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How should fluid therapy be performed in severe sepsis?
- Crystalloids as the initial ﬂuid of choice
- 30 mL/kg of crystalloids (a portion of this may be albumin equivalent) – More rapid or large amounts as needed
- Avoid hydroxyethyl starches
- Albumin only when patients require substantial amounts of crystalloids
What are the Crystalloid solutions?
- Plasma Lyte A
- Normisol R
If giving a lot of fluids, you might want to avoid NS, why?
May cause non-gap acidosis because of high levels of Cl-
What is the ionic content of NS?
What is the ionic content of LR?
- Na 130 mEq/L
- Cl 109 mEq/L
- K 4 mEq/L
- Ca 3 mEq/L
- Lactate 28 mEq/L
What is the ionic content of Plasmalyte Aand Normisol R?
- Na 140 mEq/L
- K 3 mEq/L
- Cl 98 mEq/L
- Mg 5 mEq/L
- Acetate 27 mEq/L
- Gluconate 23 mEq/L
What are the causes of Normal Saline and Hyperchloremic Metabolic Acidosis (Non-gap)?
- Anion Gap < 10-12 mEq/L
- Ureteral diversion
- Saline infusions
- Exogenous acid
- Carbonic anhydrase inhibitors (acetazolamide)
- Adrenal insufficiency
- Renal tubular acidosis
- (USED CAR)
What are the consequences of Normal Saline and Hyperchloremic Metabolic Acidosis (Non-gap)?
- Immune dysfunction
- GI dysfunction
- Decreased renal blood flow
- Decreased and delayed urine output
- Acute renal failure (sometimes)
Is NS the best choice for sepsis resuscitation?
The use of calcium free balanced crystalloid solution for replacement of fluid losses on day of major surgery was associated with ________postoperative morbidity than 0.9%
______________had improved acid-base status and less hyperchloremia at 24 hours post injury compared to 0.9% NaCl in resuscitation of trauma patients
Plasma Lyte A
The implementation of a __________________in the ICU was associated with a significant decrease in the incidence of AKI and use of RRT
In critically ill patients with sepsis, resuscitation with balanced fluids was associated with _______________.
lower risk of in hospital mortality
Analysis of critically ill patients with traumatic brain injury: fluid resuscitation with albumin was associated with ___________mortality than NS.
Only use albumin for sepsis when ___________________.
You are not getting adequate response from crystalloids
Vasopressor therapy initially to target a mean arterial pressure (MAP) of ___ mm Hg.
What is the ﬁrst choice vasopressor ?
When is Epinephrine added to NE therapy in Sepsis?
Added or potentially substituted for norepinephrine when an additional agent is needed to maintain adequate blood pressure
When is Vasopressin added to NE therapy in sepsis?
0.03 units/minute can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage
______________________________is not recommended as the single initial vasopressor for treatment of sepsis-induced hypotension.
Low dose vasopressin
When should vasopressin doses higher than 0.03-0.04 units/minute be used?
Reserved for salvage therapy (failure to achieve adequate MAP with other vasopressor agents)
Dopamine as an alternative vasopressor agent to norepinephrine only in h patients with low risk of ________________and_________________.
Phenylephrine is not recommended in the treatment of septic shock except in circumstances where:
- NE is associated with serious arrhythmias
- Cardiac output is known to be high
- Blood pressure persistently low
- As salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target
Low-dose dopamine should not be used for ____________________.
All patients requiring vasopressors have an ________________placed as soon as practical if resources are available.
Dobutamine is a ______________add on. Give in presence of _________________________.
- Cardiogenic shock/Mycocardial dysfunction
________________infusion up to _______ micrograms/kg/min can be administered or added to vasopressor (if in use) in the presence of myocardial dysfunction or ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and MAP.
Dobutamine infusion up to 20 micrograms/kg/min
Dobutamine infusion up to 20 micrograms/kg/min can be administered or added to vasopressor (if in use) in the presence of___________________________________, despite achieving adequate intravascular volume and MAP.
Myocardial dysfunction or ongoing signs of hypoperfusion
When fluids, vasopressors and inotropes fail to bring a patient to goal, what therapy can then be tried?
IV hydrocortisone alone at a dose of 200 mg per day
When should hydrocortisone be tapered?
When vasopressors are no longer required