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welcome everybody good evening everybody I'm Dr Neil and on behalf of Netflix I work with you all today to the session today we have today we have our guest speaker Dr Arjun Alva and he completed his MD in anesthesiology and also did his uh super specialty and cardiovascular anesthesiology in India after they went to the UK and there is critical care medicine from the nhsud of course he currently is the administrative head and consultant Critical Care in medicine I would phrase at MSM Hospital in Bangalore and today will be speaking to us about the evolution and management of septic shock thank you for being here and take over the session that's all right yeah uh good evening everybody thank you for that um so let me straight away go into the topic uh of uh Big Shot um so sepsis as you all know uh is a he is considered as a medical emergency like how we have uh time matters in case of stroke in myocardial infarction where they say time is brain time is hot similarly time is very very crucial in such management of sepsis patients as well the early recognition hourly institution of resuscitative measures uh go a big way in managing patients with sepsis um so if you look at the statistics that unfortunately the last two or three years have been a difficult time for all of us with uh a lot of mortalities when it came to covet almost 5 million people died worldwide and about 500 000 people died in India uh till January 2022 . um when it comes compare it with with sepsis about 49 million people are infected uh every um every year uh biceps is a big number isn't it um about 11 million people die every Earth sepsis almost one in three deaths in the country or you know in the world is because of sepsis the most important thing to note that that statistics is being five percent of the sepsis and sepsis related deaths are so uh 85 percent of the sepsis and sepsis related that's uh are among vulnerable population like newborn uh the pregnancy the popular sepsis and people who live in low resource population um again very important thing to note 49 of the patients in sepsis in the Intensive Care Unit are acquired infection in the hospital okay it's very very important uh it's easy to note that down an estimated 27 percent of the people with sepsis in hospitals and 42 percent of the people in intensive care unit die so I just wanted to make sure you understand how how severe the sepsis and its complications are uh this bit of History uh sepsis was first mentioned in the ancient Greece um sipo means I wrote um so uh Hypocrites in this uh literature has spoken about our alcohol uh is uh has this anti-antiseptic properties back and forth 400 BC electron in uh 280 gallon respected a Roman physician made theories about wound healing and pus uh 1800s was a golden era for germ theories a Hungarian physician San Elvis a very popular physician at that time uh was working on why perforated sepsis was very very common and he what what he found out was is medical students would do autopsy on the cadaver and then we deliver the babies without washing their hands uh and he was the one who popularized washing hands at that time uh Joseph Lister one of the very Pioneer British surgeons um he used antiseptic which was used to uh clear the sewers um you know he soaked them with his gauzers and they used it on the wounds so for wound infection Joseph Lister was a big name similarly Louis Pasteur we can't forget uh Florence Nightingale in the 1830s during the Crimean War played a very vital role in popularizing and watching and and trying to reduce infection in the in the in the soldiers and in in our patients um so yeah so it has been uh ages uh since then in the 1900s since 1960 again sepsis became became uh more popular uh to a point where in between 1991 and 2023 we've had multiple consensus uh and we've had multiple uh have multiple consensus of surviving sepsis guidelines so surviving success guidelines they were mainly introduced to make sure that the the intern is the medical students the general physicians get an idea get this basic guidelines for treating septic patients okay so the consensus was happening every every four years 2000 and they started between 2001 to 2004 to 2004 and then uh the next concert next the second edition of 2008 2012 2016 and unfortunately because the covet it didn't happen between 2019-20 and we have the new Francis is in 2021. uh based on these consensus guidelines uh surviving sepsis campaign uh we have some definitions so let's begin with some definitions what do you mean by sepsis okay so sepsis according to the first uh that sepsis one uh campaign uh sepsis was defined as sauce I'm sure all of you have heard the term Source response that the systemic inflammatory response in row due to a suspected or a confirmed infection with two or more of the following criteria search response you will have to have a temporary either hypothermia or hypothermia heart rate more than 90 tachycardic resp patients should be packet respiratory of more than 20 and the white blood cells should be either less than four or more than more than 12. so that was a definition for sepsis they also had other differences for severe sepsis and Centric shocks severe sepsis was defined as progression of the sepsis to organ dysfunction tissue perfusion or hypotension that was severe sepsis and then septic shock will described as hypotension and organist function that persisted despite volume resuscitation very important very first the hypotension persistent in spite of adequate volume resuscitation which required Base active agents and of course included two or more of the cells criteria so that was nothing but the big shock so these were the three definition that was introduced in 2000 between 2001 and 2004 um based you know they're all protocol based models um and by the time you release the second uh surviving sepsis guidelines in 2004 they had introduced inflammatory markers like lactate levels So based on that they they introduced lactate levels at that time and Source was still quite popular and the definitions still had sepsis severe sepsis and septic shock um again this is just a uh very important if you see search if the patient has searched that doesn't mean that he has sepsis now patients can have serves because of trauma because of burns uh abdominal conditions like pancreatitis he can have the search for response okay the patient can have infection and can have those uh first response so the the in-betweener is you know what is called of the sepsis okay that was the definition of sepsis at that time severe sepsis sepsis with signs of organ dysfunction I mean at least one of the following systems okay it could be cardiovasana the troponin might have been raised along with uh in a patient with already septic is called a severe substance propane metabolism you know the liver functions are all over the place the neurological new division has got increased classical Mass scale but mentation is for and metabolically be ranged so basically there is organ dysfunction the sepsis with signs of organ dysfunction in in uh it was a definition which is called sepsis severe sepsis aseptic shock of course the third one as you see it's a conceptual model so you start with cerse infection and sepsis um as the severity goes up the severe substance a big shock as I described to show like perfusion uh hypertension in spite of volume resuscitation in 2016 in the sepsis 3 okay such as three committee this is quite popular because through the through the covet we saw a lot of patients having sepsis and surviving sepsis guidelines was one of the benchmarks for the management of sepsis in covet as well uh the one of the most important changes in the definition uh during this surviving safeties campaign of 2016 sepsis 3 was the term severe sepsis was eliminated now we do not use severe sepsis okay although a lot of people still use those terms as we accept this but ideally the the term severe sepsis has been eliminated okay and uh there are the concept of cues of other source was removed in 2016. okay because uh a lot of patients did not have sepsis with the source response okay then they introduced A New Concept called the queue sofa that is a little sepsis related organ failure assessment and then later on in 2020 so uh based on the uh based on what we have discussed in the last 10 15 slides uh a few questions if you uh quickly can look into this regarding the definition of sepsis uh question number a all the definition of substance on the definitions of substance are based on the source criteria true or false systolic blood pressure is one of the four clinical criteria that determines us according to the 1992 definition of the 91 definition of source response is the presence of infection is defined as sepsis the criteria of race lactate was first introduced in 2001 update and in the 2001 update the term severe sepsis was defined as sepsis when all the four criteria of cells were were met is to give you a problem if 10 seconds to just look into it again um then the answers so uh so the the first question all the definition of sepsis are based on the source criteria uh that's that's false isn't it the the sepsis three definition is not based on the source okay here uh the sepsis three definition of 2000 and um 16 was uh basically Q so far okay the sun's response was this Earth was removed from from the criteria systolic blood pressure obviously the search criteria does not include a systolic blood pressure it has body temperature heart rate respiratory rate and the white cell counts okay uh what about uh according to 1992 definition of sepsis response in the presence of infection with Concepts that's true uh the criteria of race lactate was first introduced as a part of 2001 to 2004 update that's true again and in the 2001 update the term severe sepsis was defined as sepsis when all the four criteria that's false is per sepsis complicated with organ dysfunction second impression in the sepsis 3 definition okay such as three definitions this is the 2016 definition we talked about severe sepsis is defined as a life threatening organ dysfunction caused by this regulation post response is it true or false the second question is the clinical criteria of sepsis are infection plus two or more so far points above the Baseline it's true or false patient new score and ews score of greater than 2 has a little mortality of meter than 10 percent in a patient with septic shock the lactate will be greater than two whether mortality risk of 40 percent and lactate is a we are biomarker for sepsis true or false okay probably give you 10 seconds to look into the questions again okay so the answer is looking at answers I I'm sure you've much already thought the since sepsis three definitions severe successful is not bad okay the term was removed completely okay it was uh sepsis was a definition uh was like flipping or when this function was very circulated First Response okay the clinical criteria of sepsis are infection plus two or more so far that's true um the third option is false a patient with no new score new score is not there at all in sepsis three it was a queue sofa which is introduced and the fourth one is true the clinical diagnosis of septic shock in the new new definition is hypertension requires a basic plus lactate over two that's correct the fourth one uh there is no biomarker for for sepsis okay and that will not accept this three now coming to the main main discussion of uh of evaluation and management of substances a big shock okay I'm just going to discuss these these six important things how do we screen patients and what is that how do we initially resuscitate patients or the role of infection okay A little bit of antibiotics for the hemodynamic markers uh how do you ventilate patients with septic shock uh what are the additional therapies okay and what are the goals of care and long-term outcomes all right these are all based on the 2021 consensus and what was this excuse so far I was talking about okay this is a screening screening tool which had you know it was a bedside screening okay which had three important criteria one of the respiratory rate if it was more than 22 per minute did they give it one point if there was all Turks and sodium they got one point and this is the systolic blood pressure was less than 100 millimeter of mercury they got one okay the queue sofa score of two or three means it is over outcome okay this is a quick um uh quick cleaning mode to identify that the patient is sick the patient might have infection the patient might have might have sepsis all right so every time you guys are working in the world you guys are working in the htu OR ICU you need to look at these few things which will be talked about Let It Be sauce let it be cool so far you know the heart rate the respiratory rate the temperature the blood pressure the white cells count you need to continue to keep looking at them every every time when you think of something something's not right here all right so this is Q so passcode uh uh when compared to 2016 consensus and compared to sepsis 3 [Music] 2016 2021 had the news the new thing which has come up it's surviving a campaign in 2021 they found that Q so far by itself is not a very good screening screening uh option for identifying sepsis so what they said was you have combined you so far along with the Stars along with The Muse that is modified early warning system early warning a new special you have to combine the different uh screening tools to identify a patient who might be having having sepsis it's very important that you don't miss patients with with sepsis because it can be it can increase the mortality if if you delay the treatment process okay so again thank you so far just keep in mind we'll get the respiratory rate keep an eye on what is mentation and what is my scale is uh look at what his systolic blood pressure is okay in in Celsius criteria you did not have the blood pressure okay you did have the respiratory okay so uh next coming to fluid resuscitation it's very important so I'm I'm talking about screening very very important uh education is important in in uh in hospitals the nurses the junior doctors you have to uh do the training program so that they are able to identify patients with sepsis early you need to have continuous programs happening in the in in the hospitals related related to sepsis it's very important uh second thing is fluid resuscitation okay it's a very important thing every I'm sure all of you have heard of this 30 ml per kg body weight that was during uh during the surviving Services campaign it was very very popular uh every patient would they had recommended that everybody to load them with 30 ml per kg body weight we initial resuscitation um hit them hard that was the initial that was a basis of the whole thing um uh so what I would personally say is you have to be very careful when you're giving giving fluid it yes it's very important that you give through please evaluate them before you give the fluids okay um if you give uh if the fluid Visa station is beyond a certain price very detrimental okay having overload is uh very very dangerous and it increases the hospital stay increases the mortality as well uh using Dynamic measurements why they're doing fruit resuscitation also very very important okay uh this was uh a very important study called as a reverse study it was a landmark study where where uh which is based on your Earthly cold directed therapy and which may advise is for that we are from 2001 to 2000 and 2016 and even now okay even uh this was the basis for uh goal directed therapy giving fluids in a well-mannered way you know monitor the central venous pressures monitor the scb02 the central Venus line is present okay use of use of uh blood and blood products they're very very nicely explained the use of coal directed therapy it was a landmark drive at the same time so that at the same time they're also in Ghana okay into this uh African countries they did a large study called The Feast trial and it was done in a pediatric age group okay and if you see if you look at the graph um the 48 are mortality okay in patients who received saline as uh as a people who received resuscitation with trueisms throughout the albumin or saline had higher mortality rate when compared with no fluids okay so these were the different arms that they used when they did the tribe yes you might argue that this is not the adult population this was more of a pediatric population and it was done in African country is that that uh this you know you do not have access to uh good medications antibiotics and so forth but still uh it is quite you know it's quite important to understand that uh the mortality can be quite high if you overload the patients they are talking about the freestyle um uh even the the new uh the 2011 consensus continued to say that there was a low evidence uh uh so in 2021 they said we recommend using 30 ml per kg body weight okay but now they have a bit of change in in their in their uh reasoning and they've said for patients with sepsis induced hyper perfusion or septic shock we suggest that at least 30 ml per kg of intravenous fluid should be given within the first three hours of resuscitation okay and there again you can there are multiple studies there that was done which showed uh these results uh some of the popular ones I promise process arise if you get time to read then please please go through them again it's just explaining that you know you have to be careful when you're giving uh fluid research this liberal resuscitation risks of fluid overload and vast Valentine states with impairment of the organ dysfunctions okay uh there's always and you can always maintain the mean arterial blood pressure by introducing the waste suppressor early so that you know so that you can reduce the reduce the use of uh too much of fluid to chase to change the clinical clinical parameters okay now since it's a end point was you would you still resist it yes you would still resuscitate but use Dynamic parameters to to monitor How much fluids you are How much fluids you are giving but yes fluid still continues to be a major part of uh management of early management research okay try again golden question which fluid for resuscitation uh as per the uh surviving campaign they have very clearly said that use crystalloids and preferably use it in your lactate okay what's the problem with uh with the normal saline uh or the normals are like the basic trial which is done in Brazil uh recently during the Kobe time of the short no change in mortality between using Northern saline and uh plasma light um other crystallite solution uh [Music] but the volume that was given is the that study was a very small but whatever said and done we have seen that sodium chloride can cause a lot of hyperloremia which can result in metabolic acidosis okay and can worsen worse in the worst and the sepsis all right uh so consensus was that foreign otherwise what about starch um again very clearly hydroxythyl star space contraindicated in resuscitative and resuscitation initial resuscitation because of his high risk of acute kidney injury okay uh albumin expensive um if you once you've given enough in your lactates and still patient with volume responsive uh you can use albumin and beneficial views and patients with liver disease okay uh so yeah uh summarize the whole thing again as I said uh fluid resuscitation to correct hypovolemia I support objects big shock recent randomized trials have not confirmed the benefit of targeting invasive physiological parameters they are not told how much is the ideals you would volume what is the end point in sepsis resuscitation they all remain unknown okay and as I said uh starts will you know avoid using stars as a result of the risk of kidney injury similarly with normal saline It Cosmetics acidosis and may increase the risk of acute kidney injury whether you use a balanced crystalline can prevent a cricket injury and decrease mortality Still Remains unknown okay try to avoid hypovolemia as much as possible use Dynamic uh use Dynamic parameters for your resuscitation very important I'm sure all of you have gone through or have at some point of time when you're looking at your arterial blood gases you've looked at lactates okay and it is lack the Irish fluid administration to improve the lactase has been one of the gold standards in the treatment of acute yes or in the treatment of sepsis and septic shock we see our residents chasing that lactate until they see that normal electric keep on giving the keep on giving IV fluids is it really uh is it really um necessary you know the initial initial phases of sepsis then the patient is in the ER lactic is not a not because of anaerobic metabolism okay you see the uh if you see what happens here in sepsis is the glucose Transporters increases and therefore the the glucose entering into the cell is very high and therefore uh if you go to the cycle your by increasing the glucose to increase your pyruvate normally it would enter in Western is enters into the Krebs cycle and uses uses the ATP energy in the cells but what happens in sepsis because of increased glucose increased glucose transport receptors your system gets over when ayurved dehydrogenase gets overwhelmed and the pyruvate gets converted to lactate in the presence of lactating hydrogenase but reflected is not not harmful at that initiative it's actually a defense mechanism and it acts as a fuel for your brain and for your for your heart okay so you should not consider uh during the initial phases it is you need to understand that it is not the anaerobic failure failure because using the increasing the lactates there are a lot of what happens during the late phases of sepsis or there are you know uh receptors can cause multi-organ failure your liver can get injured and that can increase your lactase okay in latest sepsis when the ards section you know that time the analogical a bill set in and that is the source for your for your high Lac trades okay um so there was this very groundbreaking uh I'll call the Android made a short trial where they compelled the uh lactate based resuscitation with capillary we still time resuscitation and I'm sure many many of you guys we see a lot of residents and doctors working in the ICU have been all advanced you know they want to use the ultrasound they want to stand at the end of the bed look at them look at the investigations and and treat the patients and the the number of students going and examining the patients has reduced significantly okay I'm not sure how many of you have ever done a capillary research and it's a very very basic uh and basic thing I mean if you have touched the patients you know it's very very important that you clinically evaluate the patient you know it's very important you will you will identify so many important things similarly this capillary Regional time that you know you just press the press the uh fingers and see what was the capital bits in time you know how they did how did the test what they did was to use a glass slab a small glass slab which used in your microbiology they use that they press that for press that and released it and saw the capillary fill time was if it was more than more than three seconds they would give more fluids to reduce it and if it was less than three less than three seconds then they were happy that it was well resuscitated but uh so they use the two arms one arm they used capillary refill the second arm was lactic guided resuscitation they looked at the 28 days mortality and there was increased mortality with the lactate arm although there was no Clinic you know there was no statistical significance small size they disregarded it uh but still after after a few years they did a post-hoc analysis although with its own uh problems with stock analysis but still uh so what they did at that time was the in patients who satisfied the capillary retail time uh and uh related was still not normal when they had to change that and they gave more fluids okay and then that was evaluated and what they realized was uh the postdoc analysis that the significant increase in the mortality Innovations where where which is uh lactates um uh lacto policing that's what that's what that's what we call uh when the seasons chase the lacked its uh in case of shock okay so be very I'm not saying elected is not very important it is definitely important in the in the late later phases uh in the late phase of sepsis uh sepsis management but uh do not chase the lactates to a very significant amount go by the dynamic parameters of fluid resuscitation okay uh there's the same thing uh again saying uh foreign especially in the late late late Okay so we've covered the fluids about how much fluids to give we discussed about uh what kind of fluids we should be giving what kind of food we should not be giving we discussed about lactates and uh and uh what happens when we give too much of food it's based on based on lactates uh and then uh even after giving the fluid resuscitation if your blood pressure doesn't improve you have to look at the Vaso active agents so the first choice of ways to active agents that we use is the it is not epinephrine is used in the first line of first line of agent uh in septic shock on or epinephrine with inadequate map levels we suggest adding vasopressin okay instead of escalating the dose of null epinephrine okay when do we start basis then you know if you have a place and a point to two mics per kg per minute or you know each amp fuel is four milligrams you know and setting in our hospital we use four milligrams of PML and once it is crossing the 20 ml we change it to double strength before we change it to double strength we uh that is eight milligrams of DNS which we change it to uh okay um so and if even in spite of not epinephrine and basically your next agent would be happiness and they suggested against using very used or depressive the only person can be used in the wards uh as an in solution in mainly patients with with hepatic with hepatic disease okay then stage hepatitis is liver disease in the Box we use to use [Music] um what about septic shock and cardiac dysfunction with persistent perfusion despite adequate volume status such as either adding dobutamine okay so or use epinephrine all alone okay so add so if you begin with the irrespective of what kind of sepsis it is okay now Refinery would usually be the first choice of first order of choice and add if there is cardiac disregulation if you if the echocardiogram bedside dysfunction patients the known cases cardiomyopathies you can probably with sepsis you can the probably the agent to add is stop it again okay there's no role of limousine um uh sorry yeah WWE increases the cardiac output and oxygen transport increases this plant splint and the perfusion and takes your oxidation improves the intramural acidosis and also can cause cycle okay okay um so when the patient do we do we have to immediately rush and and put the central lines uh Central Venus catheters uh no okay if the initial resuscitation of the patient has good Venus axis we put a big 18 gauge 16 gauge and we can lastly sustain it with IV provides you also if in fight of resuscitation if the blood pressure is still not improving you still have high so until you are able to secure a central line a central we must get data you can start the patient on peripheral ionotropes okay do not continue using it for a prolonged amount of time but you can keep it for uh for a few hours until you have a simple line or sometimes you know once the fluid resuscitation is done once antibiotics is gone in probably the patient might not require the recipient you might not require a central release headache okay so for the initial RS or the creation you know probably there's no particular time but for three or four hours you can try and see if the patient manages or not epinephrine and with uh with the fluid resuscitation the blood pressure improves okay uh emperic antibiotic therapy okay the front identity prompt identification and treatment of the site of infection is the primary therapeutic intervention with most other intervention we will be supportive okay what is the antibiotic timing okay uh 2016 recommends using antibiotics within the first one hour okay so as soon as the patient comes in you have a suspicion of uh infection you within the first one hour you give that give the antibiotics that was uh that was what was practiced uh in in 2016 uh in 2021 uh the uh newer uh thing showed that uh if so the they gave us some time okay uh if there is sepsis is a definite or if it is definite or probable then administer antimicrobials immediately do not delay but if the sepsis is a possibility okay and shock is absent so probably you do a rapid assessment of infectious versus non-infectures causes of acute illness okay the administer antimicrobial within three hours if the concern for infection infection process okay so there is within the first three hours you have to give antibiotics if you know if you really think that uh it's an infection it's an infectious cause Okay um uh initially so what are the initial evaluation that you do during that first three hours along with you know sending for blood cultures fluid resuscitation interface you decide to work use it as hypertension at the same time look for uh others you know other sources of impaction okay just try and investigate what are these things clinically examine the patient take a history based on that you would you would get to uh get to see uh if there is any common source of uh common source of sepsis okay whether the patient is on a long term you're medicated reason is that even a compromised situation uh has it got the fourth quadcat is easy caught alone a vascular for dialysis for a long time you know those are the things that you need to see each other and patient has catheter related interaction whether the patient has advanced with there is a wound this is causing infection um okay um you know whether it could be a viral infection okay those are the things that you need to evaluate uh initially okay um again that you look at basically two clinical examination and try to see uh whether whether you are able to do any kind of course control as well very important Source control before the antibiotics are along with the antibiotics is uh one of the important things for management of sepsis uh early antibiotic delivery although it is you know very clearly mentioned and it's got moderate uh evidence for use of early uh antibiotics causes a lot of pressure on the clinicians and it could be a pharmacy driven as well uh but sometimes and regarding uses unnecessary okay because they might confuse uh the shock as you know it could be a heart failure it could be pulmonary embolism so every every patient if you start giving them antibiotics it will result in unnecessary use of antibiotics it will give rise to uh xdr MDR organs which they are all be struggling with okay select choose the antibiotics based on patient conditions very very important what about the role of empirical antifungals again there's no no rule for empirical antifungals at all until unless the patient is in the in the ward has come to lies you with serious absence and has got very very high very high risk factors into abdominal surgery uh the fecal contamination a neutropenic patients patients who have been in the hospital for many months you know those kind of patients if they are not improving the basic through the substation basic antibiotics if you can give them empirical antivirus thank you okay um yeah time to antibiotics matters particularly for sicker patients um when do you stop antimicrobials okay um so it is again there is no perfect time to stop antibiotics when to stop uh see whether clinically he's getting better okay uh if if his total counts are fine if there's more fever for 48 hours if you know blood pressures are okay he is feeling better oxygen requirements are less uh images are all right you can decide on um decide on uh stopping the antibiotics usually you give antibiotics for three to five days okay because some people tend to continue and finish off that three to five days of course and serious episodes in uh they might also continue to take this and this as well okay this was a study which showed in Netherlands this how soon would you give antibiotics so this one are you know as soon as they came to the hospital within one hour uh you have to give antibiotics that was the victim and then New England they did a study where in the ambulance itself the paramedics would give the uh give the biotics as soon as they they get the patience and they compared it with uh with giving patients once they arriving about 70 minutes after arriving in the ER and what you define the mortality at the end of the end of 28 days was was similar so eight percent is there any role of combination of antibiotics um multiple studies if you see here itself there were about eight or ten studies which say that there is no role of combination combination therapy okay but again it is again Patient to Patient depends upon how sick the patient is if you're suspecting somebody with an electrical and resistance therefore the focus obvious along with uh MRSA being one of the sources of uh of community in sections you probably need to give a couple of antibiotics combination uh antibiotics but again based on the clinical clinical condition of the patients you you decide on whether to give this one antibiotic or or do antibiotics okay 3r bundle uh these are the three bundles that we have or a three hour bundle as soon as the patient comes within the first three hours make sure uh antibiotics is gone and if you're suspecting the patient to have substances of septic shock uh make sure the antibiotic is gone and makes your blood culture is gone and you know you can do paste this total blood cultures um uh if the vision is lying we send uh pulses and not the not the catheter don't please don't send the people because they don't you know you can send uh what one of the samples from the center line and probably two from the from the peripheral lines measure the lactates if there is uh if there is provision to uh for uh ABCs um and uh if is uh based on the dynamic Dynamic response this resuscitate the patient with adequate amount of IV IV fluids and then they said there is six hour bundle okay where uh where we introduced the waste activated so this is a septic shock where the patient is being resuscitated adequately for the first three to six hours in spite of that your blood pressure is on the lower side is less than 65 and then you start a vasop agent okay this is the time when you start also this six Urban view was in 2016 so the uh four to 2016 so they use the early code electric therapy when they put simple line they monitor the CVT they monitor the sco2 they would repeat uh lactates one on admission and one after six hours okay if if the persistent hypertension is present a very important physical examination following the resuscitation um and the one hour bundle again always remember although I don't think how within one hour you can do all these things you know you can do the blood cultures and administrative giving antibiotics uh it will take some time with the taking blood cultures takes time and they expect us to also give rapid administration of 30 ml per kg of crystalloids uh in the lactates are more than four uh applied so they're saying this one abundant do all of this but yeah if possible if you're suspecting a severe substance a big shock and a patient who comes to the ER if you are able to give uh everything in one hour go ahead and try and drive so why are they so you know about giving you know giving resuscitation lactate guided guided giving IV fluids why why are there [Music] if you look at the mortality okay if the lactates of more than 2 million millimoles the for the for a significant period of time the mortality is about 25 percent it's very high isn't it and it's the way supers are requirement is there the mortality has been 30 percent whispers are hypertension and elevated lactaids together the mortality is about 42 percent okay and that's we also say that the survival increases by about eight percent in the first six hours of the antibiotic is yeah it is very important yeah uh oxygenation other than there are no targets you can maintain a saturations anywhere between 88 and 92 again from Patient to Patient ideally between 9 to 96 uh partial pressure of oxygen more than 55 millimeters of mercury and uh yeah can we use hyphoon nasal cannula uh instead of NIV yes the use of high flow missile cannula is ideal for hypoxemic respiratory failure um and then non-invasive ventilator okay ventilation please follow the Arts net protocol of 6 ml per kg body weight or Hydro volume um mixture flat pressure is 30 to 30 centimeters of water um [Music] categories of 30 centimeters of water give adequate recruitment so please follow the arch Network cost okay and just quickly running through the last last 10 minutes uh also uh during the covet due to the H1N1 we've all seen that patients who have struggled with ards probably sepsis or any other conditions um uh if the ventilation is not helping them if oxidation is still not improving acidosis is not improving uh you know vvmo is an option if you have social Vision to do so okay so vvf more is a is something that people should keep in mind when patients are not improving in their ventilation in patients with substance related to ards um what are the other alternative native therapies Okay so we've spoken about antibiotics we've spoken about hemodynamics we've spoken about uh IV fluids okay lactate clearance and all of that and along with that we'll talk about some of the alternative therapists what about IV cortical steroids okay there is a very high there's a very moderate moderate evidence okay saying that foreign [Music] um if uh when do you give it uh usually in our Center anybody who is on uh on minimal or adrenaline not in blood pressure is not improving for four hours not original requirement is going slightly more than 0.15 actually we usually start them on steroids and it has shown quite uh quite significant uh Improvement in the okay what about vitamin C vitamin C very popular during recovery times unfortunately has no role in management of patients in in septic shocks okay um other therapies like polymix and deep hemoprofusion uh all these fancy filters uh again there's more evidence for the for their use there's a strong evidence for uh restrictive transfusion strategy okay you don't have to chase the uh you know you're going to more than 10 grams uh more than 30. I think I think a majority of the centers across the world are maintaining a strategy of about 7 grams per deciliter okay in the icus which should be enough in situations um and uh there's no change in the mortality uh after 28 days in either of the either of the arms okay um uh very strong evidence in using VTE profile axis okay Venus somewhere balls and profile axis uh it is not only in substitution but anybody who is there in the Intensive Care Unit very high risk of pulmonary problems extremities so please use a low molecular weight in the patients against strong evidence for uh insulin therapy with glucose level of greater than 180 milligram per test liter use insulin infusions okay and uh the last slide on um on post sepsis okay once the patient are in reception it's very traumatic for the patients people who are living in that who stay in the ICU Pages you to end up staying four to seven days in the ICU they end up having education delirium uh they see a lot of bad things going around them they are addressed to a lot of uh you know Central lines there is lost modesty um yeah there's uh so it's not a nice place to be in you see a lot of people who recover and go home and having post-traumatic stress disorders okay so it's very important to train them to send some pamphlets uh to uh for uh to train them and to you know give them psychological support you can get them uh get them back to the ask them to come back to to see see people in the in the hospital as well psychology psychiatric review as well okay um so those are the that was the basic uh discussion on uh on uh evaluation and management of uh Centric shock okay some few places that I have if I have time I think I have about five minutes do I have time do I have uh yeah so the first case was um uh so this is somebody who had was in the world so you were asked to see a 35 year old man who has been in the hospital for three weeks with acute alcoholic pancreatitis uh he was discharged from the ICU two days ago uh you're asked to review him because the nurse is concerned about this condition wait is about 30 per minute is on 8 liters of oxygen maintaining a saturation of 92 percent okay his blood pressure is about 89 by 40 pulse rate is 120 this temperature is 35 okay so he is uh if you see uh his hypertensive his tachycardic uh his uh temperature is below 36 he's requiring oxygen he stuck it Nick all right the initial Airway assessment you see him you don't have to do anything isn't it an air base pattern he's giving him giving him some oxygen uh with ADHD there's a box if you can jack up the oxygen 50 degrees because if you plan uh eight inches of oxygen it's quite difficult to manage it in the water so you probably might be looking at Shifting the station to the Ico or the high dependency unit okay the ideal way of shifting a patient is by by using a non-driving mask okay um uh so why I'm talking about this these assessment is any patient who you see you need to make sure you do the ABCD approach okay Airway breathing circulation and disability okay make sure the Airways pattern is on some oxygen if his saturation is not maintaining well make sure it is breathing well look so the science is pneumothorax look for uh saturations okay um whether it's this week or not what is the spirit weight is circulation very important to make sure that if any patient who is sick has an IV cannula okay you don't you never know when you would uh when you rush through it you need to sometimes facial disconnects they might have Cardiac Arrest when you have time when the patient gives you time make sure you get in IV access very very important okay and then do your basic things you know where that responds to voice um or not all right um so yeah so following the initial assessment and resuscitation which of the following should be considered as a part of secondary a secondary assessment okay do you want to do a city abdomen blood gases blood cultures unes chest x-ray urine cultures food and culture okay yeah um so let's let's see what what we did uh so I think uh uh all the all the answers are probably right isn't it so CT abdomen you would hear somebody who's had a pancreas uh surgery he would uh as issued with pancreas so probably if it will become unwell you might have to look at the implantominal source and therefore see the abdomen okay very important ABG okay ABG is very important you need to look at the lactates you can see how much fluids is given it might be in late stage the sepsis okay blood cultures again before you give any antibiotics very important to give to blood cultures okay before the antibiotic goes in make sure is much better as well if you send the blood cultures before you send in the first antibiotic dose okay uh you you and is yeah very important to see what the real functions functions are doing chest x-ray to see if it's developed any Hospital acquired interactions um and urine cultures and also scrutin cultures for any any Hospital aquarium actions okay so if he has by you examine it means about bilateral basal preparation abdomen is not and the standard uh it's not peripromatic though urinary catheter is in place and client has been there for four days at the site okay what could be the cause of the patient is hypothermic rather isn't that so uh and if he was a Pyrex what would have been this issue it's going to be chest infection yes of course chest infection is very common in patients in the in the hospital uh pancreatic necrosis very very common in patients who have stayed in the hospital with alcoholic pancreatitis they end up staying for months and months together in the hospital they're requiring requiring necro seconds okay line sepsis yes very much possible uh CBP handling of the Centerline one of the Communist line related if you don't find any Source patient has a central venous catheter make sure you get rid of it okay even the reception as a Humanity okay it could be any of this isn't a drug reaction on the very rare can cause a fever in patients in the hospital okay um again another case where the patient is suspected in the hospital with suspected pneumonia the sputum is green no past medical history do not uh over the last days has been having increased in the breath it goes to the GP gpcc sinus sensing the hospital his wife is very very concerned okay based on sub 66 treatment bundle uh what are you going to give and what are you going to take okay so these are the six things that are there so you are going to going to take um what if you could measure the batteries you're going to send some blood cultures reduce the blood you know lfts plotting times CRPS are you going to catheterize the patient okay you're going to give him uh IV through Visa station IV antibiotics and also hydromate isn't it um he's breathing at 30 per minute because Ox shows 92 on high flow hypotensive tachycardic temperature is still low his creatinine is about two so uh which of the following syndromes is the patient suffering from he has pneumonia and sepsis isn't it um uh not septic shock because he's uh high potential but we have not given him adequate fluid resuscitation yet okay um another example 68 year old three days is this Uric feverish numerous urinal tract infections come to the hospital with the background of hypertension no allergies um with uh tachycardic slightly hypertensive your diagnosis that you have maybe sepsis okay you would expect to see these actions on your initial resuscitation bundles what are they uh would you do serum lactaids uh what about um taking blood cultures prior to antibiotic Administration admission antibody within one hour food resuscitation insert a CBC or treat with uh the initial initial uh phase you would not want to directly put as I said don't want to put CVC straight away isn't that you can manage with the peripheral line you don't need the one or three R bundles do not include bundle which includes uh um uh so you give him some antibiotics after taking the blood cultures um given some fluid resuscitation of about 750 mlc Blacklist is about 3.4 uh after you do the assessment uh you do continue to do a ABC letters have come down to about 1.4 where are you going to keep them I'm going to ship them to the ICU they're going to ship them to the award or review the antibiotic prescription uh in the prescription baby if you're going to do uh review the discussion of course uh you're going to lead me to the water you see that you need to be in the ICU because you've given a fluids electrics it's nicely coming down blood pressures have gone up so probably he's somebody who we can manage in the uh in the uh Ward I think I think that's that's some that's a majority of my my talk uh so if you want to know more uh please go to surviving sepsis campaign surviving services.org uh it has very very extensive discussion on on guidelines and definitely help you in managing places better in the hospital thank you very much thank you drama that was really an educational session we could take this question uh Dr Alva gave a couple of questions which are already there I'm going to read them out yes Dr mahadeva was asking that shouldn't we be careful about uh giving ringer Lactaid if you're unsure of the liver ischemia in this condition uh the amount of lactaids that are there in the ring elected is very very minimal and uh uh in in patients with sepsis uh you the the most important thing is probably resuscitation fluid and resuscitation fluid with the way the balance crystallite solution with a plasma light or orinolected is the is the goal so the amount of lactate will not that is there in the regular it's very very responsible five millimeters per liter to cause any damage to work so Dr Ramesh Kumar is saying that in should the inferior vena Cavalry sound be used to guide the fluid resuscitation yes diameter uh is uh not the ideal choice in spontaneously breathing patients um the inferior being in in the mechanically ventilated paralyzed patient uh probably the IVC diameter IVC collapsibility index is probably something that we can use to guide the fluid resuscitation but that it is not a dynamic dynamic in this okay Dynamic they're all static indices like uh including the CVP and uh pulmonary artery prices so you you what you require now is a dynamic dynamic measurements Dynamic measurement is based on you know probably a passive negative testing which is quite easy to do in the in the icus or in the emergency room um uh which will you know if the patient is too responsive while we do the best it will increase his blood pressure and it does you give it more fluids instead of doing the IVC diameter if there is if you are quite good in doing bedside your feet the left ventricular out outflow tract velocity time integral that is VT uh that is something that we we look at when we are doing uh resuscitation of patients in the ICU yeah so the IVC diameter as I said in spontaneously breathing patients it is not reliable in a mechanically ventilated patient we can use that to indirect our fluids sure again Dr rameshma is the question what about warm and cold shock and sepsis how do we deal with that uh again I uh I am not very familiar with the warm and cold sepsis I'm not sure whether you try to talk about uh ways of validation invasive constriction whether you're talking about peripherals shut down during cardiogenic shock so again uh you uh if there is sepsis you you look at the guidelines you make sure that um whether in our fluids are given whether you've taken the blood cultures whether antibiotics are gone or not look for the source of infection maintenance I mean arterial mean arterial arterial blood pressures um yeah try to try to uh the main thing is source of infection whether you're giving the right sources the right antibiotics or not um you know that that irrespective of what kind of shop you're looking at uh if you you are you have to go through the guidelines and give the give the required I'm saying how do we how do we localize the focus of the shock in this in any if you get a patient of shakavi local as a focuser look again uh clinical examination try to find what the patient has come with history history is important take what kind of History if you come with cough breathlessness look at Boost uh chest x-rays send the blood cultures um the sputum cultures uh if you if the patient's abdomen is tender you know do it as per the clinical clinical clinical findings and the universe is not do step wise investigations and see what the sources so you can localize it by doing your clinical examination and investigation is any role of blood transfusions in shock blood transfusion again as I said there is a very robust evidence saying that uh transfusion trigger is about seven gram per day deciliters um by giving by there has been studies which have shown that by giving more amount of Blood by giving more amount of fluids you've been because in hypovolemia you will cause ards and you will increase the increase of modality yes if it is a hypoalemic shock definitely go ahead and give the blood if you know the sources there's a trauma is breathing from somewhere it's correctly hemotherapy leaving his brain postpartum membranes please go ahead and resuscitate them with with blood but it was a septic shock there is no uh keep the hemoglobin at seven grafts per deciliter and that has shown uh restrictive transfusion figure has shown to have better evidence so if in an elderly person if we see a person he's coming with delirium is there any difference in our approach again you have to uh investigate to do the clinical examination investigate see if there is any source of infection anywhere and then uh see why what is the source of delirium the sepsis itself can reduce uh can cause mental confusion see whether there are any metabolic parameters which are in a hyponatalia can cause your uh if he's in a meditation septic encephalopathy very very commences try to find the source of infection there is no difference in how you manage a patient if if they are in sepsis irrespective whether it's a new age whether it's a child adult or Elder but be careful about their cardiovascular status do an echocardiogram again Dynamic measurements for food resuscitation that's what is important because these elderly people can tip and just go into pulmonary very very quickly foreign ages and give some stronger antibiotics yes it can cause success so I'm not exactly getting this question uh Dr Ramesh Kumar is asking the echo for myocardial dysfunction he dropped this question during the session I'm not sure in context of what he was asking about yes if there is a every pace of uh in uh in the Intensive Care Unit or in the emergency room uh currently uh uh ultrasound has replaced your your stethoscope it is going to be a time when uh when uh all the medical students are going to have the Pocket Ultrasound and it's not not far away um so uh every patient who comes to the hospital needs to have a bedside ultrasound fast can fast Canada so it is very important and it will definitely help in in seeing whether the patient has sepsis has Associated cardiac dysfunction that will help us in either in septic shock that will help us in identifying what uh what as a racial active age and you need to give I mean be careful about how much fluids we give yes because because you should be using in septic shock septic shock if you are not very comfortable uh just go ahead and use our adrenaline is the drug of choice until and unless there is a contraindication like everything else uh well you know patient has AF where you want to change it to something else otherwise start with not adrenaline uh if not which is not maintained at recipient it is not maintained if the patient has got a cardiac dysfunction with noradenaline Adobe to me or just Admiral in by itself uh in patients who are sensitive or sensitive to most of it either patient's cardiac of food is high you can also use peripheral IV phenylaxene as well uh patients with uh hepatic failure uh causing sepsis please use that early question but yeah not epinephrine is right so the last question uh Dr rameshma is asking what is the role of granular set stimulating factor in sepsis uh again in patients with neutrophenic sepsis stimulating Factor has some role in improving the counts but otherwise in sepsis per se as per the surviving sepsis guidelines there is no uh more role of uh foreign forward to having Senate decisions
Evaluation & Management of Septic Shock
Critically reduced tissue perfusion occurs in septic shock, and numerous organs, including the liver, kidneys, and lungs, may experience acute failure. Symptoms include fever, hypotension, oliguria, and confusion. Early detection and treatment are crucial. The diagnosis is predominantly clinical, supplemented with culture results showing infection. Aggressive fluid resuscitation, antibiotics, surgical removal of pus-filled necrotic or infected tissue, and supportive care comprise the course of treatment. Join us live as Dr. Arjun Alva, Consultant in Critical Care Medicine at the Mazumdar Shaw Multispeciality Hospital in Bangalore, explains how to employ the various management techniques in septic shock and sepsis cases.
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