx of post-prandial upper abdominal pain and subjective fevers Gallstones on USS Treated with doxycycline and metronidazole by GP KC RK 336011

 Acute increase in pain, waking pt from sleep late 10/05: RUQ/epigastric radiating to Acute increase in pain, waking pt from sleep late 10/05: RUQ/epigastric radiating to back Initial presentation at Biloela Hospital at 0100 hrs 11/05, c/o 10/10 pain Seen by NS who called GP-SMO on call and got a phone order for S/C morphine, IM metoclopramide, and PO hyoscine Permission to repeat morphine Q 2 H PRN KC RK 336011

 No documentation from treating clinician are present in EDIS or in Progress Notes No documentation from treating clinician are present in EDIS or in Progress Notes Based on nursing notes, pt cannulated by a different doctor ~1300 hrs, i. Stat bloods done KC RK 336011

 Chem 8: Cr 163, Ur 16. 7, Hb 160 CG 4: p. H Chem 8: Cr 163, Ur 16. 7, Hb 160 CG 4: p. H 7. 19, PCO 2 62, HCO 3 23. 8 Lactate 2. 93 At NS request, treating clinician attended at 1600 hrs KC RK 336011

 0100 hrs BP 128/87 HR 77 RR 20 0300 hrs BP 112/60 HR 0100 hrs BP 128/87 HR 77 RR 20 0300 hrs BP 112/60 HR --- RR 18 0600 hrs BP 108/60 HR 60 RR 18 1000 hrs BP 99/64 HR 95 RR 18 1400 hrs BP 124/70 HR 114 RR 18 1515 hrs BP 138/74 HR 122 RR 18 1600 hrs BP 126/68 HR 102 RR 18 On O 2 1850 hrs BP ---- HR 93 RR 18 On O 2 KC RK 336011

KC RK 336011 KC RK 336011

 Arrived at Hillcrest Sp. O 2 93% on 3 L via NP BP Arrived at Hillcrest Sp. O 2 93% on 3 L via NP BP 93/60 HR 100 Ongoing pain Afebrile Referred to Rockhampton Hospital KC RK 336011

 Dx with perforated ulcer and AKI Admitted HDU/ICU Laparoscopy + omental patch 12/05 Dx with perforated ulcer and AKI Admitted HDU/ICU Laparoscopy + omental patch 12/05 Leak, laprarotomy and repatch 16/5 Washout of subphrenic collection 23/5 Trachy 25/5 for ongoing vent dependence Decannulated 6/6, to ward 7/6 KC RK 336011

 Shock (BMJ Best Practice): A failure of adequate oxygen delivery to tissue, most Shock (BMJ Best Practice): A failure of adequate oxygen delivery to tissue, most commonly recognized as hypotension with organ dysfunction Sepsis (Surviving Sepsis Campaign): Lifethreatening organ dysfunction caused by a dysregulated host response to infection Septic Shock (SSC): sepsis with circulatory and cellular/metabolic dysfunction Definitions

Best Practices Best Practices

 Recognition based on population, patterns, obs, clinical suspicion and at the same time Recognition based on population, patterns, obs, clinical suspicion and at the same time commence treatment 30 m. L/kg IV crystalloid within first 3/24 Further fluids based on haemodynamics BP, HR, RR, T, Pa. O 2, UO, . . . Aim to normalize lactate through good resus http: //journals. lww. com/ccmjournal/Fulltext/2017/03000/Surviving_Sepsis_Campaign___International. 15. aspx Recognition and Resus

 Two sets of blood cultures Does not have to coincide with fever Can Two sets of blood cultures Does not have to coincide with fever Can be taken at same time (from different sites) B/C should not delay antibiotics Should be completed within 45 min Diagnosis

 Broad spectrum Abx coverage within 1 hr of recognition and preferably sooner Can Broad spectrum Abx coverage within 1 hr of recognition and preferably sooner Can be given IO or IM if vascular access cannot be established Drug choice as per local guidelines Antibiotics

 Surgical source control Target recommendation is 6 -12 hrs Removal and replacement of Surgical source control Target recommendation is 6 -12 hrs Removal and replacement of infected devices (IDCs, IVCs, CVCs) Source Control

Discussion & Questions Discussion & Questions