Resuscitation Before Emergency Surgeries FEIRAN LOU SUNY DOWNSTATE MEDICAL CENTER KINGS COUNTY HOSPITAL
|
|
|
- Abigail Dennis
- 6 years ago
- Views:
Transcription
1 Resuscitation Before Emergency Surgeries FEIRAN LOU SUNY DOWNSTATE MEDICAL CENTER KINGS COUNTY HOSPITAL
2 Case 73 yo woman h/o HTN three days abdominal pain and nausea. The pain was diffuse, cramp-like, intermittent. No exacerbating or relieving factors No vomiting No flatus or BM for 1 day No prior abdominal surgeries
3 Case PM/SH: HTN CVA 10 years ago, no residual deficits Gyn cancer 25 years ago s/p cobalt radiation Last c-scope 7 years ago, negative Meds: vasotec Allergies: None SH: ex-40-pack-year smoker
4 Case PE 97.3, 154/109, 124, 20, 98% NAD S1, S2, CTAB Abd: soft, distended, + bowel sounds, diffuse mild to moderate tenderness without guarding or rebound DRE: No stool, no masses, + mucoid discharge, no gross blood, + guiac Ext: wwp, no edema
5 Case Laboratory CBC Coags 10.2/0.9/27.1 BMP BE 1.3 Lactate 5.0
6 CT abd/pelvis w/o IV contrast
7 CT abd/pelvis w/o IV contrast
8 CT abd/pelvis w/o IV contrast
9 After 4 hours NGT placed with 700 cc of bilious output Foley, 2 IV s placed Initial urine 75 cc 3 liters of NS boluses After boluses, urine output cc/hr
10 After 4 hours Labs: Lactate 2.4 BE -0.6 CBC BMP
11 After 6 hours Seizure activity (?) Acute desaturation to 80% Decreased responsiveness Intubated for airway protection Emergent CT head: negative Taken to OR for exploratory laparotomy
12 OR Course 2 segments nonviable small bowel No perforation 95 cm segment in the ileum, 50 cm from ileocecal valve 8 cm segment in the jejunum Resected with primary anastomosis
13 OR Course Rest of bowel viable No palpable SMA pulse at root of mesentery Brisk arterial bleeding at distal mesentery and resection sites
14 POD 0: CTA abd/pelvis proximal obstruction of the SMA collateralization of distal SMA branches narrowing at the origin of the celiac artery distal celiac branches well opacified IMA patent
15 Post Operative Course POD 1 heparin gtt started POD 4 ventilator associated pneumonia POD 7 enteral feeds, TPN POD 10 NSTEMI POD 12 tracheostomy POD 17 hemodialysis Remains in ICU, vent and dialysis dependent
16 Topics Monitoring and resuscitating patients prior to emergency surgery Endpoints of resuscitation
17 Resuscitation for Emergency Surgeries Shock 1. Hypovolemic (hemorrhagic) 2. Distributive (sepsis) 3. Obstructive (cardiac tamponade) 4. Cardiogenic (primary pump failure) 5. Endocrine (Addisonian crisis)
18 Monitoring Methods Central venous pressure monitoring Right ventricular filling pressure, CVP Pulmonary artery catheter monitoring Left ventricular filling pressure PA pressure PA wedge pressure CO/CI Mixed venous sat SVR PVR Stroke volume
19
20 Survival Survival w/o vent
21 PA Catheter International consensus conference: Against the routine use of the PAC in shock Use in critical pts with acute coronary syndrome mortality
22 Echocardiography Ventricular function Volume status Cardiac output (esophageal doppler) Operator dependent More useful in diagnosis than monitoring
23 Minimally Invasive Arterial Pressure Waveform Systems Basic principle Relationship between pulse pressure and stroke volume Systolic pressure variation predicts fluid responsiveness to volume loading
24
25 Fluid Administration
26 Types of Fluid Administration Crystalloids Colloids Hypertonic Saline Blood products
27 Types of Fluid Administration Crystalloids Normal Saline, Lactate Ringers Advantage: Inexpensive, plentiful Rapid equilibration across interstitial and intravascular compartments Disadvantages NS-hypertonic, hyperchloremic metabolic acidosis LR-possible immune modulation Limited use in hemorrhaging patients
28 Types of Fluid Administration Colloids Albumin, hydroxy ethyl starch, dextran Advantages: remain in the intravascular compartment improve microcirculation and MAP, anti-inflammatory (?) Disadvantages: expensive, meta-analysis of clinical studies showed no significant improvement in survival
29 Types of Fluid Administration Hypertonic saline Smaller volumes (1:1.5 vs 1:3) circulating volume complications from large volume resuscitation: pulmonary edema, TBW, coagulopathy No significant improvement in survival in hemorrhagic shock
30 Adjuvant Therapies for Resuscitation Hypotensive despite aggressive fluid resuscitation Patients who received crystalloids in the first 12 hours had higher survival than those who received pressors Vasopressors Levophed, phenylephrine, vasopressin, etc Inotropes Dobutamine, milrinone, etc
31 RECEPTOR ACTIVITY HEMODYNAMIC RESPONSE DRUG α β 1 β 2 HR MAP CO SVR Dopamine (-) ++ (-) (-) Dobutamine (-) ++ + Norepinephrine ++ + (-) Phenylephrine ++ (-) (-) Epinephrine (-) Isoproterenol (-) ++ + Amiodarone Milrinone
32 End Points of Early Resuscitation Hemorrhagic shock Septic shock
33 Early Resuscitation in Hemorrhage Shock Greatest risk: exsanguination Almost always more important to achieve surgical control than to wait for additional monitoring Frequent assessment of arterial blood gas (BE, lactate levels) instead of CBC, coags
34 Early Fluid Resuscitation in Hemorrhagic Shock Large fluid bolus wash off fragile early clots Dilution of the clotting system Progressive hypothermia if fluids not warmed Animal models: attempts to normalize blood pressure are counterproductive Increased rebleeding and total blood loss Reduced survival
35 Prospective randomized trial Immediate vs delayed fluid resuscitation (no fluid resuscitation until OR) 598 adults with penetrating torso with SBP <90 mmhg
36
37 Early Resuscitation of Emergency Surgery Patients not bleeding Greatest risk: septic shock Fluids administration is beneficial Early support of intravascular volume will facilitate organ system perfusion during initial resuscitation In contrast to hemorrhaging patient: more benefit early than late Early goal-directed resuscitation
38 Randomized control trial Cohort: pts with severe sepsis or septic shock Control: standard therapy Intervention: 6 hours of early goal-directed therapy 130 assigned to intervention group, 133 in control group
39
40
41
42 Initial Resuscitation Goals during the first 6 hours of resuscitation: A. Central venous pressure 8-12 mm Hg B. Mean arterial pressure (MAP) 65 mmhg C. Urine output 0.5 ml/kg/hr D. Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively E. Patients with elevated lactate levels targeting resuscitation to normalized lactate
43 Antimicrobial Therapy Administration within the first hour Effective against all likely pathogens Assessment for de-escalation
44 Vasopressors Initial target MAP 65 Norepinephrine: first choice vasopressor Vasopressin can be added to norepinephrine Epinephrine: second line
45 Conclusions End Points of Early Resuscitation Complex Causes for emergency surgery Expectations of the course No absolute numeric targets Patient age, comorbidity, degree of instability Impact of surgery: tissue injury, blood loss
46 Thank you
47 Questions A 65 yo woman is admitted to the ICU after exploratory laparotomy for sigmoid diverticulitis. She is brought to the ICU intubated. Her vital signs are a temperature of 97.5, HR 105, BP 70/50, SaO2 96%. In the first hour her urine output is 20 ml; she has received 4L of crystalloid and 1 unit of PRBCs. Her CVP is 10 mmhg but she remains hypotensive. Choose the next intervention that will be the most beneficial. A. Additional 2L of a normal saline bolus B. Hydrocortisone, 100 mg intravenously C. Administration of furosemide for low urine output D. Initiation of norepinephrine E. Initiation of dobutamine
48 Question Which of the goals is not included in the initial resuscitation recommended in the Surviving Sepsis Guidelines? A. Target CVP of 8-12 mmhg B. Mixed venous > 70% C. Institution of antibiotics within 12 hours of admission D. MAP higher than 65 mmhg E. Urine output greater than 0.5 ml/kg
49
50 Ultimate End Points of Resuscitation After Successful Surgical Control Awake, functional, hemodynamically stable patient Normality in vital signs, labs, organ system functions
51 After surgery, patients who achieved supranormal values of CO, DO2, and VO2 had reduced morbidity and mortality
52 Normal vs. Supranormal State Many studies comparing supranormal vs. normal states yielded mixed results Biases in supranormal studies Attempting to push patients into supranormal states with inotropic agents is not likely to be successful
Presented by: Indah Dwi Pratiwi
Presented by: Indah Dwi Pratiwi Normal Fluid Requirements Resuscitation Fluids Goals of Resuscitation Maintain normal body temperature In most cases, elevate the feet and legs above the level of the heart
Case Scenario 3: Shock and Sepsis
Name: Molly Boyle 1. Define the term shock (Lewis textbook): Shock is a syndrome characterized by decreased perfusion and impaired metabolism. Shock can have a number of causes that result in damage to
DESIGNER RESUSCITATION: TITRATING TO TISSUE NEEDS
DESIGNER RESUSCITATION: TITRATING TO TISSUE NEEDS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical School of Rowan University Chief of Medicine Cooper University Hospital
Introduction. Invasive Hemodynamic Monitoring. Determinants of Cardiovascular Function. Cardiovascular System. Hemodynamic Monitoring
Introduction Invasive Hemodynamic Monitoring Audis Bethea, Pharm.D. Assistant Professor Therapeutics IV January 21, 2004 Hemodynamic monitoring is necessary to assess and manage shock Information obtained
SHOCK. Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital
SHOCK Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital 1 Definition Shock is an acute, complex state of circulatory dysfunction
John Park, MD Assistant Professor of Medicine
John Park, MD Assistant Professor of Medicine Faculty photo will be placed here park.john@mayo.edu 2015 MFMER 3543652-1 Sepsis Out with the Old, In with the New Mayo School of Continuous Professional Development
Shock and hemodynamic monitorization. Nilüfer Yalındağ Öztürk Marmara University Pendik Research and Training Hospital
Shock and hemodynamic monitorization Nilüfer Yalındağ Öztürk Marmara University Pendik Research and Training Hospital Shock Leading cause of morbidity and mortality Worldwide: dehydration and hypovolemic
Case year old female nursing home resident with a hx CAD, PUD, recent hip fracture Transferred to ED with decreased mental status BP in ED 80/50
Case 1 65 year old female nursing home resident with a hx CAD, PUD, recent hip fracture Transferred to ED with decreased mental status BP in ED 80/50 Case 1 65 year old female nursing home resident with
Staging Sepsis for the Emergency Department: Physician
Staging Sepsis for the Emergency Department: Physician Sepsis Continuum 1 Sepsis Continuum SIRS = 2 or more clinical criteria, resulting in Systemic Inflammatory Response Syndrome Sepsis = SIRS + proven/suspected
HYPOVOLEMIA AND HEMORRHAGE UPDATE ON VOLUME RESUSCITATION HEMORRHAGE AND HYPOVOLEMIA DISTRIBUTION OF BODY FLUIDS 11/7/2015
UPDATE ON VOLUME RESUSCITATION HYPOVOLEMIA AND HEMORRHAGE HUMAN CIRCULATORY SYSTEM OPERATES WITH A SMALL VOLUME AND A VERY EFFICIENT VOLUME RESPONSIVE PUMP. HOWEVER THIS PUMP FAILS QUICKLY WITH VOLUME
Surviving Sepsis Campaign Guidelines 2012 & Update for David E. Tannehill, DO Critical Care Medicine Mercy Hospital St.
Surviving Sepsis Campaign Guidelines 2012 & Update for 2015 David E. Tannehill, DO Critical Care Medicine Mercy Hospital St. Louis Be appropriately aggressive the longer one delays aggressive metabolic
Objectives. Epidemiology of Sepsis. Review Guidelines for Resuscitation. Tx: EGDT, timing/choice of abx, activated
Update on Surviving Sepsis 2008 Objectives Epidemiology of Sepsis Definition of Sepsis and Septic Shock Review Guidelines for Resuscitation Dx: Lactate, t cultures, SVO2 Tx: EGDT, timing/choice of abx,
Sepsis: Identification and Management in an Acute Care Setting
Sepsis: Identification and Management in an Acute Care Setting Dr. Barbara M. Mills DNP Director Rapid Response Team/ Code Resuscitation Stony Brook University Medical Center SEPSIS LECTURE NPA 2018 OBJECTIVES
Rounds in the ICU. Eran Segal, MD Director General ICU Sheba Medical Center
Rounds in the ICU Eran Segal, MD Director General ICU Sheba Medical Center Real Clinical cases (including our mistakes) Emphasis on hemodynamic monitoring Usually no single correct answer We will conduct
Evidence-Based. Management of Severe Sepsis. What is the BP Target?
Evidence-Based Management of Severe Sepsis Michael A. Gropper, MD, PhD Professor and Vice Chair of Anesthesia Director, Critical Care Medicine Chair, Quality Improvment University of California San Francisco
Sepsis is an important issue. Clinician s decision-making capability. Guideline recommendations
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 Clinicians decision-making capability Guideline recommendations Sepsis is an important issue 8.7%
R2R: Severe sepsis/septic shock. Surat Tongyoo Critical care medicine Siriraj Hospital
R2R: Severe sepsis/septic shock Surat Tongyoo Critical care medicine Siriraj Hospital Diagnostic criteria ACCP/SCCM consensus conference 1991 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference
Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE
Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE In critically ill patients: too little fluid Low preload,
Septic Shock. Rontgene M. Solante, MD, FPCP,FPSMID
Septic Shock Rontgene M. Solante, MD, FPCP,FPSMID Learning Objectives Identify situations wherein high or low BP are hemodynamically significant Recognize complications arising from BP emergencies Manage
Sepsis Management: Past, Present, and Future
Sepsis Management: Past, Present, and Future Benjamin Ferrell, MD Tennessee ACP Meeting October 28, 2017 Learning Objectives Identify the most updated definition and clinical criteria for sepsis Describe
Objectives. Management of Septic Shock. Definitions Progression of sepsis. Epidemiology of severe sepsis. Major goals of therapy
Objectives Management of Septic Shock Review of the Evidence and Implementation of Pediatric Guidelines at Christus Santa Rosa Manish Desai, M.D. PL 5 2 nd year Pediatric Critical Care Fellow Review of
The Septic Patient. Dr Arunraj Navaratnarajah. Renal SpR Imperial College NHS Healthcare Trust
The Septic Patient Dr Arunraj Navaratnarajah Renal SpR Imperial College NHS Healthcare Trust Objectives of this session Define SIRS / sepsis / severe sepsis / septic shock Early recognition of Sepsis The
Titrating Critical Care Medications
Titrating Critical Care Medications Chad Johnson, MSN (NED), RN, CNCC(C), CNS-cc Clinical Nurse Specialist: Critical Care and Neurosurgical Services E-mail: johnsoc@tbh.net Copyright 2017 1 Learning Objectives
Dilemmas in Septic Shock
Dilemmas in Septic Shock William Janssen, M.D. Assistant Professor of Medicine National Jewish Health University of Colorado Denver Health Sciences Center A 62 year-old female presents to the ED with fever,
Patient Safety Safe Table Webcast: Sepsis (Part III and IV) December 17, 2014
Patient Safety Safe Table Webcast: Sepsis (Part III and IV) December 17, 2014 Presenters Mark Blaney, RN Regional Nurse Educator CHI Franciscan Health Karen Lautermilch Director, Quality & Performance
The Hypotensive Poisoned Patient. Robert S. Hoffman, MD Director, NYC PCC
The Hypotensive Poisoned Patient Robert S. Hoffman, MD Director, NYC PCC Some Definitions Hypotension = Low blood pressure Failure of macrocirculation Shock = Poor tissue perfusion Failure of microcirculation
HYPOTENSION IS DANGEROUS C. R Y A N K E A Y, M D, F A C E P 1 6 M A R C H
HYPOTENSION IS DANGEROUS C. R Y A N K E A Y, M D, F A C E P 1 6 M A R C H 2 0 1 8 OBJECTIVES Case-based overview of pressors Debunking pressor myths Utilizing push-dose pressors CASE 1 82-year old male,
Vasoactive Medications. Matthew J. Korobey Pharm.D., BCCCP Critical Care Clinical Specialist Mercy St. Louis
Vasoactive Medications Matthew J. Korobey Pharm.D., BCCCP Critical Care Clinical Specialist Mercy St. Louis Objectives List components of physiology involved in blood pressure Review terminology related
INTENSIVE CARE MEDICINE CPD EVENING. Dr Alastair Morgan Wednesday 13 th September 2017
INTENSIVE CARE MEDICINE CPD EVENING Dr Alastair Morgan Wednesday 13 th September 2017 WHAT IS NEW IN ICU? (RELEVANT TO ANAESTHETISTS) Not much! SURVIVING SEPSIS How many deaths in England were thought
Sepsis Bundle Project (SEP) Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: April 2015 Most recent Revision: December 2018
Sepsis Bundle Project (SEP) Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: April 2015 Most recent Revision: December 2018 Objectives 1. To identify the symptom of severe sepsis and septic shock syndrome.
Goal-directed resuscitation in sepsis; a case-based approach
Goal-directed resuscitation in sepsis; a case-based approach Jorge A Guzman, MD, FCCM Head, Section Critical Care Medicine Respiratory Institute Cleveland Clinic Foundation The challenges to managing septic
How and why I give IV fluid Disclosures SCA Fluids and public health 4/1/15. Andrew Shaw MB FRCA FCCM FFICM
How and why I give IV fluid Andrew Shaw MB FRCA FCCM FFICM Professor and Chief Cardiothoracic Anesthesiology Vanderbilt University Medical Center 2015 Disclosures Consultant for Grifols manufacturer of
Frank Sebat, MD - June 29, 2006
Types of Shock Hypovolemic Shock Low blood volume decreasing cardiac output. AN INTEGRATED SYSTEM OF CARE FOR PATIENTS AT RISK SHOCK TEAM and RAPID RESPONSE TEAM Septic or Distributive Shock Decrease in
Sepsis Management Update 2014
Sepsis Management Update 2014 Laura J. Moore, MD, FACS Associate Professor, Department of Surgery The University of Texas Health Science Center, Houston Medical Director, Shock Trauma ICU Texas Trauma
12/1/2009. Chapter 19: Hemorrhage. Hemorrhage and Shock Occurs when there is a disruption or leak in the vascular system Internal hemorrhage
Chapter 19: Hemorrhage Hemorrhage and Shock Occurs when there is a disruption or leak in the vascular system External hemorrhage Internal hemorrhage Associated with higher morbidity and mortality than
Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium
Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium MARIA E. MANDICH MD Fairbanks Memorial Hospital Emergency Department Attending Physician Interior Region EMS Council Medical Director
Case I: Shock. A) What additional history would you like from the nursing home staff, patient s chart, and ambulance team?
Case I: Shock It is your first night of call during your subinternship month, and you are asked by your resident to evaluate a patient in the emergency room. The patient is a 85yo female with a history
What is. InSpectra StO 2?
What is InSpectra StO 2? www.htibiomeasurement.com What is InSpectra StO 2? Hemoglobin O 2 saturation is measured in three areas: 1) Arterial (SaO 2, SpO 2 ) Assesses how well oxygen is loading onto hemoglobin
6/5/2014. Sepsis Management and Hemodynamics. 2004: International group of experts,
Sepsis Management and Hemodynamics Javier Perez-Fernandez, M.D., F.C.C.P. Medical Director Critical Care Services, Baptist t Hospital of Miamii Medical Director Pulmonary Services, West Kendall Baptist
Tailored Volume Resuscitation in the Critically Ill is Achievable. Objectives. Clinical Case 2/16/2018
Tailored Volume Resuscitation in the Critically Ill is Achievable Heath E Latham, MD Associate Professor Fellowship Program Director Pulmonary and Critical Care Objectives Describe the goal of resuscitation
การอบรมว ทยาศาสตร พ นฐานทางศ ลยศาสตร เร อง นพ.ส ณฐ ต โมราก ล ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาวทยาลยมหดล
การอบรมว ทยาศาสตร พ นฐานทางศ ลยศาสตร เร อง นพ.ส ณฐ ต โมราก ล ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาวทยาลยมหดล Distributive shock Severe sepsis and Septic shock Anaphylactic shock Neurogenic
Index. Note: Page numbers of article titles are in boldface type.
Note: Page numbers of article titles are in boldface type. A Abdomen, and aorta, as causes of shock, point-of-care ultrasonography in assessment of, 915 917 Abdominal compartment syndrome, trauma patient
Swans and Pressors. Vanderbilt Surgery Summer School Ricky Shinall
Swans and Pressors Vanderbilt Surgery Summer School Ricky Shinall Shock, Swans, Pressors in 15 minutes 4 Reasons for Shock 4 Swan numbers to know 7 Pressors =15 things to know 4 Reasons for Shock Not enough
MANAGEMENT OF CIRCULATORY FAILURE
MANAGEMENT OF CIRCULATORY FAILURE BACKGROUND AND DEFINITION There is no consensus on the definition of circulatory failure or shock in newborns; it can be defined as global tissue hypoxia secondary to
Swans and Pressors. Vanderbilt Surgery Summer School Ricky Shinall
Swans and Pressors Vanderbilt Surgery Summer School Ricky Shinall SHOCK Hypotension SHOCK Hypotension SHOCK=Reduction of systemic tissue perfusion, resulting in decreased oxygen delivery to the tissues.
PHYSIOLOGY AND MANAGEMENT OF THE SEPTIC PATIENT
PHYSIOLOGY AND MANAGEMENT OF THE SEPTIC PATIENT Melanie Sanchez, RN, MSNE, OCN, CCRN Clinical Nurse III City of Hope National Medical Center HOW THE EXPERTS TREAT HEMATOLOGIC MALIGNANCIES LAS VEGAS, NV
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Mitchell M. Levy MD, MCCM Professor of Medicine Chief, Division of Pulmonary, Sleep, and Critical Care
9/13/2015. Laboratory. HPI and PE
Critical Care HPI and PE 74 yo male confused SBP 90/20 MAP50, P 122, RR 34 Ox1 w/o nuchal rigidity S1S2 wo m RLL reduced breath sounds Skin warm dry Laboratory» WBC 15,600 Hgb 8.4 HCt 23%, Plts 95000,
The syndrome formerly known as. Severe Sepsis. James Rooks MD. Coordinator of critical care education OU College of Medicine, Tulsa
The syndrome formerly known as Severe Sepsis James Rooks MD Coordinator of critical care education OU College of Medicine, Tulsa Disclosures I have no actual or practical conflicts of interest in relation
Nurse Driven Fluid Optimization Using Dynamic Assessments
Nurse Driven Fluid Optimization Using Dynamic Assessments 2016 1 WHAT WE BELIEVE We believe that clinicians make vital fluid and drug decisions every day with limited and inconclusive information Cheetah
Acute Liver Failure: Supporting Other Organs
Acute Liver Failure: Supporting Other Organs Michael A. Gropper, MD, PhD Professor of Anesthesia and Physiology Director, Critical Care Medicine University of California San Francisco Acute Liver Failure
Pediatric Shock. National Pediatric Nighttime Curriculum Written by Julia M. Gabhart, M.D. Lucile Packard Children s Hospital at Stanford
Pediatric Shock National Pediatric Nighttime Curriculum Written by Julia M. Gabhart, M.D. Lucile Packard Children s Hospital at Stanford Pre-Topic Questions 1. Why is it important to identify the stage
Albumina nel paziente critico. Savona 18 aprile 2007
Albumina nel paziente critico Savona 18 aprile 2007 What Is Unique About Critical Care RCTs patients eligibility is primarily defined by location of care in the ICU rather than by the presence of a specific
Hemodynamic Monitoring and Circulatory Assist Devices
Hemodynamic Monitoring and Circulatory Assist Devices Speaker: Jana Ogden Learning Unit 2: Hemodynamic Monitoring and Circulatory Assist Devices Hemodynamic monitoring refers to the measurement of pressure,
the bleeding won t stop? Liane Manz RN, BScN, CNCC(c) Royal Alexandra Hospital
What do you do when the bleeding won t stop? Teddie Tanguay RN, MN, NP, CNCC(c) Teddie Tanguay RN, MN, NP, CNCC(c) Liane Manz RN, BScN, CNCC(c) Royal Alexandra Hospital Outline Case study Normal coagulation
SEPSIS 2015 DISCLOSURES FINANCIAL DISCLOSURES 9/1/2015. William M. Johnson, MD Nebraska Pulmonary Specialties. William Johnson
SEPSIS 2015 William M. Johnson, MD Nebraska Pulmonary Specialties 1 DISCLOSURES William Johnson No financial interests related to this presentation 2 FINANCIAL DISCLOSURES I do however have 3 children
-Cardiogenic: shock state resulting from impairment or failure of myocardium
Shock chapter Shock -Condition in which tissue perfusion is inadequate to deliver oxygen, nutrients to support vital organs, cellular function -Affects all body systems -Classic signs of early shock: Tachycardia,tachypnea,restlessness,anxiety,
Purist? or Pragmatist? Assessment & Management of ICU Volume Status
Assessment & Management of ICU Volume Status 9 th Annual Rocky Mountain Hospital Medicine Symposium Denver, Colorado Paula Dennen, MD Assistant Professor of Medicine Nephrology and Critical Care Medicine
Early Goal-Directed Therapy
Early Goal-Directed Therapy Where do we stand? Jean-Daniel Chiche, MD PhD MICU & Dept of Host-Pathogen Interaction Hôpital Cochin & Institut Cochin, Paris-F Resuscitation targets in septic shock 1 The
towards early goal directed therapy
Paediatric Septic Shock- towards early goal directed therapy Elliot Long Paediatric Acute Care 2011 Conference Outline Emergency Department Rivers Protocol (EGDT) ACCM Sepsis Protocol Evidence Barriers
Surviving Sepsis Campaign
Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock An Overview By professor Ahmad Alaysh BMC-MICU 1 Surviving Sepsis A global program to Reduce mortality rates in severe
Cardiovascular Management of Septic Shock
Cardiovascular Management of Septic Shock R. Phillip Dellinger, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Critical Care Medicine and Med/Surg ICU Cooper University Hospital
SHOCK. May 12, 2011 Body and Disease
SHOCK May 12, 2011 Body and Disease Shock Definition of shock Pathophysiology Types of shock Management of shock Shock Definition? Shock What the Duke Community would have experienced if Gordon Hayward
Printed copies of this document may not be up to date, obtain the most recent version from
Children s Acute Transport Service Clinical Guidelines Septic Shock Document Control Information Author Claire Fraser P.Ramnarayan Author Position tanp CATS Consultant Document Owner E. Polke Document
AnnMarie Papa, DNP,RN,CEN,NE-BC,FAEN, FAAN Clinical Director, Emergency, Medical & Observation Nursing Hospital of the University of Pennsylvania
AnnMarie Papa, DNP,RN,CEN,NE-BC,FAEN, FAAN Clinical Director, Emergency, Medical & Observation Nursing Hospital of the University of Pennsylvania Who Am I? Except on few occasions, the patient appears
Relax and Learn At the Farm 2012
Relax and Learn At the Farm Session 9: Invasive Hemodynamic Assessment and What to Do with the Data Carol Jacobson RN, MN Cardiovascular Nursing Education Associates Function of CV system is to deliver
Initial Resuscitation of Sepsis & Septic Shock
Initial Resuscitation of Sepsis & Septic Shock Dr. Fatema Ahmed MD (Critical Care Medicine) FCPS (Medicine) Associate professor Dept. of Critical Care Medicine BIRDEM General Hospital Is Sepsis a known
Intravenous Infusions
Intravenous Infusions 1) An IV insulin infusion can be used for patients: a) with out of control diabetes b) with DKA (Diabetic Ketoacidosis) c) after a heart attack 2) Hyperglycemia is an adaptive response
Shock and Vasopressors. Nina E. Glass, MD TACS Fellow SICU Didactic Curriculum 9/24/14
Shock and Vasopressors Nina E. Glass, MD TACS Fellow SICU Didactic Curriculum 9/24/14 Review Question Unilaterally diminished breath sounds A. Figure 1 B. Figure 2 C. Both D. Neither Related Specialties
Conflicts of Interest
Anesthesia for Major Abdominal Cancer Resection John E. Ellis MD Adjunct Professor University of Pennsylvania johnellis1700@gmail.com Conflicts of Interest 1 Upper Abdominal Surgery Focus on oncologic
Management of Severe Sepsis:
Management of Severe Sepsis: Update from the Surviving Sepsis Campaign Barbara Birriel, MSN, ACNP-BC, FCCM The Pennsylvania State University NONE Disclosures Review evidence-based international sepsis
4/5/2018. Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY. I have no financial disclosures
Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY I have no financial disclosures 1 Objectives Why do we care about sepsis Understanding the core measures by Centers for Medicare
FLUIDS AND SOLUTIONS IN THE CRITICALLY ILL. Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium
FLUIDS AND SOLUTIONS IN THE CRITICALLY ILL Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium Why do we want to administer fluids? To correct hypovolemia? To increase
Acute Mesenteric Ischemia. Michael Klein, MD SUNY Downstate Medical Center August 20, 2015
Acute Mesenteric Ischemia Michael Klein, MD SUNY Downstate Medical Center August 20, 2015 85F www.downstatesurgery.org 5 months of intermittent diffuse abdominal pain Approximately 30-lb weight loss Abdominal
IV fluid administration in sepsis. Dr David Inwald Consultant in PICU St Mary s Hospital, London CATS, London
IV fluid administration in sepsis Dr David Inwald Consultant in PICU St Mary s Hospital, London CATS, London The talk What is septic shock? What are the recommendations? What is the evidence? Do we follow
SHOCK and the Trauma Victim. JP Pretorius Department of Surgery & SICU Steve Biko Academic Hospital.
SHOCK and the Trauma Victim JP Pretorius Department of Surgery & SICU Steve Biko Academic Hospital. Classification of Shock Cardiogenic - Myopathic Arrythmic Mechanical Hypovolaemic - Haemorrhagic Non-haemorrhagic
Goal-directed vs Flow-guidedresponsive
Goal-directed vs Flow-guidedresponsive therapy S Magder Department of Critical Care, McGill University Health Centre Flow-directed vs goal directed strategy for management of hemodynamics S Magder Curr
Sepsis Awareness and Education
Sepsis Awareness and Education Meets the updated New York State Department of Health (NYSDOH) requirements for Infection Control and Barrier Precautions coursework Element VII: Sepsis Awareness and Education
Shock. William Schecter, MD
Shock William Schecter, MD The Cell as a furnace O 2 1 mole Glucose Cell C0 2 ATP 38 moles H 2 0 Shock = Inadequate Delivery of 02 and Glucose to the Cell 0 2 Cell ATP 2 moles Lactic Acid Treatment of
SHOCK Susanna Hilda Hutajulu, MD, PhD
SHOCK Susanna Hilda Hutajulu, MD, PhD Div Hematology and Medical Oncology Department of Internal Medicine Universitas Gadjah Mada Yogyakarta Outline Definition Epidemiology Physiology Classes of Shock
Failure of the circulation to maintain Tissue cellular. Tissue hypoperfusion Cellular hypoxia SHOCK. Perfusion
Shock SHOCK Failure of the circulation to maintain Tissue cellular Perfusion Organs Syndrome RR
Shock Quiz! By Clare Di Bona
Shock Quiz! By Clare Di Bona Test Question What is Mr Burns full legal name? Answer Charles Montgomery Plantagenet Schicklgruber Burns. (Season 22, episode 11) Question 1. What is the definition of shock?
Christopher Lau Kings County Hospital SUNY Downstate Medical Center February 24, 2011
Christopher Lau Kings County Hospital SUNY Downstate Medical Center February 24, 2011 37 year old male presented with 1 day history of abdominal pain Pain was diffuse but worst in the epigastric area No
Sepsis Story At Intermountain Healthcare Intensive Medicine Clinical Program
Sepsis Story At Intermountain Healthcare 2004-2012 Intensive Medicine Clinical Program The International Surviving Sepsis Campaign Was Organized In 2002 During The ESICM International Meeting In Barcelona,
SEPSIS: Seeing Through the. W. Graham Carlos MD, MSCR, ATSF, FACP
SEPSIS: Seeing Through the W. Graham Carlos MD, MSCR, ATSF, FACP Objectives Forget everything you have known about sepsis Learn new things Objectives Define sepsis Explain why Early Goal Directed Therapy
No conflicts of interest
Robert M. Rodriguez, MD FAAEM Clinical Professor of Medicine and Emergency Medicine, UCSF No conflicts of interest Major Points Most ICU patients start in ED Chain of critical care starting in field and
PEEP recruitment maneuver
Robert M. Rodriguez, MD FAAEM Clinical Professor of Medicine and Emergency Medicine, UCSF Case 1: 40 yo Male restrained driver high speed MVA P 140, RR 40 labored, BP 100/70, O 2 sat 70 Chest wheeze, crackles
Iatrogenic Cardiac Injuries. Kings County Hospital Center Verena Liu, MD 9/1/2011
Iatrogenic Cardiac Injuries Kings County Hospital Center Verena Liu, MD 9/1/2011 Case Presentation 69 year old male recently diagnosed with a 3.8 cm x 4.3 cm hepatocellular CA in the superior segment of
Surviving Sepsis. Brian Woodcock MBChB MRCP FRCA FCCM
1 Surviving Sepsis Brian Woodcock MBChB MRCP FRCA FCCM 2 Disclosures No conflicts of interest 3 Sepsis Principles of management of septic shock in the operating room "Surviving Sepsis" guidelines 4 Add-on
6-horas 24 horas Coleta de lactato Hemoculturas. Corticosteróides. Controle glicêmico. Fluidos/vasopressores. Otimização de SvO 2
Novas diretrizes da Surviving Sepsis Campaign 2012 o que foi atualizado? Os pacotes da sepse 6-horas 24 horas Coleta de lactato Hemoculturas Corticosteróides Antibióticos Proteína C ativdada Fluidos/vasopressores
Sepsis Wave II Webinar Series. Sepsis Reassessment
Sepsis Wave II Webinar Series Sepsis Reassessment Presenters Nova Panebianco, MD Todd Slesinger, MD Fluid Reassessment in Sepsis Todd L. Slesinger, MD, FACEP, FCCM, FCCP, FAAEM Residency Program Director
TRAUMA RESUSCITATION. Dr. Carlos Palisi Dr. Nicholas Smith Liverpool Hospital
TRAUMA RESUSCITATION Dr. Carlos Palisi Dr. Nicholas Smith Liverpool Hospital First Principles.ATLS/EMST A- Airway and C-spine B- Breathing C- Circulation and Access D- Neurological deficit E- adequate
Fluid Resuscitation and Monitoring in Sepsis. Deepa Gotur, MD, FCCP Anne Rain T. Brown, PharmD, BCPS
Fluid Resuscitation and Monitoring in Sepsis Deepa Gotur, MD, FCCP Anne Rain T. Brown, PharmD, BCPS Learning Objectives Compare and contrast fluid resuscitation strategies in septic shock Discuss available
Sepsis. From EMS to ER to ICU. What we need to be doing
Sepsis From EMS to ER to ICU What we need to be doing NEHAL BHATT, MD ATHENS PULMONARY, CRITICAL CARE AND SLEEP Objectives 1. Define the changes to the definition of Sepsis 2. Describe the assessment,
Surviving Sepsis: A CRASH Course. Justin Jones, PharmD Sanford Medical Center, Fargo Staff Education 2015
Surviving Sepsis: A CRASH Course Justin Jones, PharmD Sanford Medical Center, Fargo Staff Education 2015 Disclosures No financial conflicts of interest Abbreviations ULN Upper limit of normal SVCO2 Central
Sepsis Learning Collaborative: Evidence-based Approaches to Sepsis Resuscitation Sepsis Resuscitation in Medically Complex Patients
Sepsis Learning Collaborative: Evidence-based Approaches to Sepsis Resuscitation Sepsis Resuscitation in Medically Complex Patients Presenters Dr. Nathan Shapiro Dr. Laurence Dubensky Evidence Based Approaches
Vasopressors for shock
Vasopressors for shock Background Reviews and Observational Studies Holler 2015. Nontraumatic Hypotension and Shock in the Emergency Department and Prehospital Setting Prevalence, Etiology and Mortality:
Sepsis Combine experience and Evidence. Eran Segal, MD Director General ICU, Sheba Medical Center, Israel
Sepsis Combine experience and Evidence Eran Segal, MD Director General ICU, Sheba Medical Center, Israel The Science of Sepsis A complex and diverse clinical entity Outcome is affected by: Infecting organism
Agenda เอกราช อร ยะช ยพาณ ชย. - Cardiac physiology - Pathophysiology of shock - Pathophysiology of heart failure 9/6/2016
6 September 2016 เอกราช อร ยะช ยพาณ ชย Heart Failure and Transplant Cardiology aekarach.a@chula.ac.th Agenda - Cardiac physiology - Pathophysiology of shock - Pathophysiology of heart failure http://fullpulse.weebly.com/conversation
Bolus (Push Dose) Pressors: Good Idea or a bit Much?
Bolus (Push Dose) Pressors: Good Idea or a bit Much? Robert Katzer MD MBA FACEP FAEMS Associate Professor, Emergency Medicine University of California, Irvine Pressors: Which Ones Are Out There, What Do