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SEPSIS AND DRUGS JHH ICU CME June 2014 Lynn Choo ICU Pharmacist.

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Presentation on theme: "SEPSIS AND DRUGS JHH ICU CME June 2014 Lynn Choo ICU Pharmacist."— Presentation transcript:

1 SEPSIS AND DRUGS JHH ICU CME June 2014 Lynn Choo ICU Pharmacist

2 DEFINITIONS This patient looks “septic”

3  SIRS Infection Sepsis SEPTIC SHOCK Severe Sepsis Multi-organ failure  organ dysfunction, tissue hypoperfusion  hypotension despite adequate fluid resuscitation Temp > 38.3°C or < 36°C HR > 90 RR > 20 or PaCO 2 < 32 WCC > 12 or < 4 + other diagnostic criteria  Lactate  CRT Vasopressors +/- Inotropes and more… Brain confusion, delirium Heart SBP 40 decrease) Lungs acute lung injury Liver  LFTs Gut ileus Kidneys stop pee,  Cr Blood  platelets, DIC Levy et al SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31 (4): 1250 – 56. Bone et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. CHEST 1992;101: 1644 – 55. COMPLEX INTERACTION

4 Bone et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. CHEST 1992;101: 1644 – 55. Pinsky. Septic shock. Medscape Reference: Drugs, Diseases & Procedures updated Oct 25, Available on [Accessed 29 March 2012]

5 SEPTIC SHOCK

6  intravascular volume +  SVR + (  CO)   BP +  perfusion leaky capillaries vasodilation compensatory (by  HR) Antibiotics  Treat the CAUSE Vasopressors   SVR   BP Oxygenation   organ perfusion Fluid resuscitation   intravascular volume   BP Septic shock

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8 58 year old female admitted to ICU after 1 day on the ward with respiratory failure requiring intubation. She was agitated and confused prior to intubation. HPC: 3 days of productive cough. SOB. General malaise. PMH: Hypertension, osteoarthritis, T2DM Meds: Ramipril 10 mg d, Atenolol 50 mg d, Panadol Osteo Metformin 1g nocte Prior to intubation: T 35.6°C BP 130/66 HR 98 RR 34 Results:Na 141 K 4 Ur 12.4 Cr 188 WCC 21 CXR left lower lobe consolidation

9 On ICU Day 3, she deteriorates with increased requirements for ventilatory support and profuse purulent tracheal aspirates. What further information would you require? What is the most likely cause of her deterioration? How will this affect her drug treatments?

10 HNE RESOURCES

11 SEPSIS KILLS PROGRAM

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13 SURVIVING SEPSIS CAMPAIGN Improving diagnosis, survival and management

14 Dellinger et al. Surviving Sepsis Campaign: international guidelines for the management of severe sepsis and septic shock Crit Care Med 2013; 41: 580 – 637 Further reading: “Surviving sepsis: going beyond the guidelines” Marik P. Annals of Intensive Care 2011; 1: 17. Available online: NEW GUIDELINES 2012

15 1.Measure serum lactate 2.Blood cultures before antibiotics 3.Broad spectrum antibiotics 4.30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L 5.Vasopressors (for hypotension despite initial fluid resuscitation) to maintain MAP ≥ 65 mmHg 6.Persistent hypotension despite volume resuscitation (septic shock) or initial lactate ≥ 4 mmol/L Measure central venous pressure (CVP) *controversial* Measure central venous oxygen saturation (Scvo2) *controversial* 7.Re-measure lactate if initial lactate was elevated Dellinger et al. Surviving Sepsis Campaign: international guidelines for the management of severe sepsis and septic shock Crit Care Med 2013; 41: 580 – 637 SURVIVING SEPSIS CAMPAIGN BUNDLES To be completed within 6 hours of presentation or diagnosis To be completed within 3 hours of presentation or diagnosis

16 Initial resuscitation (first 6 hours) Goals: CVP 8-12 MAP ≥ 65 UO ≥ 0.5mL/kg/hr S cv O 2 ≥ 70% normalise lactate Screening for sepsis and performance improvement Diagnosis Antimicrobial therapy Source control Infection prevention Fluid therapy Inotropic therapy Vasopressors Corticosteroids Blood product administrationRenal replacement ImmunoglobulinsBicarbonate (do not use..) SeleniumDVT prophylaxis Mechanical ventilation (ARDS)Stress ulcer prophylaxis Sedation, analgesia, and NMBNutrition Glucose controlSetting goals of care Recommendations: Initial Resuscitation and Infection Issues Recommendations: Haemodynamic Support and Adjunctive Therapy Recommendations: Other Supportive Therapy of Severe Sepsis

17 PHARMACOLOGICAL THERAPIES antibiotics. fluids. vasopressors. inotropes. steroids. dvt px. su px

18 ANTIBIOTICS But really includes all antimicrobials…

19 Antibiotics Timing administer within 1 hour of diagnosis 79.9% survival rate when antibiotics administered within 1 hour. Each hour delay (over first 6 hours)  7.6% decrease in survival. Kumar et al. Critical Care Med 2006; 34 (6): 1589 – 96

20 Antibiotics Loading dose high to start with Volume of distribution (V):hydrophillic  increase in sepsis lipophillic  increase in obese Required plasma concentration (C p ):MICs Renal function plays NO ROLE in calculation of loading dose McKenzie. Antibiotic dosing in critical illness. J Antimicrob Chemother 2011; 66 Supp 2: ii25 – ii31 LD = V x C p

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22 Antibiotics SEPSIS Increased cardiac output Leaky capillaries Multi-organ failure Increased clearance Increased volume of distribution Decreased clearance Low plasma concentrations High plasma concentrations Adequate initial dosing important Reassess and adjust Roberts J and Lipman J. Pharmacokinetic issues for antibiotics in the critically ill patient. Crit Care Med 2009; 37: 840 – 851.

23 What initial dose would you give? Vancomycin Gentamicin Tazocin

24 McKenzie. Antibiotic dosing in critical illness. J Antimicrob Chemother 2011; 66 Supp 2: ii25 – ii31


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