Sepsis course II.The debt which can kill Zsolt Molnr

SZTE, AITI

40 year old femaleDrug overdose: 20 tbl antipsychotic drugAmbulance PsychiatryGastric lavageIn a few hours: acute abdominal painSurgeryPerforated stomach 4th postoperative dayDeterioration acute abdomen?ICU callCase

Why do patients get into trouble?

The debtDO2= (SVP) (Hb1.39SaO2+0.003PaO2) ~ 1000ml/p (SaO2=100%)

VO2 = CO (CaO2 - CvO2) ~ 250 ml/p (ScvO2~70-75%)

COCaO2

The debtDO2= (SVP) (Hb1.39SaO2+0.003PaO2) ~ 1000ml/m (SaO2=100%)

VO2 = CO (CaO2 - CvO2) ~ 250 ml/m (ScvO2~70-75%)In critical illness:

Sokk = VO2>DO2

VO2DO2COCaO2

On arrival 02.10, 12:00Sleepy, looks poorlySweaty skinTachypnoePeripheral cynosisTreatment: 22G (blue) canule + LRFirst actions:1 Thorough physical examination2 Oxygen + venous access + fluid3 Immediate abd. X-ray/CT4 Immediate surgery

X-rayFree air under the diaphragmDg: suture breakdown acute laparotomyThers no free theatreICU On mask: SpO2 = 92%, resp. rate = ~30/min500 ml colloid: HR = 130/m, BP = 75/35 Hgmm

12:15Which algorhythm would you choose?1 CVP fluid vasopressor - anaesth/ET2 Vasopressor art. line anaesth/ET CVP3 Anaesth/ET art. line CVP vasopressor

Int. jugular vein

Subclavian vein

Femoral veinCentral linesMolnr 99

Central venous catheter setMolnr 99

Seldingers techniqueMolnr 99

Int. jug. vein punctureMolnr 99

X-rayFree air under the diaphragmDg: suture breakdown acute laparotomyThers no free theatreICU On mask: SpO2 = 92%, resp. rate = ~30/min500 ml colloid: HR = 130/m, BP = 75/35 Hgmm

12:15Which algorhythm would you choose?1 CVP fluid vasopressor - anaesth/ET2 Vasopressor art. line anaesth/ET CVP3 Anaesth/ET art. line CVP vasopressor

X-rayFree air under the diaphragmDg: suture breakdown acute laparotomyThers no free theatreICU On mask: SpO2 = 92%, resp. rate = ~30/min500 ml colloid: HR = 130/m, BP = 75/35 HgmmCardio-respiratory stabilisation SurgeryTo continued

12:15

Examples

On assessment (cardiac arrest call)Midle aged man, after lung surgeryFew minutes CPRICUHistoryAge: 58 yearsComplaints: Lobectomy 4 days agoSputum retentionBronchoscopy What happened?Svere hypoxia

1. case

The debtDO2= (SVP) (Hb1.39SaO2+0.003PaO2) ~ 600ml/m (SaO2=70%)

VO2 = CO (CaO2 - CvO2) ~ 400ml/m (ScvO2~20%)

Possible explanation:There was no monitoringSaO2 DO2 was reduced VO2 increasedWhat should have been done?O2 + SpO2 monitoringIf SpO2 low (~

On assessment on A&E:Elderly femaleSweaty, agitatedLaboured breathing, bubbly noiseHow to proceed?Semi sitting position, O2, venous access, monitoring (SpO2, NIBP, EKG)HistoryAge: 68 yearsHigh BP, IHDComplaints: Difficulty in breathing for a few hoursBP: 195/100 mmHg, HR: 112/min, SpO2 = 88%

2. case

The debtDO2= (SVP) (Hb1.39SaO2+0.003PaO2) ~ 800ml/p (SaO2=88%)

VO2 = CO (CaO2 - CvO2) ~ 400 ml/p (ScvO2~50%)

Possible explanation:Acute LVFReduced myocardial contractility (CO) pulmonary oedema (hypoxia)High systemic vascular resistence (SVR)TreatmentO2 + SpO2 monitoringReducing SVR (afterload): vasodilator (nitroglycerin spray)Pain relief/sedation: morphine i.v. (2-4-... mg)+/- diuretics, positive inotrope treatment

COCaO2

EffectsSpO2=93 %BP: 140/80 mmHg, HR: 100/minDiagnosticsEKG, CXR, blood testsIs there time?Dg: Acute LVFConservative treatment: A&E - Cardiology2. case

Instead of summaryEarly Goal-Directed Therapy (EGDT)Rivers E et al. N Engl J Med 2001; 345: 1368Septic patients treated on A&E for 6 hours:Control group (n=133):O2CVP: 8-12 mmHgMAP >65 mmHg EGDT group (n=130):Same as aboveScvO2 > 70%More fluid, bloodMore dobutamineMortality: 46 vs. 30% (p=0.009)

MottoThe question isnt whether weve made the right decision, but wether weve done everything to make the right decisionDiagnosis can wait, but cells cant!

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