252 ) A 75 year old african-american woman with history of Alzheimer’s dementia and recent cerebro-vascular accident is transferred from the Nursing home for deterioration in mental status and fever. As per the nursing home staff, she has stopped feeding and has been having fever for the past three days. On examination, her temperature is 102F, Heart rate is 130/min, Respiratory rate 28/min and Blood pressure 80/45 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A foley catheter is in place draining very cloudy urine. Dipstick urinalysis revealed 2+ protein, positive leucoesterase and nitrite. Blood cultures are obtained and the intravenous normal saline is started via. two large bore needles. Which of the following is the most important next step in managing this patient?
A) Put in reverse trendelenberg position
B) Place a central venos catheter
C) Start Dopamie infusion via. peripheral access
D) Intravenous Hydrocortisone
E) Obtain Arterial Blood Gas analysis
note: Surviving Sepsis guidelines
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C
e
B
B – to figure out the central venous oxygen saturation to be higher than 70%. also dopamine or norepi first choice need to be given centrally.
B) Place a central venos catheter
B………
First…Supplemental oxygen + endotracheal intubation and mechanical ventilation
Second……Central venous and arterial catheterization. Sedation and then……. elements must be accomplished within the first 6 h of presentation
• Early goal directed resuscitation of the septic patient within the first 6
hours after recognition (1C)
• Administration of either crystalloid or colloid fluid resuscitation (1B)
• Vasopressor preference for norepinephrine or dopamine to maintain an initial target mean arterial pressure > 65 mmHg (1C)
• Stress dose steroid therapy given only in septic shock after blood
pressure is identified to be poorly responsive to fluid and vasopressor
therapy (2C)
• Recombinant activated protein C in patients with severe sepsis and
clinical assessment of high risk for death (2B except 2C for postoperative
patients)
• Institution of glycemic control targeting a blood glucose of < 150 mg/dL
after initial stabilization