Is there a role for protein C?
Protein C is usually decreased in sepsis resulting in multivascular thrombosis.
However, Cochrane study do not support this and may lead to more bleeding…River’s disagrees and gives it early, if you are going to give it at all
River’s usually does not give until 12 hours, still hypotensive, not improving, and APACHE greater than or equal to 25
It works best in patients with PNEUMONIA!How do you implement EGDT in the community?
There must be a collaborative effort between the ED and ICU, or a networking with other hospitals.Future of sepsis…is in the ED
IL-1 peaks at 6 hours so if you give receptor antagonist in this time then may show some benefit. Same goes for TNF-alpha antagonist. These meds need to be given in the ED.
Statins in shock?
Some studies show a decrease severe sepsis and acute lung injury and mortality reduction. However, this is controversial.
River’s suspects there are some confounders to the studies that say statins are beneficial.
What do you do for a patient that is tachycardic and has myocardial depression?
Rivers believes in getting Hgb to 10 and optimal time for transfusion is at ScvO2 of 69.5.
Rivers considers .5mg Digoxin or Dobutamine….he does not recommend beta blockers.
If ScvO2 is still low then consider intubation.
Who gets steroids?
Patient who has reached end points, ie 6 liters, on pressors
Rivers still believes in measuring cortisol levels
Sometimes, patient actually just has myocardial depression and may only need dobutamine to get off levophed
MAP =SVR x CO….volume replete, give vasopressors, optimize hgb, inotrope as needed, and then if still on pressors, draw cortisol and give hydrocortisone
What about procalcitonin as a marker for sepsis?
May not rise for 6 hours…long time to wait to give abx…we can usually diagnose sepsis clinically without this and give abx as early as possible
However, could possibly use serial procalcitonin for when to stop abx later when they are trending down. Has its place not on the front lines.
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