Early goal directed therapy in the treatment of sepsis Nouf Y.Akeel General surgery demonstrator Saudi board trainee R3

Introduction Case presentation EGDT Review Summery

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13 y/o male patient known to have IDDM presented to ER with 3-day history of abdominal pain. Hx of vomiting and fever.

He was confused T HR 130 RR 24 BP 77/50 Abdomen on examination was distended and rigid WBC 17,OOO Hb 11 HCT 31 PLT 251 Na 134 K 4.1 Ur 7 Cr 119

How to manage this patient?

EGDT This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with an increased oxygen demand

I. Fluid therapy Crystalloids vs colloids (no difference in the mortality) CVP 8-12 mmHg Fluid challenge: *infusion of crystalloids boluses of 20ml/kg over5-10 min (up to 3 boluses) *1L of crystalloids or ml of colloids over 30min

I. Fluid therapy Reduce the rate of fluid administration if there is sign of adequate cardiac filling with no hemodynamic improvement

II. Vasopressors MAP mmHg Start with Dopamine or nor epinephrine (centrally) Insert A-line for continues monitoring Low-dose dopamine doesn’t protect the kidneys!

III. ScvO2 monitoring ScvO2 > 70% DO2=CO X 1.34 X Hb X SaO2 X 10

These benefits arise from the early identification of patients at high risk for cardiovascular collapse and from early therapeutic intervention to restore a balance between oxygen delivery and oxygen demand.

Review

EGDT results in significant reductions in morbidity, mortality, vasopressor use, and health-care resource consumption Mortality reduction at 28-d is 16%

49.2% 33.3% Standard Therapy N=133 EGDT N=130 P = 0.01* Early Goal-Directed Therapy Results: 28 Day Mortality NEJM 2001;345: Mortality

Initial resuscitation Diagnosis Antibiotic therapy Source control Fluid therapy Vasopressors Inotropic therapy Corticosteroids rhAPC Blood products administration Mechanical ventilation (ARDS/ALI) Sedation, analgesia, and neuromuscular blockade Glucose control Renal replacement Bicarbonate therapy DVT prophylaxis Stress ulcer prophylaxix Consideration for limitation of support

Summery Approach targeted on the first 6 hours of care in the emergency department and ICU. Focuses on 1.adequate fluid replacement 2.vasopressors 3.optimizing oxygen delivery