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Severe Sepsis Resuscitation Protocol: Invasive WHO
Severe Sepsis Resuscitation Protocol: Invasive WHO
SepticPatientwithLactate4mmol/LorMAP<65after2literscrystalloid AND Goalsofcarearecurative Administer2030ml/kgisotoniccrystalloidbolusover20minutes Sendculturesofalllikelysourcesofinfection Thinkofsourcecontrol(Infectedcatheter?Operativeinterventionforinfection?Drainablepus?) Administerantibioticstocoveralllikelysourcesofinfection PlacefullsterilecentrallineintheIJ(preferablywithultrasound)orsubclavianvein IfpatientsO2saturationis<90%onhighfiO supplementaloxygen(nonrebreathermask),consider:
2
SpO2
Intubation(Beware,thepatientmaydroptheirbloodpressureprecipitously) Placeonlungprotectiveventilation Placeonpaincontrolregimen,administersedationafterpaincontrolled Choose1Strategy DynamicIVCUltrasoundKeepgiving5001000mlbolusesofisotoniccrystalloiduntilthereis<30% changeinIVCsizeifnotintubatedor>12%ifintubated. CVPAdministerfluidsuntilCVP>10mmHginnonintubatedpatientsand>14mmHginintubated patients. EmpiricFluidLoadingPatientswithseveresepsis/septicshockmayrequireatleast6litersoffluid duringtheiracuteresuscitation(first6hoursofcare). IfMAPis<65afteradequatefluidloading,startvasopressors. TitratevasopressorstoachieveaMAP65.
FLUIDS
RECHECKING MAP
TISSUE OXYGENATION
DISPOSITION
SendrepeatlactateANDScvO2 Iflactatehasclearedby10%ANDScvO270%,gotodisposition IfScvO2<70ORlactatehasntclearedby10%,choose1Option: IfHb<7:transfuse1unitofPRBC or AdditionalFluids:ifusingCVPtodeterminefluidstatus,administeranadditionalliterof isotoniccrystalloid or Inotropes:especiallyifheartappearshypodynamiconecho.Ifcalciumislow,repletethat first.Ifnot,administerdobutamine520mcg/kg/min. or Intubate:todecreasepulmonarymetabolicload or IfHb710:considertransfusion.Especiallyinelderlypatientsorpatientswithcoronary arterydisease SendrepeatlactateandScvO2.IfScvO2<70oriflactatestillhasnotclearedby10%,continue withtheabove,trendinglactatesandScvO2every1houruntilthesetwogoalsaremet. PatientsshouldgetICUconsultation.IfnotanICUcandidate,shouldgotoappropriatelymonitored bed. PeriodicallyrecheckpatientforMAP65,goodmentalstatus,andgoodurineoutput. ConsidertrendinglactateeveryQ24hours.Ifitstartsrisingagain,restartprotocol.
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