WEBVTT
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Thank you. I am Basic, hosted by me, Dr. Eric
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Acker, and Dr. Tarp, as well as other resident
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physicians. This podcast is directed towards
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PGY1s and medical students to give a brief overview
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of medical topics. This podcast is intended for
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medical professionals and is not intended to
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be used for medical advice. We are going to continue
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our series on shock, and we're going to go down
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the pathway of distributed shock and down a little
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bit further to septic shock. So with septic shock,
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Tarek, we always talk about the presentation
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and the presentation is relatively similar to
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general shock, but like just again, recap as
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much as you can or what's unique to some of the
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presentation symptoms, vital signs, et cetera.
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Septic shock. Sometimes you're going to have
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fever most of the time if they're in septic shock,
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but don't like harp on just having fever. They're
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going to have tachycardia, hypotension. Sometimes
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they're going to have altermental status. Depending
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on where your source of infection is, they might
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have abdominal pain, they might have flank pain,
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depending on your source. There's no set findings
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for these patients. They're tachycardic, febrile,
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altered. They have warm extremities because this
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is part of your distributive shock. At least
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initially they have one. So you're thinking more
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this is septic. They have wide valve pressure,
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low systolic, low diastolic, but diastolic is
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lower. compared to your systolic. The other thing
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I guess I would mention with febrile, because
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some people think, oh, febrile, septic shock,
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there you go. But if they don't have a fever,
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also keep in mind, low temperatures can also
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be considered in this category as well. So not
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always high can be also low. They sometimes don't
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have to be tachycardic. They might be bradycardic,
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normal heart rate, because they're going into
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irreversible stages of shock. So you have to
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think of everything together. I am purposely
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avoiding the definition right now. Try to circle
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back because definition, I think, has a lot to
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do with the labs and whatnot, because I think
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you get this big old workup. You decide that
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it's septic shock. You can plug the labs in and
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they will tell you what stage sepsis one, two,
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three, four, et cetera. And maybe not four. I'm
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not sure four even exists. But I'm avoiding the
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definition at this moment. We will try to circle
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back to that a little bit because it does help
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with the management. But as far as the workup,
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a lot of this is going to be. related to where
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the source of your infection is. If you know
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where it's at, then great, you can go that direction.
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But at least in the initial workup on these patients,
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what kind of things are you grabbing? So you're
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going to have a broad workup. Initially, you're
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getting a CMP, CBC, a lactate. You can get Procal,
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CRP. It's not necessary for treatment. It's just
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something to see, oh, they have severe sepsis.
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I'm putting them on antibiotics. I want to see
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their response. Most of them are going to get
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a chest x -ray because most of them are altered.
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You can't really say, oh, they don't have a chest
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infection or something, but it's not necessary
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in your treatment, but everyone gets a chest
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x -ray. Then you think about what's causing this.
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So depending on what's causing your sepsis or
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septic shock, then you go down the lane. Oh,
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I want to do a CT scan of their head, CT scan
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of their chest. Because I'm thinking they have
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a brain abscess, they have mucormycosis, they
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have lung abscess, empyema, they have severe
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pneumonia. Then I'm doing a CT test to figure
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out what's causing them to be in septic shock
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because that's sounding like a late presentation
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of just infection. Oh, I'm thinking they have
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something intra -abdominal, intra -abdominal
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abscess, peritonitis, or they have liver abscess,
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severe cholecystitis, perforation, whatever.
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Then I'm going to do a CT abdomen. I'm essentially
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going to want to look at the liver. I want to
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do an ultrasound. I want to do... I think this
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is the first time you've almost pan -scanned
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the patient. Yeah, you're going to tailor. Because
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ultrasound, you can do an ultrasound look, but
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it's still not going to give you that picture
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you're going to paint. And then I think along
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with this, procalcitonin plus or minus, I think,
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honestly, it can be used later on for de -escalating
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some of your antibiotics. I think there's some
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literature out there that kind of suggests in
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the first 24 hours, at least on any presentation,
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procalcitonin can be low. It's delayed. So you
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have to think it's delayed. The procal is negative
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at first because it's a range. This number is
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positive. This number is negative. It's a range
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of numbers. You look at less than 0 .5, then
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it... They're less likely to have an infection.
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They will say less likely. It's not a negative
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number because they might have come in an early
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presentation. They just started having fevers.
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Then you have a negative procalcitonin. You're
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not going to say, oh, they have negative procal.
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I'm not going to put them on antibiotics. That
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doesn't work. And then with these patients, obviously
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the physical exam, the history taking is going
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to be paramount. They've had a recent surgery,
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hardware place, lines place, ports. You want
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to check all those things out. This patient's
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bed bound or they're complaining that maybe some
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pain in the groin if they're altered and they're
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not complaining you don't have a source you should
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start looking for things like necrotizing fasciitis
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it's never necessarily top of our list as medical
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professionals to check out the groin area of
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our patients. But this might be one of those
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situations where doing that could pay off with
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finding that crash. And that will lead you down
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a pathway where you can emergently ask your friendly
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general surgeon to come in at two o 'clock in
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the morning to operate on this patient. But that
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could save that patient's life as opposed to
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finding out maybe 24 hours later when the patient
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finally gets to the unit and the nurse does a
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full skin exam and says, hey, this doesn't look
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right. Now you've missed a little bit of your
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window to intervene on a patient. So if you're
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not finding an immediate source that explains
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why this patient's febrile, they're in this shock
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state, try to expand out and look for all different
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things that could be helping to explain. Also,
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look at the medical medication history as well,
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because sometimes there's mimics of septic shock,
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which we'll get into a little bit later. And
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then, of course, if you're thinking. meningitis,
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then go ahead and try to get an LP on these patients.
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As an intern, as a medical student, it might
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be a little bit rarer. Your ED residents might
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have already beat you to that. Other things they
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throw into the mix is some coags, look for platelets,
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fibrinogen, PT -INR, this source I was looking
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at. mentions D -dimer, I think in the year of
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post -COVID, the D -dimer is a dangerous lab
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to order. Yeah, everyone gets a D -dimer if they're
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thinking P -E. If you're thinking P -E just for
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the CTA, D -dimer is going to be high. D -dimer
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is just to justify it. You want to get that CTA.
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This is a completely aside from separation. You
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want to get that CTA. You just want a D -dimer
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to tell you that it's okay to do it. So we initiated
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their treatment, or at least a workout. There's
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a few different mainstays of treating septic
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shock. Obviously, they're treating the underlying
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cause, so the infection. So we have the antibiotics.
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We have the resuscitation. We have keeping the
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MAP above 65, ideally, and then protecting the
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MAP, yes. So then for that, we have our pressors
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and we have fluids, which is going to be a more
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relatively controversial thing, but at least
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in the initial workup. I know there's some guidelines
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that Tarek wants to talk about. The problem with
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fluid resuscitation is that you have to think
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about it's not a shoe that fits all, right? You
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have to individualize how much fluid each patient
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gets. I know a surviving sepsis campaign says
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30 ml per kg is ideal body weight. You have to
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remember it's ideal, it's not total body weight.
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It's like you have a 300 -pound patient and you're
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just going to give them... Nine liters of fluid,
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because that's what the guidelines say. It's
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everything is taken into consideration. Like
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heart failure, this is their ideal body weight.
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You want to reach euvolemic state. That's your
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goal. So previously, like you go read the guidelines,
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surviving sepsis is 30 ml per case in the first
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90 minutes. So you have to be in that window
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for 90 minutes. That's where the benefit was
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seen. That's where the mortality benefit was
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seen. That's where everything, 90 minutes. Then
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the emergency medicine team said, no, your guys
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are saying 30 ml per kick for everyone. That's
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not how it works. Yeah, we have seen complications.
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That's true. Because if you give everyone 30
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ml for the patient that has an EF of 10%, they're
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having great heart failure, they have pulmonary
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hypertension, without knowing what's going on
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behind this, you see mortality. We're going to
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start a multifactorial shock. We have a septic
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shock, we have a cardiogenic shock. Yeah, it's
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hard because, like, I've seen patients that have
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septic shock. They have right -sided heart failure,
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and they get the 30 milliliters per kg. And nobody
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says it's ideal, it's not total. And they give
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them four liters, and their RV just gives up.
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And you have a whole other complication. This
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is the guideline. This is the CMS. Every hospital,
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EED, is going to say 30 milliliters per kg bolus.
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You get a lactate. You initiate antibiotics for
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90 minutes and then you reassess three hours
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and then you either repeat that, you start pressors.
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This is the series of steps I think most hospitals
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follow. I'm going to throw just a little bit
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of controversy into the mix. I know this is generally
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an educational thing. My take is that septic
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shock is a maldistribution. Blood to different
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organ systems is a maldistributed hallmark of
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low diastolic pressure. So you have very poor
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vascular resistance, leaky capillaries. Leaky
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vessels. And so the idea that just throwing fluid
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at these patients is going to somehow improve
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the blood pressure is, I think, dubious a little
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bit. It's definitely something that can show
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improved mortality after hospitalization compared
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to more liberal uses of fluid. At least 30 milliliters
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per kilogram tends to show. reasonable good results,
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but fluid doesn't always equate to good perfusion.
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And the other thing I want to, I guess, bring
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up to this is that oxygen delivery to tissue
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is another issue that we're dealing with, with
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organ malperfusion. These organs aren't getting
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perfused very good. What they need is oxygen.
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And so what you're doing is you're giving this
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crystalloid, let's say you're giving a liter.
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Well, your body has about six, about six liters.
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blood in. So you give another liter, you've just
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diluted your blood hemoglobin content by one
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sec. You do that again and you do that again.
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So your hemoglobin is going down. So the oxygen
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delivery to tissue equation is like a constant
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times cardiac output times hemoglobin times O2
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saturation. So if your O2 saturation is good,
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cardiac output, maybe it improves with some fluid.
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Your constant, of course, is constant, but your
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hemoglobin now is going down because you diluted
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it. Your oxygen delivery is also not particularly
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great either. So I'm not Not saying don't give
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the fluid, but just think about it. Everything
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has to be in balance because too much fluid.
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Think it was in the trauma patients that have
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to do resuscitation. You're resuscitating them
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with fluid, but that puts them at a higher risk
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of DIC. That's why we're later on going to talk
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about this and hemorrhagic shock and everything.
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You think about giving fluids. how much is too
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much and how little is too little there's no
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this is enough for everyone that there's nothing
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like that okay you have to balance everything
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depending your patient their volume size you
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have to follow up repeat do ultrasound get your
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ivc get your volume status check it They're obviously
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still collapsed or they start having to have
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B lines in their lungs. My fluid is not staying.
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So maybe I should give them protein. There's
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a lot of different stuff to think about before
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deciding. I'm just going to keep bolusing these
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patients a liter at a time and see when you start
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reaching that five liters, maybe start thinking
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this is not working for this patient. Maybe it
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needs pressers. Maybe your intensivist should
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be. And sometimes depending on where you're at,
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your intensivist may want to see that you've
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given it the old college try on the fluids. But
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just try to keep that in the back of your mind.
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We're going to shift to the sepsis criterias
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and the definitions, which I think will help
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guide maybe when you do reach out to. Let's go
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ahead and shift into that. So you got the sofas.
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Yeah. So based on what I read, the most recent
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sepsis criteria is sepsis 3 .0. Talks about sepsis,
00:12:49.019 --> 00:12:51.720
not just by their tachycardia, because every
00:12:51.720 --> 00:12:55.120
billing system is depending on the SIRS criteria.
00:12:55.240 --> 00:12:59.139
They have three of the above, tachycardia, tachypnea,
00:12:59.519 --> 00:13:03.519
altered mental status, fever, hypothermia, leukocytosis,
00:13:03.799 --> 00:13:06.679
leukopenia. That's essentially what SIRS criteria
00:13:06.679 --> 00:13:09.379
is. Has SIRS criteria should benefit in diagnosing
00:13:09.379 --> 00:13:12.179
or early management of these patients? I don't
00:13:12.179 --> 00:13:14.259
think so. I haven't read anything. Eric can correct
00:13:14.259 --> 00:13:16.669
me if I'm wrong, but. The last guidelines of
00:13:16.669 --> 00:13:20.669
sepsis 3 .0 definition is like sepsis is equal
00:13:20.669 --> 00:13:23.549
to end organ damage. And the way to look at end
00:13:23.549 --> 00:13:26.389
organ damage is to do the SOFA score for these
00:13:26.389 --> 00:13:28.690
patients. And they don't just say do SOFA score
00:13:28.690 --> 00:13:31.610
on admission. It's like it's a constant revision
00:13:31.610 --> 00:13:34.470
of that SOFA score to say they're having end
00:13:34.470 --> 00:13:36.789
organ damage. Their SOFA score is more than two.
00:13:36.909 --> 00:13:40.639
So they have sepsis with a likely source. You
00:13:40.639 --> 00:13:43.080
remeasure everything. You remeasure it in 48
00:13:43.080 --> 00:13:45.220
hours to see, oh, their SOFA score is dropping
00:13:45.220 --> 00:13:47.379
down by two. Then I'm going in the right direction.
00:13:47.620 --> 00:13:51.460
So antibiotics is working. Their volume is okay.
00:13:51.740 --> 00:13:54.059
Their oxygen is okay. They're not having any
00:13:54.059 --> 00:13:56.340
more end organ damage, essentially. No, their
00:13:56.340 --> 00:13:58.879
SOFA score is going up. Then I'm doing something
00:13:58.879 --> 00:14:01.419
wrong. This gives you an idea. I need to look
00:14:01.419 --> 00:14:03.399
at everything again. They're having end organ
00:14:03.399 --> 00:14:05.899
damage for some reason. Am I giving them too
00:14:05.899 --> 00:14:08.019
much fluid? They went into pulmonary edema and
00:14:08.019 --> 00:14:10.460
that's why their oxygen is low. Their MAP is
00:14:10.460 --> 00:14:13.179
low. Do I need them to be on pressers? Do I need
00:14:13.179 --> 00:14:15.559
to call the ICU? It's giving you that leeway
00:14:15.559 --> 00:14:18.940
to think about reaching out to other specialties,
00:14:18.940 --> 00:14:21.659
to think about revising your management. And
00:14:21.659 --> 00:14:24.259
so this is where you get the sepsis 2 and the
00:14:24.259 --> 00:14:27.759
sepsis 3 criteria there. So you can look at MD
00:14:27.759 --> 00:14:30.889
-Calc. They have a QSOFA score, which is a little
00:14:30.889 --> 00:14:33.590
bit more of a reduced amount of data you have
00:14:33.590 --> 00:14:36.350
to input, whereas the SOFA score has a lot more
00:14:36.350 --> 00:14:39.370
data you can input. And again, it's also if you're
00:14:39.370 --> 00:14:41.049
practicing for a little while, you can see how
00:14:41.049 --> 00:14:43.809
some of these lab values change and correlate
00:14:43.809 --> 00:14:45.850
to the clinical picture and direction of the
00:14:45.850 --> 00:14:48.110
patient. So it's just a nice way of quantifying
00:14:48.110 --> 00:14:51.570
it. I think it's relatively validated. And so
00:14:51.570 --> 00:14:53.409
then that's a nice little thing you can get and
00:14:53.409 --> 00:14:55.230
go to your friendly intensivist and say, hey,
00:14:55.250 --> 00:14:57.309
I've been doing this X, Y and Z. They're not
00:14:57.309 --> 00:14:58.960
getting better. Looks like they're getting worse.
00:14:59.159 --> 00:15:01.559
I feel like they might need some pressure support.
00:15:01.740 --> 00:15:03.340
They might need intensive care. They might need
00:15:03.340 --> 00:15:05.659
escalation of care. And you get more specialists
00:15:05.659 --> 00:15:08.279
on board if you need them. It helps with your
00:15:08.279 --> 00:15:10.039
definition as well. Now we've covered definition.
00:15:10.320 --> 00:15:13.179
So I guess the next level I'm going to go, since
00:15:13.179 --> 00:15:15.419
we were talking about protecting the map. Let's
00:15:15.419 --> 00:15:17.080
go ahead and stay on that course for a second.
00:15:17.139 --> 00:15:19.620
We'll get to, I think, the real foundation of
00:15:19.620 --> 00:15:22.159
this, which is antibiotics. But let's go ahead
00:15:22.159 --> 00:15:24.919
and continue with pressers. We've talked about
00:15:24.919 --> 00:15:27.740
these in the past on the cardiogenic, but obviously
00:15:27.740 --> 00:15:30.399
now we're on a kind of a different shock. So
00:15:30.399 --> 00:15:32.700
we need to think about presser support and what
00:15:32.700 --> 00:15:35.179
that means for our patients. What's your go -to
00:15:35.179 --> 00:15:38.120
or what kind of ones can you go for? Sepsis.
00:15:38.559 --> 00:15:42.879
is equal to levophed. He's a levophed guy. Because
00:15:42.879 --> 00:15:45.480
you have to think about what's the main thing
00:15:45.480 --> 00:15:47.840
that's causing your patients to go into septic
00:15:47.840 --> 00:15:51.059
shock. Their SVR is gone because they're vasodilated
00:15:51.059 --> 00:15:54.179
everywhere. So the first thing that's going to
00:15:54.179 --> 00:15:56.500
help with this is your levophed. They compared,
00:15:56.639 --> 00:15:58.700
I think there was a trial comparing levophed
00:15:58.700 --> 00:16:02.039
to adrenaline because they both help with SVR.
00:16:02.080 --> 00:16:04.100
They found that levophed had a better outcome.
00:16:04.379 --> 00:16:07.480
So levophed is your go -to. It changed a lot.
00:16:07.600 --> 00:16:09.899
Previously, levophed was the last line because
00:16:09.899 --> 00:16:11.919
you're putting this patient on levophed after
00:16:11.919 --> 00:16:14.039
trying Hepis when you put them on diputamine
00:16:14.039 --> 00:16:16.139
because their chronic alpha is gone and you still
00:16:16.139 --> 00:16:18.480
haven't gotten anywhere. So it's the fourth.
00:16:18.679 --> 00:16:21.759
Now it changed. I've read other literature. or
00:16:21.759 --> 00:16:24.399
other resources that levophed tends to be the
00:16:24.399 --> 00:16:27.059
mainstay. We can get into dosing of levophed
00:16:27.059 --> 00:16:29.059
because I think dosing that we've talked about
00:16:29.059 --> 00:16:31.879
in the past is dosing of levophed does change
00:16:31.879 --> 00:16:35.259
from inotrophic to oppressor. There's also other
00:16:35.259 --> 00:16:37.480
studies that kind of do suggest that vasopressin
00:16:37.480 --> 00:16:39.639
could be first line as well. And there's like
00:16:39.639 --> 00:16:41.559
the VANISH trial, I think that mentions that
00:16:41.559 --> 00:16:46.460
vasopressin is okay. It's still playing on the
00:16:46.460 --> 00:16:49.600
same idea that I need something to increase my
00:16:49.600 --> 00:16:52.460
SVR, essentially. You're getting good outcome
00:16:52.460 --> 00:16:55.659
with the levophan because it has some eunotropic
00:16:55.659 --> 00:16:57.679
effect. That's how I think about it. If you're
00:16:57.679 --> 00:17:00.320
facing this tachycardic and you're afraid that
00:17:00.320 --> 00:17:03.200
they're still going to go into more tachyarrhythmia,
00:17:03.299 --> 00:17:05.799
you can think about vaso, but... Mostly, you're
00:17:05.799 --> 00:17:07.500
having that tachycardia because you're having
00:17:07.500 --> 00:17:09.339
hypop. That's how I think about it. I try and
00:17:09.339 --> 00:17:11.539
go oligophyte first. See how they do. If I'm
00:17:11.539 --> 00:17:13.900
escalating too fast, think about adding something
00:17:13.900 --> 00:17:16.119
else. Are you starting on the low -dose Levo?
00:17:16.200 --> 00:17:19.200
Are you moving towards the medium or higher doses?
00:17:19.619 --> 00:17:21.579
I'm moving towards the medium. I like staying
00:17:21.579 --> 00:17:23.599
in the medium dose. I don't like going high dose
00:17:23.599 --> 00:17:26.180
because on a high dose, you're going to have...
00:17:26.180 --> 00:17:29.160
Extra chronotrophy on top of the thing. You're
00:17:29.160 --> 00:17:31.000
going to have the tachycardia. You're going to
00:17:31.000 --> 00:17:33.180
have blemish skin because you're affecting the
00:17:33.180 --> 00:17:35.279
capillary perfusion. you're going to have severe
00:17:35.279 --> 00:17:37.920
ischemia up to the dry gangrene. I've seen that
00:17:37.920 --> 00:17:40.700
happen before, starting at a low dose of escalating,
00:17:40.700 --> 00:17:43.380
then I'm starting to go at a medium dose. I'm
00:17:43.380 --> 00:17:45.460
thinking about adding something else to help
00:17:45.460 --> 00:17:48.079
me. I'm not going to keep bumping up that levophed.
00:17:48.279 --> 00:17:50.740
That's the only one I have. No, you have a lot
00:17:50.740 --> 00:17:52.640
of other medications to help along. You have
00:17:52.640 --> 00:17:56.309
the vaso, you have the epi. We can add steroids.
00:17:56.630 --> 00:17:58.910
You have phenylephrine as well. Phenylephrine.
00:17:58.930 --> 00:18:01.029
You have a lot of other options. I think CAT
00:18:01.029 --> 00:18:03.930
trial indicates that epinephrine can also be
00:18:03.930 --> 00:18:06.369
considered. I think it was non -inferior to the
00:18:06.369 --> 00:18:09.380
norepinephrine. It's not in sheer, but... But
00:18:09.380 --> 00:18:11.759
there was a resource I was reading about how
00:18:11.759 --> 00:18:14.079
if you were pressing the patient, you're working
00:18:14.079 --> 00:18:15.980
on getting the blood pressure up, and let's say
00:18:15.980 --> 00:18:18.599
you're on norepinephrine, you're on vasopressin,
00:18:18.599 --> 00:18:21.119
and maybe you check on the heart, and the heart's
00:18:21.119 --> 00:18:23.099
just not squeezing quite the way you want. This
00:18:23.099 --> 00:18:24.700
is going a little bit back to the cardiogenic
00:18:24.700 --> 00:18:27.480
side of things. Epinephrine can be really great
00:18:27.480 --> 00:18:30.380
for that inotrophic support at low doses. So
00:18:30.380 --> 00:18:32.619
you have to remember that some of these patients
00:18:32.619 --> 00:18:35.289
are not going to be isolated. If you have severe
00:18:35.289 --> 00:18:37.910
sepsis, you have end organ damage. Heart is one
00:18:37.910 --> 00:18:40.769
of the organs. So you might have myocardial ischemia.
00:18:40.910 --> 00:18:43.109
You might have stunning of myocardium. You might
00:18:43.109 --> 00:18:45.490
have tachycephalus on top of everything. So it's
00:18:45.490 --> 00:18:47.529
not, I'm going to try this. And this is what
00:18:47.529 --> 00:18:49.789
the guidelines, there's no, I don't think I've
00:18:49.789 --> 00:18:52.809
read anyone that say you go through norepi first.
00:18:52.990 --> 00:18:55.920
That fails. You add this, you do this. I don't
00:18:55.920 --> 00:18:57.940
think I've seen anything like that. And again,
00:18:58.000 --> 00:19:00.059
this goes back to the art of medicine. You add
00:19:00.059 --> 00:19:03.279
things on, you can start taking things off. Sometimes
00:19:03.279 --> 00:19:05.900
you're on high dose norepinephrine, you're on
00:19:05.900 --> 00:19:08.259
vasopressin and pheninephrine. You can go down
00:19:08.259 --> 00:19:11.160
on the LevoFed and find that it has no difference.
00:19:11.940 --> 00:19:13.980
You have the LevoFed and you're still having
00:19:13.980 --> 00:19:16.819
the same benefits. So just a little bit of art.
00:19:16.900 --> 00:19:19.039
There are medications, there are oppressors that
00:19:19.039 --> 00:19:21.799
you want to avoid. Which ones? You have the dirty
00:19:21.799 --> 00:19:23.700
dope. Yeah, dopamine. We're going to hate on
00:19:23.700 --> 00:19:26.200
dopamine a lot. Yeah. There's really no good
00:19:26.200 --> 00:19:28.220
indication for it. There's no indication for
00:19:28.220 --> 00:19:31.140
dopamine in any... I've never seen it used. The
00:19:31.140 --> 00:19:33.700
only time I've seen it used, if it's bradycardia
00:19:33.700 --> 00:19:36.259
-induced and not a lot of people use it anymore,
00:19:36.440 --> 00:19:39.559
I'm just going to do epi. Like, let's not go
00:19:39.559 --> 00:19:42.599
down that pathway. Don't use dopamine. The other
00:19:42.599 --> 00:19:46.119
one I think is interesting, dobutamine, I think
00:19:46.119 --> 00:19:48.700
some people do use. I find it interesting because
00:19:48.700 --> 00:19:51.900
it has vasodilatory effect, and that can be problematic
00:19:51.900 --> 00:19:53.759
with a patient who already has vasodilation.
00:19:54.180 --> 00:19:57.759
It's not on its own. I don't think I've ever
00:19:57.759 --> 00:20:01.480
used dobutamine on its own for sepsis, for septic
00:20:01.480 --> 00:20:04.279
shock. You can use it as an add -on, like thinking
00:20:04.279 --> 00:20:07.440
he has a mixed picture of cardiogenic and septic
00:20:07.440 --> 00:20:09.769
shock, so I want to get it. good cardiac output
00:20:09.769 --> 00:20:13.490
and I want to titrate that SVR to a point that
00:20:13.490 --> 00:20:16.049
it's within normal. It's not too high, too low.
00:20:16.210 --> 00:20:19.349
So I always think of it as an add -on or a mixed
00:20:19.349 --> 00:20:21.750
picture that I use. Fair enough. And then, so
00:20:21.750 --> 00:20:23.650
I guess the general takeaway here on the presses
00:20:23.650 --> 00:20:26.289
is levophed is probably going to be your go -to.
00:20:26.410 --> 00:20:28.569
No one's going to fault you for starting levophed.
00:20:28.789 --> 00:20:31.250
You can do vasopressin, you can do epinephrine.
00:20:31.640 --> 00:20:33.880
You can start adding things on as you need things,
00:20:33.940 --> 00:20:36.339
as the blood pressure is allowing or does not
00:20:36.339 --> 00:20:38.960
allow. And then just keep in mind taking things
00:20:38.960 --> 00:20:42.000
off as you don't need them. Let's go to the final
00:20:42.000 --> 00:20:46.539
pillar of our septic shock antibiotics. I think
00:20:46.539 --> 00:20:48.400
I'm going to keep this relatively general because
00:20:48.400 --> 00:20:51.799
there's so many bugs that can cause septic shock.
00:20:52.000 --> 00:20:54.180
You can't really, we can't go into each and every
00:20:54.180 --> 00:20:56.740
one of them. But in a general sense, patients
00:20:56.740 --> 00:20:59.259
coming out of the ED, what would you start them
00:20:59.259 --> 00:21:01.250
on? I'm going to cover everything, right? You
00:21:01.250 --> 00:21:03.589
want to cover your gram positive, gram negative,
00:21:03.630 --> 00:21:05.950
and your MRSA. Essentially, I'm going to put
00:21:05.950 --> 00:21:08.549
them on vancomycin to cover that. Then I'm thinking
00:21:08.549 --> 00:21:10.609
I want to cover everything else. Then I put in
00:21:10.609 --> 00:21:13.289
mind, do they have kidney infection or not? So
00:21:13.289 --> 00:21:15.869
let's say they don't have kidney infection. I'm
00:21:15.869 --> 00:21:18.470
not just going to put them on zosyn and vancomycin
00:21:18.470 --> 00:21:20.289
because you're going to see a lot of kidney damage
00:21:20.289 --> 00:21:23.150
with that. I want to cover pseudomonas. I have
00:21:23.150 --> 00:21:25.470
the option of doing cefepime. It's going to give
00:21:25.470 --> 00:21:29.910
me almost the same coverage as zosyn. I'm thinking
00:21:29.910 --> 00:21:33.009
I want to cover anaerobics. I might add flagell
00:21:33.009 --> 00:21:36.230
on top of it. But I think most of us just do
00:21:36.230 --> 00:21:39.769
cefepime and vancomycin or zosyn vancomycin and
00:21:39.769 --> 00:21:42.910
see how they get out of that first 24 hours,
00:21:42.970 --> 00:21:46.089
48 hours and decide how to escalate or deescalate.
00:21:46.190 --> 00:21:48.029
If I have a patient that has already history
00:21:48.029 --> 00:21:51.069
of ESPL, like extended resistance, I'm going
00:21:51.069 --> 00:21:53.410
to guide my therapy pending that. I'm going to
00:21:53.410 --> 00:21:57.390
say meropenem from the get -go. Yeah. You could
00:21:57.390 --> 00:22:00.410
start with meropenem if you think of nosocomial
00:22:00.410 --> 00:22:04.269
infection. Cefepine does have a little bit of
00:22:04.269 --> 00:22:07.210
CNS penetration, so it can be better in that
00:22:07.210 --> 00:22:09.589
regard. I have also seen some literature now
00:22:09.589 --> 00:22:13.130
that says cefepine seems to prolong hospital
00:22:13.130 --> 00:22:16.690
delirium in older populations. Yeah, if you're
00:22:16.690 --> 00:22:20.349
thinking more older history of seizures, you
00:22:20.349 --> 00:22:23.069
want to stay about away from the cephalosporins.
00:22:23.549 --> 00:22:26.369
Because they tend to have more delirium, more
00:22:26.369 --> 00:22:29.190
seizure activity. So they tend to get away from
00:22:29.190 --> 00:22:32.730
them. But still, in that first 48 hours, everything
00:22:32.730 --> 00:22:36.069
is open for you. You try whatever you think is
00:22:36.069 --> 00:22:37.990
going to benefit the patient, depending on their
00:22:37.990 --> 00:22:40.609
previous cultures. And then if you're thinking
00:22:40.609 --> 00:22:43.369
maybe a MRSA, you had the vancomycin for coverage,
00:22:43.450 --> 00:22:45.549
and you're thinking maybe a pneumonia, get that
00:22:45.549 --> 00:22:50.009
MRSA, PCR swab. Get it negative and you can probably
00:22:50.009 --> 00:22:53.029
de -escalate that vancomycin. You can progression
00:22:53.029 --> 00:22:55.789
de -escalate your antibiotics as you figure out
00:22:55.789 --> 00:22:58.309
your blood culture results and as you figure
00:22:58.309 --> 00:23:00.549
out what kind of bug exactly you're dealing with.
00:23:00.690 --> 00:23:03.049
Other kind of add -ons here, if you're thinking
00:23:03.049 --> 00:23:04.910
community -acquired pneumonia, you can throw
00:23:04.910 --> 00:23:09.210
on azithromycin or doxycycline for atypical coverage.
00:23:09.589 --> 00:23:12.230
Tick -borne illnesses, we're not really in the
00:23:12.230 --> 00:23:14.650
tick area here, but you have your doxycycline
00:23:14.650 --> 00:23:17.519
still as an option for that. P. diff. If you're
00:23:17.519 --> 00:23:20.720
thinking C. diff, oral vanc, if you're thinking
00:23:20.720 --> 00:23:23.519
that they have previous resistance or they've
00:23:23.519 --> 00:23:26.400
had C. diff before and they didn't tolerate or
00:23:26.400 --> 00:23:29.000
didn't benefit from vancomycin. And then I don't
00:23:29.000 --> 00:23:31.299
know how much evidence is for this one. One of
00:23:31.299 --> 00:23:33.680
my resources talked about if you're thinking
00:23:33.680 --> 00:23:36.980
about toxin suppression of using clindamycin
00:23:36.980 --> 00:23:39.859
and then with that one, just that clinda goes
00:23:39.859 --> 00:23:42.839
first, give clinda first and then give you other
00:23:42.839 --> 00:23:45.900
stuff. Again, I haven't done a whole lot of research
00:23:45.900 --> 00:23:49.339
on that. A lot of infectious disease people think
00:23:49.339 --> 00:23:51.920
about adding clindamycin just for the toxins.
00:23:52.039 --> 00:23:54.480
I've seen a lot of them say, oh, it doesn't really
00:23:54.480 --> 00:23:56.779
show benefit. Just treat the infection, treat
00:23:56.779 --> 00:23:59.259
everything. But if you're thinking this is gas
00:23:59.259 --> 00:24:02.079
forming, you want to cover everything. So just
00:24:02.079 --> 00:24:04.920
throw the clind on and see what else is going
00:24:04.920 --> 00:24:07.880
on. And then finally, this is the pillar. I think
00:24:07.880 --> 00:24:09.599
this is the biggest pillar. Obviously, if someone
00:24:09.599 --> 00:24:11.799
is sick, has a bacterial infection, clearing
00:24:11.799 --> 00:24:13.519
that is going to be paramount. It's going to
00:24:13.519 --> 00:24:15.440
clear the way for the patient getting better.
00:24:15.579 --> 00:24:18.180
The compressors can keep someone alive. Fluids
00:24:18.180 --> 00:24:20.339
can, I guess, keep the blood pressure up a little
00:24:20.339 --> 00:24:22.619
bit. But in the end, you're going to want that
00:24:22.619 --> 00:24:24.680
source of control. Source of control is bacteria.
00:24:24.900 --> 00:24:27.019
So source of control is going to be key. So these
00:24:27.019 --> 00:24:29.539
patients have lines. Think about getting rid
00:24:29.539 --> 00:24:31.900
of them. If they have ports that might be infected,
00:24:32.200 --> 00:24:34.630
maybe it's... It's time to take them out. Time
00:24:34.630 --> 00:24:35.890
to take them out depending on your bacteria.
00:24:36.150 --> 00:24:38.410
Talk to your ID doctor. Talk to your specialist
00:24:38.410 --> 00:24:40.509
if that's something that needs to happen. They
00:24:40.509 --> 00:24:42.789
add hardware like a hip replacement and they
00:24:42.789 --> 00:24:45.549
have a pretty severely infected incision site.
00:24:45.769 --> 00:24:48.369
Got to talk to your orthodox and see does that
00:24:48.369 --> 00:24:51.849
infection seed into the prosthesis, endocarditis.
00:24:52.029 --> 00:24:54.390
You got to look into all these different things.
00:24:54.859 --> 00:24:57.000
Blood cultures, follow those up. If they have
00:24:57.000 --> 00:24:59.960
bacteremia, treat with antibiotics. Retake your
00:24:59.960 --> 00:25:01.759
blood cultures, see if you're actually making
00:25:01.759 --> 00:25:04.220
progress. But source control is going to be important.
00:25:04.319 --> 00:25:07.160
If you have abdominal abscesses and stuff like
00:25:07.160 --> 00:25:09.619
that, talk to your surgeons and see about draining
00:25:09.619 --> 00:25:12.519
those. Even IR drainage might be something that
00:25:12.519 --> 00:25:14.359
could be offered. Because if you don't have source
00:25:14.359 --> 00:25:16.539
control, you may not actually end up ever clearing
00:25:16.539 --> 00:25:18.720
this infection. I would say just the pearls and
00:25:18.720 --> 00:25:22.279
pitfalls here, there are... Some mimics of sepsis,
00:25:22.279 --> 00:25:24.299
like they're not true sepsis, but they might
00:25:24.299 --> 00:25:26.980
make you think of sepsis. Under the endocrine
00:25:26.980 --> 00:25:29.099
header, you got your adrenal crisis. You have
00:25:29.099 --> 00:25:32.359
your thyroid storm, your DKA. Sometimes they
00:25:32.359 --> 00:25:35.920
look like sepsis, but they're not. So don't be
00:25:35.920 --> 00:25:38.319
totally fooled. Just be aware of some of that
00:25:38.319 --> 00:25:40.079
stuff. There are some of your labs that can lead
00:25:40.079 --> 00:25:42.380
you down different pathways. And also consider
00:25:42.380 --> 00:25:47.740
like in DKA, you can have sepsis. and DKA. They're
00:25:47.740 --> 00:25:50.400
not mutually exclusive. Yeah. Sepsis presents
00:25:50.400 --> 00:25:53.160
as DKA. They don't have the other symptoms. Yeah,
00:25:53.180 --> 00:25:55.200
they just have the DKA. And then other things
00:25:55.200 --> 00:25:57.700
like pancreatitis can make some people have the
00:25:57.700 --> 00:26:00.359
knowledge of vomiting, some hypotension. Just
00:26:00.359 --> 00:26:02.839
be aware of that. You can get some lipase, get
00:26:02.839 --> 00:26:05.640
a CT scan of the abdomen. Fulminant liver failure
00:26:05.640 --> 00:26:09.220
can sometimes mask itself as kind of sepsis -like.
00:26:09.660 --> 00:26:12.980
bowel obstruction, acute mesenteric ischemia,
00:26:13.220 --> 00:26:16.759
can also present a little bit like sepsis. You
00:26:16.759 --> 00:26:19.880
have your PGAP pneumonia, and then your endocarditis
00:26:19.880 --> 00:26:24.539
can be sepsis, true sepsis, or if you have valvular
00:26:24.539 --> 00:26:28.799
dysfunctions, it can be more shocky and not necessarily
00:26:28.799 --> 00:26:31.700
sepsis. So it's just, there's a little bit of
00:26:31.700 --> 00:26:36.019
a difference there. It's not very clear. As we
00:26:36.019 --> 00:26:38.220
said, it's like you have to look at everything.
00:26:38.799 --> 00:26:41.039
Make sure you don't miss anything. You have to
00:26:41.039 --> 00:26:43.519
think about each and every organ. The way I think
00:26:43.519 --> 00:26:46.940
about these shocky patients, you have to examine
00:26:46.940 --> 00:26:49.519
them from head to toe, look at their medications,
00:26:49.740 --> 00:26:52.720
think about everything that might cause them
00:26:52.720 --> 00:26:55.779
to have this. It's not just, oh, they might have
00:26:55.779 --> 00:26:57.980
vectorinia and they might have this. It's like
00:26:57.980 --> 00:27:00.960
looking at everything together, making a full
00:27:00.960 --> 00:27:03.279
picture of what you have, what you don't have,
00:27:03.500 --> 00:27:07.180
what you're missing to make this work. All right.
00:27:07.240 --> 00:27:09.059
Is there anything else? This is a pretty big
00:27:09.059 --> 00:27:10.819
topic. We spent a little bit of time on it, but
00:27:10.819 --> 00:27:14.000
anything else we need to hit on? The only thing
00:27:14.000 --> 00:27:17.940
is steroids. Think about them when you're having
00:27:17.940 --> 00:27:21.880
less of a response to vasopressins. You can try
00:27:21.880 --> 00:27:25.680
and add a steroid because you have adrenal insufficiency
00:27:25.680 --> 00:27:29.779
in most of these patients happen along when they're
00:27:29.779 --> 00:27:32.660
having septic shocks. Their adrenal is extra
00:27:32.660 --> 00:27:36.450
credit if you know the dose. 200 to 300 milligrams
00:27:36.450 --> 00:27:40.750
per 24 hours, every 24 hours. Is it the hydrocortisone?
00:27:40.910 --> 00:27:43.250
Hydrocortisone. Oh, I've heard of like decradon,
00:27:43.250 --> 00:27:48.690
six milligrams. For sepsis, I've always heard
00:27:48.690 --> 00:27:52.029
hydrocortisone is okay to go to because it has
00:27:52.029 --> 00:27:56.339
both mineral and... glucocorticoid effect. So
00:27:56.339 --> 00:27:58.880
DEXA is more glucocorticoid. You're going to
00:27:58.880 --> 00:28:02.660
use it more in your ARDS patients, your COVID
00:28:02.660 --> 00:28:05.539
patients. Because it's more glucocorticoid, you
00:28:05.539 --> 00:28:09.279
can add aminocorticoid to it. If you're thinking
00:28:09.279 --> 00:28:12.380
this is sepsis, this is septic shock, go ahead
00:28:12.380 --> 00:28:15.200
and do the hydrocortisone at a high dose and
00:28:15.200 --> 00:28:18.200
see how they respond. All right. So we will be
00:28:18.200 --> 00:28:21.140
back with other parts of distributed shock in
00:28:21.140 --> 00:28:23.549
the future. This is just a big one. I think we're
00:28:23.549 --> 00:28:25.970
already at 35 minutes. So we will see you how
00:28:25.970 --> 00:28:29.150
we go. Thank you, guys. Thank you for listening
00:28:29.150 --> 00:28:31.329
to the podcast. I am Basics. I want to thank
00:28:31.329 --> 00:28:33.329
the residents who took part in this show. It
00:28:33.329 --> 00:28:35.109
could not have been done without them. We hope
00:28:35.109 --> 00:28:36.829
you enjoyed this production. And if you did,
00:28:36.890 --> 00:28:38.990
please rate and review on Apple Podcasts. If
00:28:38.990 --> 00:28:41.009
you especially found it useful, share us with
00:28:41.009 --> 00:28:41.809
your friends and colleagues.
00:00:02.439 --> 00:00:42.420
Thank you. I am Basic, hosted by me, Dr. Eric
00:00:42.420 --> 00:00:44.880
Acker, and Dr. Tarp, as well as other resident
00:00:44.880 --> 00:00:47.240
physicians. This podcast is directed towards
00:00:47.240 --> 00:00:50.100
PGY1s and medical students to give a brief overview
00:00:50.100 --> 00:00:52.859
of medical topics. This podcast is intended for
00:00:52.859 --> 00:00:54.859
medical professionals and is not intended to
00:00:54.859 --> 00:00:58.320
be used for medical advice. We are going to continue
00:00:58.320 --> 00:01:01.039
our series on shock, and we're going to go down
00:01:01.039 --> 00:01:04.140
the pathway of distributed shock and down a little
00:01:04.140 --> 00:01:07.569
bit further to septic shock. So with septic shock,
00:01:07.709 --> 00:01:09.329
Tarek, we always talk about the presentation
00:01:09.329 --> 00:01:11.370
and the presentation is relatively similar to
00:01:11.370 --> 00:01:14.569
general shock, but like just again, recap as
00:01:14.569 --> 00:01:17.170
much as you can or what's unique to some of the
00:01:17.170 --> 00:01:19.849
presentation symptoms, vital signs, et cetera.
00:01:20.010 --> 00:01:21.769
Septic shock. Sometimes you're going to have
00:01:21.769 --> 00:01:24.530
fever most of the time if they're in septic shock,
00:01:24.650 --> 00:01:27.769
but don't like harp on just having fever. They're
00:01:27.769 --> 00:01:31.049
going to have tachycardia, hypotension. Sometimes
00:01:31.049 --> 00:01:33.069
they're going to have altermental status. Depending
00:01:33.069 --> 00:01:35.930
on where your source of infection is, they might
00:01:35.930 --> 00:01:38.730
have abdominal pain, they might have flank pain,
00:01:38.810 --> 00:01:41.430
depending on your source. There's no set findings
00:01:41.430 --> 00:01:44.150
for these patients. They're tachycardic, febrile,
00:01:44.290 --> 00:01:46.650
altered. They have warm extremities because this
00:01:46.650 --> 00:01:48.530
is part of your distributive shock. At least
00:01:48.530 --> 00:01:51.069
initially they have one. So you're thinking more
00:01:51.069 --> 00:01:52.950
this is septic. They have wide valve pressure,
00:01:53.409 --> 00:01:56.569
low systolic, low diastolic, but diastolic is
00:01:56.569 --> 00:01:59.400
lower. compared to your systolic. The other thing
00:01:59.400 --> 00:02:01.099
I guess I would mention with febrile, because
00:02:01.099 --> 00:02:03.079
some people think, oh, febrile, septic shock,
00:02:03.200 --> 00:02:04.900
there you go. But if they don't have a fever,
00:02:05.019 --> 00:02:07.659
also keep in mind, low temperatures can also
00:02:07.659 --> 00:02:10.580
be considered in this category as well. So not
00:02:10.580 --> 00:02:13.400
always high can be also low. They sometimes don't
00:02:13.400 --> 00:02:16.740
have to be tachycardic. They might be bradycardic,
00:02:16.740 --> 00:02:18.759
normal heart rate, because they're going into
00:02:18.759 --> 00:02:21.360
irreversible stages of shock. So you have to
00:02:21.360 --> 00:02:23.919
think of everything together. I am purposely
00:02:23.919 --> 00:02:27.030
avoiding the definition right now. Try to circle
00:02:27.030 --> 00:02:28.810
back because definition, I think, has a lot to
00:02:28.810 --> 00:02:31.210
do with the labs and whatnot, because I think
00:02:31.210 --> 00:02:34.530
you get this big old workup. You decide that
00:02:34.530 --> 00:02:37.009
it's septic shock. You can plug the labs in and
00:02:37.009 --> 00:02:40.009
they will tell you what stage sepsis one, two,
00:02:40.110 --> 00:02:42.810
three, four, et cetera. And maybe not four. I'm
00:02:42.810 --> 00:02:45.050
not sure four even exists. But I'm avoiding the
00:02:45.050 --> 00:02:47.370
definition at this moment. We will try to circle
00:02:47.370 --> 00:02:49.270
back to that a little bit because it does help
00:02:49.270 --> 00:02:51.830
with the management. But as far as the workup,
00:02:51.849 --> 00:02:54.699
a lot of this is going to be. related to where
00:02:54.699 --> 00:02:56.860
the source of your infection is. If you know
00:02:56.860 --> 00:02:59.520
where it's at, then great, you can go that direction.
00:02:59.780 --> 00:03:02.180
But at least in the initial workup on these patients,
00:03:02.439 --> 00:03:04.960
what kind of things are you grabbing? So you're
00:03:04.960 --> 00:03:07.280
going to have a broad workup. Initially, you're
00:03:07.280 --> 00:03:12.240
getting a CMP, CBC, a lactate. You can get Procal,
00:03:12.460 --> 00:03:16.699
CRP. It's not necessary for treatment. It's just
00:03:16.699 --> 00:03:19.939
something to see, oh, they have severe sepsis.
00:03:19.979 --> 00:03:22.699
I'm putting them on antibiotics. I want to see
00:03:22.699 --> 00:03:24.759
their response. Most of them are going to get
00:03:24.759 --> 00:03:26.860
a chest x -ray because most of them are altered.
00:03:27.039 --> 00:03:29.780
You can't really say, oh, they don't have a chest
00:03:29.780 --> 00:03:32.319
infection or something, but it's not necessary
00:03:32.319 --> 00:03:34.599
in your treatment, but everyone gets a chest
00:03:34.599 --> 00:03:37.379
x -ray. Then you think about what's causing this.
00:03:37.500 --> 00:03:41.120
So depending on what's causing your sepsis or
00:03:41.120 --> 00:03:43.840
septic shock, then you go down the lane. Oh,
00:03:44.180 --> 00:03:47.560
I want to do a CT scan of their head, CT scan
00:03:47.560 --> 00:03:49.719
of their chest. Because I'm thinking they have
00:03:49.719 --> 00:03:52.460
a brain abscess, they have mucormycosis, they
00:03:52.460 --> 00:03:55.240
have lung abscess, empyema, they have severe
00:03:55.240 --> 00:03:58.319
pneumonia. Then I'm doing a CT test to figure
00:03:58.319 --> 00:04:00.500
out what's causing them to be in septic shock
00:04:00.500 --> 00:04:02.460
because that's sounding like a late presentation
00:04:02.460 --> 00:04:05.520
of just infection. Oh, I'm thinking they have
00:04:05.520 --> 00:04:07.759
something intra -abdominal, intra -abdominal
00:04:07.759 --> 00:04:10.680
abscess, peritonitis, or they have liver abscess,
00:04:10.939 --> 00:04:13.379
severe cholecystitis, perforation, whatever.
00:04:13.639 --> 00:04:16.199
Then I'm going to do a CT abdomen. I'm essentially
00:04:16.199 --> 00:04:18.360
going to want to look at the liver. I want to
00:04:18.360 --> 00:04:21.100
do an ultrasound. I want to do... I think this
00:04:21.100 --> 00:04:22.800
is the first time you've almost pan -scanned
00:04:22.800 --> 00:04:24.920
the patient. Yeah, you're going to tailor. Because
00:04:24.920 --> 00:04:28.100
ultrasound, you can do an ultrasound look, but
00:04:28.100 --> 00:04:30.459
it's still not going to give you that picture
00:04:30.459 --> 00:04:32.220
you're going to paint. And then I think along
00:04:32.220 --> 00:04:35.100
with this, procalcitonin plus or minus, I think,
00:04:35.139 --> 00:04:38.459
honestly, it can be used later on for de -escalating
00:04:38.459 --> 00:04:40.629
some of your antibiotics. I think there's some
00:04:40.629 --> 00:04:42.170
literature out there that kind of suggests in
00:04:42.170 --> 00:04:44.769
the first 24 hours, at least on any presentation,
00:04:45.009 --> 00:04:48.290
procalcitonin can be low. It's delayed. So you
00:04:48.290 --> 00:04:51.250
have to think it's delayed. The procal is negative
00:04:51.250 --> 00:04:54.310
at first because it's a range. This number is
00:04:54.310 --> 00:04:56.629
positive. This number is negative. It's a range
00:04:56.629 --> 00:04:59.509
of numbers. You look at less than 0 .5, then
00:04:59.509 --> 00:05:01.839
it... They're less likely to have an infection.
00:05:02.000 --> 00:05:04.120
They will say less likely. It's not a negative
00:05:04.120 --> 00:05:06.319
number because they might have come in an early
00:05:06.319 --> 00:05:09.100
presentation. They just started having fevers.
00:05:09.100 --> 00:05:11.480
Then you have a negative procalcitonin. You're
00:05:11.480 --> 00:05:13.360
not going to say, oh, they have negative procal.
00:05:13.420 --> 00:05:15.439
I'm not going to put them on antibiotics. That
00:05:15.439 --> 00:05:17.579
doesn't work. And then with these patients, obviously
00:05:17.579 --> 00:05:19.819
the physical exam, the history taking is going
00:05:19.819 --> 00:05:21.920
to be paramount. They've had a recent surgery,
00:05:22.100 --> 00:05:25.459
hardware place, lines place, ports. You want
00:05:25.459 --> 00:05:27.220
to check all those things out. This patient's
00:05:27.220 --> 00:05:29.560
bed bound or they're complaining that maybe some
00:05:29.639 --> 00:05:31.500
pain in the groin if they're altered and they're
00:05:31.500 --> 00:05:33.240
not complaining you don't have a source you should
00:05:33.240 --> 00:05:36.540
start looking for things like necrotizing fasciitis
00:05:36.540 --> 00:05:39.360
it's never necessarily top of our list as medical
00:05:39.360 --> 00:05:41.480
professionals to check out the groin area of
00:05:41.480 --> 00:05:43.480
our patients. But this might be one of those
00:05:43.480 --> 00:05:46.259
situations where doing that could pay off with
00:05:46.259 --> 00:05:48.199
finding that crash. And that will lead you down
00:05:48.199 --> 00:05:50.980
a pathway where you can emergently ask your friendly
00:05:50.980 --> 00:05:53.100
general surgeon to come in at two o 'clock in
00:05:53.100 --> 00:05:54.720
the morning to operate on this patient. But that
00:05:54.720 --> 00:05:56.740
could save that patient's life as opposed to
00:05:56.740 --> 00:05:58.959
finding out maybe 24 hours later when the patient
00:05:58.959 --> 00:06:01.000
finally gets to the unit and the nurse does a
00:06:01.000 --> 00:06:03.439
full skin exam and says, hey, this doesn't look
00:06:03.439 --> 00:06:05.319
right. Now you've missed a little bit of your
00:06:05.319 --> 00:06:07.759
window to intervene on a patient. So if you're
00:06:07.759 --> 00:06:10.660
not finding an immediate source that explains
00:06:10.660 --> 00:06:13.300
why this patient's febrile, they're in this shock
00:06:13.300 --> 00:06:16.360
state, try to expand out and look for all different
00:06:16.360 --> 00:06:18.399
things that could be helping to explain. Also,
00:06:18.459 --> 00:06:21.339
look at the medical medication history as well,
00:06:21.399 --> 00:06:23.660
because sometimes there's mimics of septic shock,
00:06:23.759 --> 00:06:25.860
which we'll get into a little bit later. And
00:06:25.860 --> 00:06:28.079
then, of course, if you're thinking. meningitis,
00:06:28.240 --> 00:06:30.600
then go ahead and try to get an LP on these patients.
00:06:30.699 --> 00:06:32.699
As an intern, as a medical student, it might
00:06:32.699 --> 00:06:35.279
be a little bit rarer. Your ED residents might
00:06:35.279 --> 00:06:37.879
have already beat you to that. Other things they
00:06:37.879 --> 00:06:41.399
throw into the mix is some coags, look for platelets,
00:06:41.480 --> 00:06:44.680
fibrinogen, PT -INR, this source I was looking
00:06:44.680 --> 00:06:47.769
at. mentions D -dimer, I think in the year of
00:06:47.769 --> 00:06:51.750
post -COVID, the D -dimer is a dangerous lab
00:06:51.750 --> 00:06:54.790
to order. Yeah, everyone gets a D -dimer if they're
00:06:54.790 --> 00:06:58.410
thinking P -E. If you're thinking P -E just for
00:06:58.410 --> 00:07:01.230
the CTA, D -dimer is going to be high. D -dimer
00:07:01.230 --> 00:07:03.949
is just to justify it. You want to get that CTA.
00:07:04.389 --> 00:07:08.269
This is a completely aside from separation. You
00:07:08.269 --> 00:07:10.149
want to get that CTA. You just want a D -dimer
00:07:10.149 --> 00:07:12.769
to tell you that it's okay to do it. So we initiated
00:07:12.769 --> 00:07:15.589
their treatment, or at least a workout. There's
00:07:15.589 --> 00:07:18.110
a few different mainstays of treating septic
00:07:18.110 --> 00:07:19.629
shock. Obviously, they're treating the underlying
00:07:19.629 --> 00:07:21.949
cause, so the infection. So we have the antibiotics.
00:07:22.290 --> 00:07:25.430
We have the resuscitation. We have keeping the
00:07:25.430 --> 00:07:29.689
MAP above 65, ideally, and then protecting the
00:07:29.689 --> 00:07:32.949
MAP, yes. So then for that, we have our pressors
00:07:32.949 --> 00:07:36.110
and we have fluids, which is going to be a more
00:07:36.110 --> 00:07:38.290
relatively controversial thing, but at least
00:07:38.290 --> 00:07:41.649
in the initial workup. I know there's some guidelines
00:07:41.649 --> 00:07:44.149
that Tarek wants to talk about. The problem with
00:07:44.149 --> 00:07:46.970
fluid resuscitation is that you have to think
00:07:46.970 --> 00:07:50.730
about it's not a shoe that fits all, right? You
00:07:50.730 --> 00:07:53.529
have to individualize how much fluid each patient
00:07:53.529 --> 00:07:56.689
gets. I know a surviving sepsis campaign says
00:07:56.689 --> 00:08:00.089
30 ml per kg is ideal body weight. You have to
00:08:00.089 --> 00:08:02.110
remember it's ideal, it's not total body weight.
00:08:02.189 --> 00:08:05.209
It's like you have a 300 -pound patient and you're
00:08:05.209 --> 00:08:07.639
just going to give them... Nine liters of fluid,
00:08:07.759 --> 00:08:10.180
because that's what the guidelines say. It's
00:08:10.180 --> 00:08:13.319
everything is taken into consideration. Like
00:08:13.319 --> 00:08:15.699
heart failure, this is their ideal body weight.
00:08:15.819 --> 00:08:18.600
You want to reach euvolemic state. That's your
00:08:18.600 --> 00:08:21.920
goal. So previously, like you go read the guidelines,
00:08:22.120 --> 00:08:25.939
surviving sepsis is 30 ml per case in the first
00:08:25.939 --> 00:08:28.600
90 minutes. So you have to be in that window
00:08:28.600 --> 00:08:31.040
for 90 minutes. That's where the benefit was
00:08:31.040 --> 00:08:33.220
seen. That's where the mortality benefit was
00:08:33.220 --> 00:08:35.960
seen. That's where everything, 90 minutes. Then
00:08:35.960 --> 00:08:38.779
the emergency medicine team said, no, your guys
00:08:38.779 --> 00:08:41.679
are saying 30 ml per kick for everyone. That's
00:08:41.679 --> 00:08:44.639
not how it works. Yeah, we have seen complications.
00:08:44.899 --> 00:08:48.559
That's true. Because if you give everyone 30
00:08:48.559 --> 00:08:51.960
ml for the patient that has an EF of 10%, they're
00:08:51.960 --> 00:08:53.799
having great heart failure, they have pulmonary
00:08:53.799 --> 00:08:56.019
hypertension, without knowing what's going on
00:08:56.019 --> 00:08:59.000
behind this, you see mortality. We're going to
00:08:59.000 --> 00:09:02.480
start a multifactorial shock. We have a septic
00:09:02.480 --> 00:09:05.190
shock, we have a cardiogenic shock. Yeah, it's
00:09:05.190 --> 00:09:08.269
hard because, like, I've seen patients that have
00:09:08.269 --> 00:09:11.549
septic shock. They have right -sided heart failure,
00:09:11.590 --> 00:09:14.830
and they get the 30 milliliters per kg. And nobody
00:09:14.830 --> 00:09:17.789
says it's ideal, it's not total. And they give
00:09:17.789 --> 00:09:20.809
them four liters, and their RV just gives up.
00:09:20.909 --> 00:09:24.450
And you have a whole other complication. This
00:09:24.450 --> 00:09:27.389
is the guideline. This is the CMS. Every hospital,
00:09:27.529 --> 00:09:31.370
EED, is going to say 30 milliliters per kg bolus.
00:09:31.629 --> 00:09:34.850
You get a lactate. You initiate antibiotics for
00:09:34.850 --> 00:09:37.889
90 minutes and then you reassess three hours
00:09:37.889 --> 00:09:41.450
and then you either repeat that, you start pressors.
00:09:41.470 --> 00:09:44.190
This is the series of steps I think most hospitals
00:09:44.190 --> 00:09:46.799
follow. I'm going to throw just a little bit
00:09:46.799 --> 00:09:48.720
of controversy into the mix. I know this is generally
00:09:48.720 --> 00:09:51.519
an educational thing. My take is that septic
00:09:51.519 --> 00:09:54.720
shock is a maldistribution. Blood to different
00:09:54.720 --> 00:09:57.399
organ systems is a maldistributed hallmark of
00:09:57.399 --> 00:10:00.360
low diastolic pressure. So you have very poor
00:10:00.360 --> 00:10:04.080
vascular resistance, leaky capillaries. Leaky
00:10:04.080 --> 00:10:07.240
vessels. And so the idea that just throwing fluid
00:10:07.240 --> 00:10:10.580
at these patients is going to somehow improve
00:10:10.580 --> 00:10:14.700
the blood pressure is, I think, dubious a little
00:10:14.700 --> 00:10:17.139
bit. It's definitely something that can show
00:10:17.139 --> 00:10:20.120
improved mortality after hospitalization compared
00:10:20.120 --> 00:10:23.980
to more liberal uses of fluid. At least 30 milliliters
00:10:23.980 --> 00:10:26.899
per kilogram tends to show. reasonable good results,
00:10:26.980 --> 00:10:29.519
but fluid doesn't always equate to good perfusion.
00:10:29.539 --> 00:10:30.940
And the other thing I want to, I guess, bring
00:10:30.940 --> 00:10:34.000
up to this is that oxygen delivery to tissue
00:10:34.000 --> 00:10:36.279
is another issue that we're dealing with, with
00:10:36.279 --> 00:10:38.759
organ malperfusion. These organs aren't getting
00:10:38.759 --> 00:10:41.419
perfused very good. What they need is oxygen.
00:10:41.659 --> 00:10:43.419
And so what you're doing is you're giving this
00:10:43.419 --> 00:10:45.259
crystalloid, let's say you're giving a liter.
00:10:45.360 --> 00:10:48.779
Well, your body has about six, about six liters.
00:10:50.029 --> 00:10:51.990
blood in. So you give another liter, you've just
00:10:51.990 --> 00:10:55.129
diluted your blood hemoglobin content by one
00:10:55.129 --> 00:10:57.289
sec. You do that again and you do that again.
00:10:57.529 --> 00:10:59.629
So your hemoglobin is going down. So the oxygen
00:10:59.629 --> 00:11:02.750
delivery to tissue equation is like a constant
00:11:02.750 --> 00:11:06.389
times cardiac output times hemoglobin times O2
00:11:06.389 --> 00:11:08.830
saturation. So if your O2 saturation is good,
00:11:08.990 --> 00:11:11.409
cardiac output, maybe it improves with some fluid.
00:11:11.590 --> 00:11:13.289
Your constant, of course, is constant, but your
00:11:13.289 --> 00:11:15.809
hemoglobin now is going down because you diluted
00:11:15.809 --> 00:11:17.929
it. Your oxygen delivery is also not particularly
00:11:17.929 --> 00:11:20.019
great either. So I'm not Not saying don't give
00:11:20.019 --> 00:11:22.399
the fluid, but just think about it. Everything
00:11:22.399 --> 00:11:25.600
has to be in balance because too much fluid.
00:11:25.779 --> 00:11:28.039
Think it was in the trauma patients that have
00:11:28.039 --> 00:11:30.840
to do resuscitation. You're resuscitating them
00:11:30.840 --> 00:11:33.000
with fluid, but that puts them at a higher risk
00:11:33.000 --> 00:11:35.639
of DIC. That's why we're later on going to talk
00:11:35.639 --> 00:11:37.659
about this and hemorrhagic shock and everything.
00:11:37.860 --> 00:11:40.980
You think about giving fluids. how much is too
00:11:40.980 --> 00:11:43.240
much and how little is too little there's no
00:11:43.240 --> 00:11:45.899
this is enough for everyone that there's nothing
00:11:45.899 --> 00:11:48.240
like that okay you have to balance everything
00:11:48.240 --> 00:11:50.460
depending your patient their volume size you
00:11:50.460 --> 00:11:53.600
have to follow up repeat do ultrasound get your
00:11:53.600 --> 00:11:57.750
ivc get your volume status check it They're obviously
00:11:57.750 --> 00:12:00.230
still collapsed or they start having to have
00:12:00.230 --> 00:12:02.809
B lines in their lungs. My fluid is not staying.
00:12:02.990 --> 00:12:05.870
So maybe I should give them protein. There's
00:12:05.870 --> 00:12:08.049
a lot of different stuff to think about before
00:12:08.049 --> 00:12:10.470
deciding. I'm just going to keep bolusing these
00:12:10.470 --> 00:12:13.289
patients a liter at a time and see when you start
00:12:13.289 --> 00:12:15.610
reaching that five liters, maybe start thinking
00:12:15.610 --> 00:12:18.029
this is not working for this patient. Maybe it
00:12:18.029 --> 00:12:20.509
needs pressers. Maybe your intensivist should
00:12:20.509 --> 00:12:22.509
be. And sometimes depending on where you're at,
00:12:22.570 --> 00:12:24.470
your intensivist may want to see that you've
00:12:24.470 --> 00:12:27.450
given it the old college try on the fluids. But
00:12:27.450 --> 00:12:29.389
just try to keep that in the back of your mind.
00:12:29.429 --> 00:12:33.129
We're going to shift to the sepsis criterias
00:12:33.129 --> 00:12:35.389
and the definitions, which I think will help
00:12:35.389 --> 00:12:37.950
guide maybe when you do reach out to. Let's go
00:12:37.950 --> 00:12:40.350
ahead and shift into that. So you got the sofas.
00:12:40.710 --> 00:12:44.570
Yeah. So based on what I read, the most recent
00:12:44.570 --> 00:12:49.019
sepsis criteria is sepsis 3 .0. Talks about sepsis,
00:12:49.019 --> 00:12:51.720
not just by their tachycardia, because every
00:12:51.720 --> 00:12:55.120
billing system is depending on the SIRS criteria.
00:12:55.240 --> 00:12:59.139
They have three of the above, tachycardia, tachypnea,
00:12:59.519 --> 00:13:03.519
altered mental status, fever, hypothermia, leukocytosis,
00:13:03.799 --> 00:13:06.679
leukopenia. That's essentially what SIRS criteria
00:13:06.679 --> 00:13:09.379
is. Has SIRS criteria should benefit in diagnosing
00:13:09.379 --> 00:13:12.179
or early management of these patients? I don't
00:13:12.179 --> 00:13:14.259
think so. I haven't read anything. Eric can correct
00:13:14.259 --> 00:13:16.669
me if I'm wrong, but. The last guidelines of
00:13:16.669 --> 00:13:20.669
sepsis 3 .0 definition is like sepsis is equal
00:13:20.669 --> 00:13:23.549
to end organ damage. And the way to look at end
00:13:23.549 --> 00:13:26.389
organ damage is to do the SOFA score for these
00:13:26.389 --> 00:13:28.690
patients. And they don't just say do SOFA score
00:13:28.690 --> 00:13:31.610
on admission. It's like it's a constant revision
00:13:31.610 --> 00:13:34.470
of that SOFA score to say they're having end
00:13:34.470 --> 00:13:36.789
organ damage. Their SOFA score is more than two.
00:13:36.909 --> 00:13:40.639
So they have sepsis with a likely source. You
00:13:40.639 --> 00:13:43.080
remeasure everything. You remeasure it in 48
00:13:43.080 --> 00:13:45.220
hours to see, oh, their SOFA score is dropping
00:13:45.220 --> 00:13:47.379
down by two. Then I'm going in the right direction.
00:13:47.620 --> 00:13:51.460
So antibiotics is working. Their volume is okay.
00:13:51.740 --> 00:13:54.059
Their oxygen is okay. They're not having any
00:13:54.059 --> 00:13:56.340
more end organ damage, essentially. No, their
00:13:56.340 --> 00:13:58.879
SOFA score is going up. Then I'm doing something
00:13:58.879 --> 00:14:01.419
wrong. This gives you an idea. I need to look
00:14:01.419 --> 00:14:03.399
at everything again. They're having end organ
00:14:03.399 --> 00:14:05.899
damage for some reason. Am I giving them too
00:14:05.899 --> 00:14:08.019
much fluid? They went into pulmonary edema and
00:14:08.019 --> 00:14:10.460
that's why their oxygen is low. Their MAP is
00:14:10.460 --> 00:14:13.179
low. Do I need them to be on pressers? Do I need
00:14:13.179 --> 00:14:15.559
to call the ICU? It's giving you that leeway
00:14:15.559 --> 00:14:18.940
to think about reaching out to other specialties,
00:14:18.940 --> 00:14:21.659
to think about revising your management. And
00:14:21.659 --> 00:14:24.259
so this is where you get the sepsis 2 and the
00:14:24.259 --> 00:14:27.759
sepsis 3 criteria there. So you can look at MD
00:14:27.759 --> 00:14:30.889
-Calc. They have a QSOFA score, which is a little
00:14:30.889 --> 00:14:33.590
bit more of a reduced amount of data you have
00:14:33.590 --> 00:14:36.350
to input, whereas the SOFA score has a lot more
00:14:36.350 --> 00:14:39.370
data you can input. And again, it's also if you're
00:14:39.370 --> 00:14:41.049
practicing for a little while, you can see how
00:14:41.049 --> 00:14:43.809
some of these lab values change and correlate
00:14:43.809 --> 00:14:45.850
to the clinical picture and direction of the
00:14:45.850 --> 00:14:48.110
patient. So it's just a nice way of quantifying
00:14:48.110 --> 00:14:51.570
it. I think it's relatively validated. And so
00:14:51.570 --> 00:14:53.409
then that's a nice little thing you can get and
00:14:53.409 --> 00:14:55.230
go to your friendly intensivist and say, hey,
00:14:55.250 --> 00:14:57.309
I've been doing this X, Y and Z. They're not
00:14:57.309 --> 00:14:58.960
getting better. Looks like they're getting worse.
00:14:59.159 --> 00:15:01.559
I feel like they might need some pressure support.
00:15:01.740 --> 00:15:03.340
They might need intensive care. They might need
00:15:03.340 --> 00:15:05.659
escalation of care. And you get more specialists
00:15:05.659 --> 00:15:08.279
on board if you need them. It helps with your
00:15:08.279 --> 00:15:10.039
definition as well. Now we've covered definition.
00:15:10.320 --> 00:15:13.179
So I guess the next level I'm going to go, since
00:15:13.179 --> 00:15:15.419
we were talking about protecting the map. Let's
00:15:15.419 --> 00:15:17.080
go ahead and stay on that course for a second.
00:15:17.139 --> 00:15:19.620
We'll get to, I think, the real foundation of
00:15:19.620 --> 00:15:22.159
this, which is antibiotics. But let's go ahead
00:15:22.159 --> 00:15:24.919
and continue with pressers. We've talked about
00:15:24.919 --> 00:15:27.740
these in the past on the cardiogenic, but obviously
00:15:27.740 --> 00:15:30.399
now we're on a kind of a different shock. So
00:15:30.399 --> 00:15:32.700
we need to think about presser support and what
00:15:32.700 --> 00:15:35.179
that means for our patients. What's your go -to
00:15:35.179 --> 00:15:38.120
or what kind of ones can you go for? Sepsis.
00:15:38.559 --> 00:15:42.879
is equal to levophed. He's a levophed guy. Because
00:15:42.879 --> 00:15:45.480
you have to think about what's the main thing
00:15:45.480 --> 00:15:47.840
that's causing your patients to go into septic
00:15:47.840 --> 00:15:51.059
shock. Their SVR is gone because they're vasodilated
00:15:51.059 --> 00:15:54.179
everywhere. So the first thing that's going to
00:15:54.179 --> 00:15:56.500
help with this is your levophed. They compared,
00:15:56.639 --> 00:15:58.700
I think there was a trial comparing levophed
00:15:58.700 --> 00:16:02.039
to adrenaline because they both help with SVR.
00:16:02.080 --> 00:16:04.100
They found that levophed had a better outcome.
00:16:04.379 --> 00:16:07.480
So levophed is your go -to. It changed a lot.
00:16:07.600 --> 00:16:09.899
Previously, levophed was the last line because
00:16:09.899 --> 00:16:11.919
you're putting this patient on levophed after
00:16:11.919 --> 00:16:14.039
trying Hepis when you put them on diputamine
00:16:14.039 --> 00:16:16.139
because their chronic alpha is gone and you still
00:16:16.139 --> 00:16:18.480
haven't gotten anywhere. So it's the fourth.
00:16:18.679 --> 00:16:21.759
Now it changed. I've read other literature. or
00:16:21.759 --> 00:16:24.399
other resources that levophed tends to be the
00:16:24.399 --> 00:16:27.059
mainstay. We can get into dosing of levophed
00:16:27.059 --> 00:16:29.059
because I think dosing that we've talked about
00:16:29.059 --> 00:16:31.879
in the past is dosing of levophed does change
00:16:31.879 --> 00:16:35.259
from inotrophic to oppressor. There's also other
00:16:35.259 --> 00:16:37.480
studies that kind of do suggest that vasopressin
00:16:37.480 --> 00:16:39.639
could be first line as well. And there's like
00:16:39.639 --> 00:16:41.559
the VANISH trial, I think that mentions that
00:16:41.559 --> 00:16:46.460
vasopressin is okay. It's still playing on the
00:16:46.460 --> 00:16:49.600
same idea that I need something to increase my
00:16:49.600 --> 00:16:52.460
SVR, essentially. You're getting good outcome
00:16:52.460 --> 00:16:55.659
with the levophan because it has some eunotropic
00:16:55.659 --> 00:16:57.679
effect. That's how I think about it. If you're
00:16:57.679 --> 00:17:00.320
facing this tachycardic and you're afraid that
00:17:00.320 --> 00:17:03.200
they're still going to go into more tachyarrhythmia,
00:17:03.299 --> 00:17:05.799
you can think about vaso, but... Mostly, you're
00:17:05.799 --> 00:17:07.500
having that tachycardia because you're having
00:17:07.500 --> 00:17:09.339
hypop. That's how I think about it. I try and
00:17:09.339 --> 00:17:11.539
go oligophyte first. See how they do. If I'm
00:17:11.539 --> 00:17:13.900
escalating too fast, think about adding something
00:17:13.900 --> 00:17:16.119
else. Are you starting on the low -dose Levo?
00:17:16.200 --> 00:17:19.200
Are you moving towards the medium or higher doses?
00:17:19.619 --> 00:17:21.579
I'm moving towards the medium. I like staying
00:17:21.579 --> 00:17:23.599
in the medium dose. I don't like going high dose
00:17:23.599 --> 00:17:26.180
because on a high dose, you're going to have...
00:17:26.180 --> 00:17:29.160
Extra chronotrophy on top of the thing. You're
00:17:29.160 --> 00:17:31.000
going to have the tachycardia. You're going to
00:17:31.000 --> 00:17:33.180
have blemish skin because you're affecting the
00:17:33.180 --> 00:17:35.279
capillary perfusion. you're going to have severe
00:17:35.279 --> 00:17:37.920
ischemia up to the dry gangrene. I've seen that
00:17:37.920 --> 00:17:40.700
happen before, starting at a low dose of escalating,
00:17:40.700 --> 00:17:43.380
then I'm starting to go at a medium dose. I'm
00:17:43.380 --> 00:17:45.460
thinking about adding something else to help
00:17:45.460 --> 00:17:48.079
me. I'm not going to keep bumping up that levophed.
00:17:48.279 --> 00:17:50.740
That's the only one I have. No, you have a lot
00:17:50.740 --> 00:17:52.640
of other medications to help along. You have
00:17:52.640 --> 00:17:56.309
the vaso, you have the epi. We can add steroids.
00:17:56.630 --> 00:17:58.910
You have phenylephrine as well. Phenylephrine.
00:17:58.930 --> 00:18:01.029
You have a lot of other options. I think CAT
00:18:01.029 --> 00:18:03.930
trial indicates that epinephrine can also be
00:18:03.930 --> 00:18:06.369
considered. I think it was non -inferior to the
00:18:06.369 --> 00:18:09.380
norepinephrine. It's not in sheer, but... But
00:18:09.380 --> 00:18:11.759
there was a resource I was reading about how
00:18:11.759 --> 00:18:14.079
if you were pressing the patient, you're working
00:18:14.079 --> 00:18:15.980
on getting the blood pressure up, and let's say
00:18:15.980 --> 00:18:18.599
you're on norepinephrine, you're on vasopressin,
00:18:18.599 --> 00:18:21.119
and maybe you check on the heart, and the heart's
00:18:21.119 --> 00:18:23.099
just not squeezing quite the way you want. This
00:18:23.099 --> 00:18:24.700
is going a little bit back to the cardiogenic
00:18:24.700 --> 00:18:27.480
side of things. Epinephrine can be really great
00:18:27.480 --> 00:18:30.380
for that inotrophic support at low doses. So
00:18:30.380 --> 00:18:32.619
you have to remember that some of these patients
00:18:32.619 --> 00:18:35.289
are not going to be isolated. If you have severe
00:18:35.289 --> 00:18:37.910
sepsis, you have end organ damage. Heart is one
00:18:37.910 --> 00:18:40.769
of the organs. So you might have myocardial ischemia.
00:18:40.910 --> 00:18:43.109
You might have stunning of myocardium. You might
00:18:43.109 --> 00:18:45.490
have tachycephalus on top of everything. So it's
00:18:45.490 --> 00:18:47.529
not, I'm going to try this. And this is what
00:18:47.529 --> 00:18:49.789
the guidelines, there's no, I don't think I've
00:18:49.789 --> 00:18:52.809
read anyone that say you go through norepi first.
00:18:52.990 --> 00:18:55.920
That fails. You add this, you do this. I don't
00:18:55.920 --> 00:18:57.940
think I've seen anything like that. And again,
00:18:58.000 --> 00:19:00.059
this goes back to the art of medicine. You add
00:19:00.059 --> 00:19:03.279
things on, you can start taking things off. Sometimes
00:19:03.279 --> 00:19:05.900
you're on high dose norepinephrine, you're on
00:19:05.900 --> 00:19:08.259
vasopressin and pheninephrine. You can go down
00:19:08.259 --> 00:19:11.160
on the LevoFed and find that it has no difference.
00:19:11.940 --> 00:19:13.980
You have the LevoFed and you're still having
00:19:13.980 --> 00:19:16.819
the same benefits. So just a little bit of art.
00:19:16.900 --> 00:19:19.039
There are medications, there are oppressors that
00:19:19.039 --> 00:19:21.799
you want to avoid. Which ones? You have the dirty
00:19:21.799 --> 00:19:23.700
dope. Yeah, dopamine. We're going to hate on
00:19:23.700 --> 00:19:26.200
dopamine a lot. Yeah. There's really no good
00:19:26.200 --> 00:19:28.220
indication for it. There's no indication for
00:19:28.220 --> 00:19:31.140
dopamine in any... I've never seen it used. The
00:19:31.140 --> 00:19:33.700
only time I've seen it used, if it's bradycardia
00:19:33.700 --> 00:19:36.259
-induced and not a lot of people use it anymore,
00:19:36.440 --> 00:19:39.559
I'm just going to do epi. Like, let's not go
00:19:39.559 --> 00:19:42.599
down that pathway. Don't use dopamine. The other
00:19:42.599 --> 00:19:46.119
one I think is interesting, dobutamine, I think
00:19:46.119 --> 00:19:48.700
some people do use. I find it interesting because
00:19:48.700 --> 00:19:51.900
it has vasodilatory effect, and that can be problematic
00:19:51.900 --> 00:19:53.759
with a patient who already has vasodilation.
00:19:54.180 --> 00:19:57.759
It's not on its own. I don't think I've ever
00:19:57.759 --> 00:20:01.480
used dobutamine on its own for sepsis, for septic
00:20:01.480 --> 00:20:04.279
shock. You can use it as an add -on, like thinking
00:20:04.279 --> 00:20:07.440
he has a mixed picture of cardiogenic and septic
00:20:07.440 --> 00:20:09.769
shock, so I want to get it. good cardiac output
00:20:09.769 --> 00:20:13.490
and I want to titrate that SVR to a point that
00:20:13.490 --> 00:20:16.049
it's within normal. It's not too high, too low.
00:20:16.210 --> 00:20:19.349
So I always think of it as an add -on or a mixed
00:20:19.349 --> 00:20:21.750
picture that I use. Fair enough. And then, so
00:20:21.750 --> 00:20:23.650
I guess the general takeaway here on the presses
00:20:23.650 --> 00:20:26.289
is levophed is probably going to be your go -to.
00:20:26.410 --> 00:20:28.569
No one's going to fault you for starting levophed.
00:20:28.789 --> 00:20:31.250
You can do vasopressin, you can do epinephrine.
00:20:31.640 --> 00:20:33.880
You can start adding things on as you need things,
00:20:33.940 --> 00:20:36.339
as the blood pressure is allowing or does not
00:20:36.339 --> 00:20:38.960
allow. And then just keep in mind taking things
00:20:38.960 --> 00:20:42.000
off as you don't need them. Let's go to the final
00:20:42.000 --> 00:20:46.539
pillar of our septic shock antibiotics. I think
00:20:46.539 --> 00:20:48.400
I'm going to keep this relatively general because
00:20:48.400 --> 00:20:51.799
there's so many bugs that can cause septic shock.
00:20:52.000 --> 00:20:54.180
You can't really, we can't go into each and every
00:20:54.180 --> 00:20:56.740
one of them. But in a general sense, patients
00:20:56.740 --> 00:20:59.259
coming out of the ED, what would you start them
00:20:59.259 --> 00:21:01.250
on? I'm going to cover everything, right? You
00:21:01.250 --> 00:21:03.589
want to cover your gram positive, gram negative,
00:21:03.630 --> 00:21:05.950
and your MRSA. Essentially, I'm going to put
00:21:05.950 --> 00:21:08.549
them on vancomycin to cover that. Then I'm thinking
00:21:08.549 --> 00:21:10.609
I want to cover everything else. Then I put in
00:21:10.609 --> 00:21:13.289
mind, do they have kidney infection or not? So
00:21:13.289 --> 00:21:15.869
let's say they don't have kidney infection. I'm
00:21:15.869 --> 00:21:18.470
not just going to put them on zosyn and vancomycin
00:21:18.470 --> 00:21:20.289
because you're going to see a lot of kidney damage
00:21:20.289 --> 00:21:23.150
with that. I want to cover pseudomonas. I have
00:21:23.150 --> 00:21:25.470
the option of doing cefepime. It's going to give
00:21:25.470 --> 00:21:29.910
me almost the same coverage as zosyn. I'm thinking
00:21:29.910 --> 00:21:33.009
I want to cover anaerobics. I might add flagell
00:21:33.009 --> 00:21:36.230
on top of it. But I think most of us just do
00:21:36.230 --> 00:21:39.769
cefepime and vancomycin or zosyn vancomycin and
00:21:39.769 --> 00:21:42.910
see how they get out of that first 24 hours,
00:21:42.970 --> 00:21:46.089
48 hours and decide how to escalate or deescalate.
00:21:46.190 --> 00:21:48.029
If I have a patient that has already history
00:21:48.029 --> 00:21:51.069
of ESPL, like extended resistance, I'm going
00:21:51.069 --> 00:21:53.410
to guide my therapy pending that. I'm going to
00:21:53.410 --> 00:21:57.390
say meropenem from the get -go. Yeah. You could
00:21:57.390 --> 00:22:00.410
start with meropenem if you think of nosocomial
00:22:00.410 --> 00:22:04.269
infection. Cefepine does have a little bit of
00:22:04.269 --> 00:22:07.210
CNS penetration, so it can be better in that
00:22:07.210 --> 00:22:09.589
regard. I have also seen some literature now
00:22:09.589 --> 00:22:13.130
that says cefepine seems to prolong hospital
00:22:13.130 --> 00:22:16.690
delirium in older populations. Yeah, if you're
00:22:16.690 --> 00:22:20.349
thinking more older history of seizures, you
00:22:20.349 --> 00:22:23.069
want to stay about away from the cephalosporins.
00:22:23.549 --> 00:22:26.369
Because they tend to have more delirium, more
00:22:26.369 --> 00:22:29.190
seizure activity. So they tend to get away from
00:22:29.190 --> 00:22:32.730
them. But still, in that first 48 hours, everything
00:22:32.730 --> 00:22:36.069
is open for you. You try whatever you think is
00:22:36.069 --> 00:22:37.990
going to benefit the patient, depending on their
00:22:37.990 --> 00:22:40.609
previous cultures. And then if you're thinking
00:22:40.609 --> 00:22:43.369
maybe a MRSA, you had the vancomycin for coverage,
00:22:43.450 --> 00:22:45.549
and you're thinking maybe a pneumonia, get that
00:22:45.549 --> 00:22:50.009
MRSA, PCR swab. Get it negative and you can probably
00:22:50.009 --> 00:22:53.029
de -escalate that vancomycin. You can progression
00:22:53.029 --> 00:22:55.789
de -escalate your antibiotics as you figure out
00:22:55.789 --> 00:22:58.309
your blood culture results and as you figure
00:22:58.309 --> 00:23:00.549
out what kind of bug exactly you're dealing with.
00:23:00.690 --> 00:23:03.049
Other kind of add -ons here, if you're thinking
00:23:03.049 --> 00:23:04.910
community -acquired pneumonia, you can throw
00:23:04.910 --> 00:23:09.210
on azithromycin or doxycycline for atypical coverage.
00:23:09.589 --> 00:23:12.230
Tick -borne illnesses, we're not really in the
00:23:12.230 --> 00:23:14.650
tick area here, but you have your doxycycline
00:23:14.650 --> 00:23:17.519
still as an option for that. P. diff. If you're
00:23:17.519 --> 00:23:20.720
thinking C. diff, oral vanc, if you're thinking
00:23:20.720 --> 00:23:23.519
that they have previous resistance or they've
00:23:23.519 --> 00:23:26.400
had C. diff before and they didn't tolerate or
00:23:26.400 --> 00:23:29.000
didn't benefit from vancomycin. And then I don't
00:23:29.000 --> 00:23:31.299
know how much evidence is for this one. One of
00:23:31.299 --> 00:23:33.680
my resources talked about if you're thinking
00:23:33.680 --> 00:23:36.980
about toxin suppression of using clindamycin
00:23:36.980 --> 00:23:39.859
and then with that one, just that clinda goes
00:23:39.859 --> 00:23:42.839
first, give clinda first and then give you other
00:23:42.839 --> 00:23:45.900
stuff. Again, I haven't done a whole lot of research
00:23:45.900 --> 00:23:49.339
on that. A lot of infectious disease people think
00:23:49.339 --> 00:23:51.920
about adding clindamycin just for the toxins.
00:23:52.039 --> 00:23:54.480
I've seen a lot of them say, oh, it doesn't really
00:23:54.480 --> 00:23:56.779
show benefit. Just treat the infection, treat
00:23:56.779 --> 00:23:59.259
everything. But if you're thinking this is gas
00:23:59.259 --> 00:24:02.079
forming, you want to cover everything. So just
00:24:02.079 --> 00:24:04.920
throw the clind on and see what else is going
00:24:04.920 --> 00:24:07.880
on. And then finally, this is the pillar. I think
00:24:07.880 --> 00:24:09.599
this is the biggest pillar. Obviously, if someone
00:24:09.599 --> 00:24:11.799
is sick, has a bacterial infection, clearing
00:24:11.799 --> 00:24:13.519
that is going to be paramount. It's going to
00:24:13.519 --> 00:24:15.440
clear the way for the patient getting better.
00:24:15.579 --> 00:24:18.180
The compressors can keep someone alive. Fluids
00:24:18.180 --> 00:24:20.339
can, I guess, keep the blood pressure up a little
00:24:20.339 --> 00:24:22.619
bit. But in the end, you're going to want that
00:24:22.619 --> 00:24:24.680
source of control. Source of control is bacteria.
00:24:24.900 --> 00:24:27.019
So source of control is going to be key. So these
00:24:27.019 --> 00:24:29.539
patients have lines. Think about getting rid
00:24:29.539 --> 00:24:31.900
of them. If they have ports that might be infected,
00:24:32.200 --> 00:24:34.630
maybe it's... It's time to take them out. Time
00:24:34.630 --> 00:24:35.890
to take them out depending on your bacteria.
00:24:36.150 --> 00:24:38.410
Talk to your ID doctor. Talk to your specialist
00:24:38.410 --> 00:24:40.509
if that's something that needs to happen. They
00:24:40.509 --> 00:24:42.789
add hardware like a hip replacement and they
00:24:42.789 --> 00:24:45.549
have a pretty severely infected incision site.
00:24:45.769 --> 00:24:48.369
Got to talk to your orthodox and see does that
00:24:48.369 --> 00:24:51.849
infection seed into the prosthesis, endocarditis.
00:24:52.029 --> 00:24:54.390
You got to look into all these different things.
00:24:54.859 --> 00:24:57.000
Blood cultures, follow those up. If they have
00:24:57.000 --> 00:24:59.960
bacteremia, treat with antibiotics. Retake your
00:24:59.960 --> 00:25:01.759
blood cultures, see if you're actually making
00:25:01.759 --> 00:25:04.220
progress. But source control is going to be important.
00:25:04.319 --> 00:25:07.160
If you have abdominal abscesses and stuff like
00:25:07.160 --> 00:25:09.619
that, talk to your surgeons and see about draining
00:25:09.619 --> 00:25:12.519
those. Even IR drainage might be something that
00:25:12.519 --> 00:25:14.359
could be offered. Because if you don't have source
00:25:14.359 --> 00:25:16.539
control, you may not actually end up ever clearing
00:25:16.539 --> 00:25:18.720
this infection. I would say just the pearls and
00:25:18.720 --> 00:25:22.279
pitfalls here, there are... Some mimics of sepsis,
00:25:22.279 --> 00:25:24.299
like they're not true sepsis, but they might
00:25:24.299 --> 00:25:26.980
make you think of sepsis. Under the endocrine
00:25:26.980 --> 00:25:29.099
header, you got your adrenal crisis. You have
00:25:29.099 --> 00:25:32.359
your thyroid storm, your DKA. Sometimes they
00:25:32.359 --> 00:25:35.920
look like sepsis, but they're not. So don't be
00:25:35.920 --> 00:25:38.319
totally fooled. Just be aware of some of that
00:25:38.319 --> 00:25:40.079
stuff. There are some of your labs that can lead
00:25:40.079 --> 00:25:42.380
you down different pathways. And also consider
00:25:42.380 --> 00:25:47.740
like in DKA, you can have sepsis. and DKA. They're
00:25:47.740 --> 00:25:50.400
not mutually exclusive. Yeah. Sepsis presents
00:25:50.400 --> 00:25:53.160
as DKA. They don't have the other symptoms. Yeah,
00:25:53.180 --> 00:25:55.200
they just have the DKA. And then other things
00:25:55.200 --> 00:25:57.700
like pancreatitis can make some people have the
00:25:57.700 --> 00:26:00.359
knowledge of vomiting, some hypotension. Just
00:26:00.359 --> 00:26:02.839
be aware of that. You can get some lipase, get
00:26:02.839 --> 00:26:05.640
a CT scan of the abdomen. Fulminant liver failure
00:26:05.640 --> 00:26:09.220
can sometimes mask itself as kind of sepsis -like.
00:26:09.660 --> 00:26:12.980
bowel obstruction, acute mesenteric ischemia,
00:26:13.220 --> 00:26:16.759
can also present a little bit like sepsis. You
00:26:16.759 --> 00:26:19.880
have your PGAP pneumonia, and then your endocarditis
00:26:19.880 --> 00:26:24.539
can be sepsis, true sepsis, or if you have valvular
00:26:24.539 --> 00:26:28.799
dysfunctions, it can be more shocky and not necessarily
00:26:28.799 --> 00:26:31.700
sepsis. So it's just, there's a little bit of
00:26:31.700 --> 00:26:36.019
a difference there. It's not very clear. As we
00:26:36.019 --> 00:26:38.220
said, it's like you have to look at everything.
00:26:38.799 --> 00:26:41.039
Make sure you don't miss anything. You have to
00:26:41.039 --> 00:26:43.519
think about each and every organ. The way I think
00:26:43.519 --> 00:26:46.940
about these shocky patients, you have to examine
00:26:46.940 --> 00:26:49.519
them from head to toe, look at their medications,
00:26:49.740 --> 00:26:52.720
think about everything that might cause them
00:26:52.720 --> 00:26:55.779
to have this. It's not just, oh, they might have
00:26:55.779 --> 00:26:57.980
vectorinia and they might have this. It's like
00:26:57.980 --> 00:27:00.960
looking at everything together, making a full
00:27:00.960 --> 00:27:03.279
picture of what you have, what you don't have,
00:27:03.500 --> 00:27:07.180
what you're missing to make this work. All right.
00:27:07.240 --> 00:27:09.059
Is there anything else? This is a pretty big
00:27:09.059 --> 00:27:10.819
topic. We spent a little bit of time on it, but
00:27:10.819 --> 00:27:14.000
anything else we need to hit on? The only thing
00:27:14.000 --> 00:27:17.940
is steroids. Think about them when you're having
00:27:17.940 --> 00:27:21.880
less of a response to vasopressins. You can try
00:27:21.880 --> 00:27:25.680
and add a steroid because you have adrenal insufficiency
00:27:25.680 --> 00:27:29.779
in most of these patients happen along when they're
00:27:29.779 --> 00:27:32.660
having septic shocks. Their adrenal is extra
00:27:32.660 --> 00:27:36.450
credit if you know the dose. 200 to 300 milligrams
00:27:36.450 --> 00:27:40.750
per 24 hours, every 24 hours. Is it the hydrocortisone?
00:27:40.910 --> 00:27:43.250
Hydrocortisone. Oh, I've heard of like decradon,
00:27:43.250 --> 00:27:48.690
six milligrams. For sepsis, I've always heard
00:27:48.690 --> 00:27:52.029
hydrocortisone is okay to go to because it has
00:27:52.029 --> 00:27:56.339
both mineral and... glucocorticoid effect. So
00:27:56.339 --> 00:27:58.880
DEXA is more glucocorticoid. You're going to
00:27:58.880 --> 00:28:02.660
use it more in your ARDS patients, your COVID
00:28:02.660 --> 00:28:05.539
patients. Because it's more glucocorticoid, you
00:28:05.539 --> 00:28:09.279
can add aminocorticoid to it. If you're thinking
00:28:09.279 --> 00:28:12.380
this is sepsis, this is septic shock, go ahead
00:28:12.380 --> 00:28:15.200
and do the hydrocortisone at a high dose and
00:28:15.200 --> 00:28:18.200
see how they respond. All right. So we will be
00:28:18.200 --> 00:28:21.140
back with other parts of distributed shock in
00:28:21.140 --> 00:28:23.549
the future. This is just a big one. I think we're
00:28:23.549 --> 00:28:25.970
already at 35 minutes. So we will see you how
00:28:25.970 --> 00:28:29.150
we go. Thank you, guys. Thank you for listening
00:28:29.150 --> 00:28:31.329
to the podcast. I am Basics. I want to thank
00:28:31.329 --> 00:28:33.329
the residents who took part in this show. It
00:28:33.329 --> 00:28:35.109
could not have been done without them. We hope
00:28:35.109 --> 00:28:36.829
you enjoyed this production. And if you did,
00:28:36.890 --> 00:28:38.990
please rate and review on Apple Podcasts. If
00:28:38.990 --> 00:28:41.009
you especially found it useful, share us with
00:28:41.009 --> 00:28:41.809
your friends and colleagues.
