Sepsis and Septic Shock Treatment in Emergency, Sepsis Treatment Guidelines, Symptoms & Management

okay so today we are going to talk about sepsis and shock a very high yield topic we'll discuss that what is sepsis what is shock what is the difference between them we'll discuss that how do you assess and approach a patient with sepsis we'll discuss that how do you treat both of them we'll discuss that what is shock index first of all what is sepsis sepsis is a life-threatening dysregulated host response to an infection it means that body is carrying an infection normally whenever there is infection in the body body has a regulated response against it a regulated immune response to fight this infection but in the condition of sepsis the host response is disregulated body is confused and the response from the body is also confused in that condition the response of the body instead of killing the microbes is actually damaging the body that is sepsis a dysregulated host response to an infection these patients of sepsis after some time usually go into shock what is shock shock is defined as sepsis with patient requiring vasopressors to maintain mean arterial pressure greater than or equal to 65 mm of energy it means that the body is unable to maintain the blood pressures now the host response is so disregulated that it is unable to maintain the blood pressure when it is unable to maintain the blood pressure it is unable to perfuse the vital organs like brain so the to maintain a normal blood pressure you have to give norepinephrine dopamine from outside if to maintain the blood pressure you have to give vasopressors from outside that is a shock another definition of shock is that sepsis in combination with lactate build up lactate greater than two milli mole per liter despite adequate fluid resuscitation remember that in shock body is unable to maintain the blood pressure when body is unable to maintain the blood pressure body is unable to perfuse the vital organs perfuse the organs of the body whenever whenever there is low perfusion to the organs there is low oxygen delivery to those organs low oxygen delivery to those organs will make the cells go into anaerobic respiration and in aerobic respiration produces acids like lactic acid in blood so whenever there is low perfusion there is lack of delivery of oxygen to the organs and those organs and those cells go into anaerobic respiration and that anaerobic respiration produces lactic acid and there is buildup of lactate in the blood you give fluids from outside to maintain the blood pressure but still there is lactate buildup that is called as shock so sepsis is a dysregulated host response to an infection but in shock the patient is unable to maintain the blood pressure in the presence of sepsis so that is the definition of sepsis and shock now whenever a patient presents to you and you think that that patient is in sepsis the first thing you should look for is the signs of infection the sources of infection look for productive cuff look for offensive oozing wound look for burning maturation if that patient is having any one of these signs or symptoms it means there is source of infection and that source of infection can lead to dysregulated response from the body leading to sepsis have low threshold for sepsis how will you have low threshold for sepsis early recognition of sepsis is very important why because early treatment produces much more better results every r delay in the treatment of sepsis will increase mortality so early recognition and early treatment of sepsis is very important have low threshold for assessing sepsis if the patient all of a sudden develops cognitive impair or communication difficulties or the patient is delirious usually the old patient who all of a sudden totally get altered in time place and person they usually are in sepsis and they have an infection source patients who are immunocompromised chemotherapy patients iv drug users these are immunosuppressed patients they can easily get infection and go into sepsis have low threshold for them patients who had surgery patients who are pregnant or who give birth have low threshold because they have been operated these are the patients who have been exposed to bacteria and have a high risk of going into sepsis in dwelling lines these iv lines if they're they are in place for a longer period of time can get infected with steroids or any foreign material like tampons or anything in the body can lead to sepsis a source of infection after assessing a patient with sepsis take detailed history and perform detailed examination in examination look for capillary refill time the capillary refill time in these patients will be delayed why because there is lack of profusion to the organs the body is unable to maintain blood pressure therefore the capillary refill time will be delayed and look for mottled ashen skin this is a picture showing mottled ash and skin due to lack of perfusion to the organs look for the conscious level these patients will be altered they will be arted in time placed in person localized infection look for infection wounds hidden by dressings bed sores iv lines and check the vitals check heart rate blood pressure saturation temperature to ecg urine output monitoring is very important now on the basis of these vitals we will classify the patient that whether that patient is in high risk category whether that patient is in a moderate risk category or that patient is in low risk category these are the vitals that we base our classification upon we assess the risk and we classify the patient now what are the patients who are in high risk criteria high risk criteria include that if the patient has evidence of altered mental status if the respiratory rate is high greater than 24 usually these patients are having acidosis because of the lactate buildup and what what it tries to do to compensate is to increase the respiratory drive to wash out carbon dioxide carbon dioxide is an acid so they wash out carbon dioxide and therefore respiratory rate is high new requirement of fio2 greater than 40 to keep saturation above 92 percent to maintain the saturation above 92 you have to give oxygen to these patients systolic blood pressure less than 90 that is a very important point patients having systolic blood pressure less than 90 mm of energy are in a higher risk criteria heart rate greater than 130 is a high risk criteria urine output nil for 18 hours or 0 less than 0.5 ml per kg if the patient is categorized it means that the urine output is very low why urine output is very low because the perfusion to the kidneys is low because the blood pressure is low because the patient is in shock so that is a high risk criteria mottled ash and cyanotic skin as i showed you in the previous picture coming to the moderate to highest criteria moderate to high risk criteria will not have a full evidence of altered mental status but there will be a deterioration of the functional status of the patient maybe that patient was walking around and now that patient is better hidden there is a deterioration in the functional status respiratory rate of 21 to 24 as compared to greater than 24 in the highest rigers and hypothermia because the body is not being perfused so that patient is kind of getting hypothermia systolic blood pressure between 91 to 100 compare it with the highest criteria where it was less than 90 heart rate of 91 to 130 bits per minute or many neural urine output nil for 12 to 18 hours 0.5 to 0.1 ml per kg per hour if the patient is categorized recent surgery or immunosuppression these are the risk moderate to high risk criteria and that one is a high risk criteria if any one of the high risk criteria is present that patient is a high risk patient or if the two of the moderate to high risk criterias are present that patient is also a high risk patient now try to understand this point if a patient fulfills one of the highest criteria that patient is a high risk patient or if the patient fulfills two of the moderate to high risk criteria points that patient is also put into high risk category now what are the patients who are moderate to high risk patients these are the patients who fulfill one of the moderate to high risk criteria points and low risks are the one who do not fulfill any of those points now if the patient is high risk or moderate to high risk you send investigations send serial arterial blood gases or venous blood cases send blood culture send electrolytes send inflammatory markers like crp blood clotting profiles cbc lft rft lfd's rfts to see organ perfusion usually these patients have low perfusion to the vital organs and therefore they are going into organ failure due to shock source directed labs must be taken like acetic tab to see the bacteria in that wound culture sputum or urine culture wherever you can find the source of infection look for that source detect that organism and kill it now coming to a very high yield topic shock index sometime it happens that you have a patient and in that patient you are suspecting that that patient might go into shock but that patient is having a normal blood pressure how would you know that this patient is a high risk patient who can go into shock after some time for that patient you calculate shock index now how do you calculate shock index basically whenever the body is going into shock the compensatory mechanisms of the body are activated compensatory mechanisms include increased heart rate when the when the organs are not being perfused properly the heart rate increases and body tries to vasoconstrict these vessels these are actually the last ditch responses of the body now body tries to increase the systemic vascular resistance by ways of constricting the vessels and increasing the heart rate now what you do is that you calculate shock index by taking the heart rate in the numerator and systolic blood pressure in the denominator if the patient is having increased heart rate you will get a value of greater than 0.9 even if the blood pressure is normal the heart rate will be high and if the patient is having a heart rate and you calculate shock index and that shock index is greater than 0.9 it means that after that some time this patient might go into shock this patient is highly susceptible to go into shock that is shock index now coming to the treatment of sepsis the most important thing in the treatment of sepsis is giving antibiotics usually when we start the treatment we do not know about the exact organisms because blood cultures are urine culture or the wounds swap that takes time so we start empiric therapy and we plan the impaired therapy such that we cover gram positive organisms including mrsa gram negative organism including the highly resistant life pseudomonas e coli and also in aerobes and we cover them by giving third generations fellows pouring like cephotexine separates beam cephtrioxone they can recover the gram positives gram negatives can be covered by gender myosin any ropes cover can be covered by metronidazole so these are all the antimicrobials that can be used in the empiric therapy of sepsis other drugs that can be used are parceling tazo back them imipan and miropenum these can be used in imperial therapy and it is important to give antibiotics within three hours of presentation before even the labs are packed start the impaired therapy every one hour delay in the start of the treatment with antibiotics increases mortality by 7.6 percent that's why i was stressing on the point that early recognition and early treatment of sepsis is very important now coming to the fluids if the systolic blood pressure is less than 90 or lactate is greater than 2 you give 500 ml bolus of normal saline 0.9 over 15 minutes if the systolic blood pressure is less than 90 give bolus fluid 5 and 500 ml over 15 minutes and if there is no improvement after two boluses then you should inform your seniors then you should consider use of vasopressors and ionotropes with suppressors like nor epinephrine dopamine norepinephrine decreases arrhythmia and it decreases mortality dopamine and norepinephrine combination is a suppressor of choice in septic shock as i said that in septic shock the main problem is that body is unable to maintain the blood pressure so so to maintain the blood pressure you have to give the vessel pressures and what you can do is that rather increasing the dose of norepinephrine you can add vessel present to it give oxygen if the saturation of oxygen is less than 92 percent go for a target of 94 to 98 percent if the patient has copd give 88 to 92 percent oxygen why to give less oxygen in copd patients i have talked about it in detail in my video on copd exacerbation treatment the link of that video is in the description below steroids steroids can be considered in the patients who have refractory shock there is a patient in which you are giving fluids you are giving escalating doses of vessel pressures but that patient is unable to maintain the blood pressure such patients are eligible for steroids you can give hydrocortisone you can give fluid records on fluid cortisone is a mineralocarticide it will help maintain the blood pressure both of them are steroids and they decrease mortality and such patients who are having refractory shock on escalating doses over suppressors and not responding to it these patients must be given steroids and as i said that the lack of perfusion damages all the vital organs in the body body can go into acute kidney injury kidney damage due to lack of perfusion tic respiratory distress syndrome excessive pumping and the heart increase heart rate can lead to arrhythmias so you have to manage these acute complications but but the giving fluids giving antibiotics giving vasopressors correcting the perfusion correcting the blood pressure usually corrects all these complications in short in summary we talked about what is sepsis what is shock we talked about how to assess the patient we talked about high risk criteria moderate risk criteria you assess the risk you send the labs and then you calculate shock index in the patient who are having normal blood pressure but you are suspecting that that patient will go into shock you give treatment with antibiotics you give fluids you give vasopressor you give oxygen you give steroids and you manage the acute complications if you liked my video please click on the subscribe button and check out my other videos on emergency medicine the link of those videos is given in the description below thank you very much

Channel: MedNerd - Dr. Waqas Fazal

Views: 112,786

Keywords: sepsis infection, sepsis nursing, sepsis symptoms, sepsis treatment, sepsis treatment guidelines 2018, septic shock, septic shock nursing, septic shock treatment, septic shock management, septic shock management algorithm, sepsis usmle, sepsis update 2021, septic shock usmle, sepsis emergency medicine, emergency medicine, how to treat sepsis, how to treat septic shock, sepsis shock, sepsis shock nursing, sepsis and septic shock, sepsis and septic shock nursing

Id: QyZ9KMZREJo

Length: 15min 6sec (906 seconds)

Published: Sat Jan 08 2022