Question of the Week # 253

253 )  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. In managing her Septic Shock, which of the following is the most appropriate goal that must be met in the first 6 hours of adequate resuscitation?

A) Mean Arterial Blood pressure > 50mm Hg

B) Serum Creatinine < 1.5 mg%

C) Urine output > 0.25ml/kg/hr

D) Mixed Venous Saturation > 65%

E) Hematocrit > 30%

Note: Surviving Sepsis guidelines

10 Responses

  1. I dont know is it C

  2. a

  3. Ans.D.

    http://ssc.sccm.org/6hr_bundles

  4. C

  5. D

  6. d
    Surviving Sepsis Work Up
    1) Serum Lactate
    2) Blood Cultures
    3) Broad Spectrum Abx
    4) Map > 65
    5) CVP > 8 or central venous oxygen > 70% or mixed venous oxygen > 65%

  7. D) Mixed Venous Saturation > 65%

  8. D…….The resuscitation bundle is a combination of evidence-based objectives that must be completed within 6 h for patients presenting with severe sepsis, septic shock, and/or lactate >4 mmol/L (36 mg/dL).

    For patients with severe sepsis, as many as seven bundle elements must be accomplished within the first 6 h of presentation.

    •Measure serum lactate
    •Obtain blood cultures prior to antibiotic administration
    •Broad-spectrum antibiotic within 3 h of ED admission and within 1 h of non-ED admission (improved time to administration)
    •Treat hypotension and/or elevated lactate with fluids
    •Administer vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) >65 mmHg.
    In the event of persistent hypertension despite fluid resuscitation (septic shock) and/or lactate >4 mmol/L, maintain adequate central venous pressure (CVP) and central venous oxygen saturation

    •Achieve a CVP of >8 mmHg
    •Achieve central venous oxygen saturation (ScvO2) >70% or mixed venous oxygen saturation (SvO2) >65%.

  9. d

  10. D) A. Initial Resuscitation

    1. Protocolized, quantitative resuscitation of patients with sepsis-induced tissue
    hypoperfusion (defined in this document as hypotension persisting after initial fluid
    challenge or blood lactate concentration ≥ 4 mmol/L). Goals during the first 6 hrs of
    resuscitation:
    a) Central venous pressure 8–12 mm Hg
    b) Mean arterial pressure (MAP) ≥ 65 mm Hg
    c) Urine output ≥ 0.5 mL/kg/hr
    d) Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%,
    respectively (grade 1C).

    2. In patients with elevated lactate levels targeting resuscitation to normalize lactate
    (grade 2C).

    B. Screening for Sepsis and Performance Improvement

    1. Routine screening of potentially infected seriously ill patients for severe sepsis to allow
    earlier implementation of therapy (grade 1C).

    2. Hospital–based performance improvement efforts in severe sepsis (UG).

    C. Diagnosis

    1. Cultures as clinically appropriate before antimicrobial therapy if no significant delay
    (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures
    (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least
    1 drawn percutaneously and 1 drawn through each vascular access device, unless the
    device was recently (<48 hrs) inserted (grade 1C).

    2. Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody
    assays (2C), if available, and invasive candidiasis is in differential diagnosis of cause of
    infection.

    3. Imaging studies performed promptly to confirm a potential source of infection (UG)

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