Introduction 0 Traditionally it has been thought that during septic shock, renal blood flow decreases leading to pre-renal kidney injury. This implied that if we could improve the cardiac output and renal blood flow, the kidneys would recover. Recent research challenges these concepts, with interesting therapeutic implications. 0 New paradigm of microvascular physiology in renal acute kidney […]
Search Results for: septic shock
Approach to shock
CONTENTS Introduction Diagnosis Causes of shock Evaluating the cause of shock Stabilization Refractory shock management ➡️ Podcast Questions & discussion Pitfalls Shock is a state of systemic hypoperfusion, with inadequate blood supply to the tissues. Unfortunately, this may occur in different ways. The most simple physiology of shock is cardiogenic shock, with low cardiac output […]
PulmCrit – Steroid for ARDS? The DEXA-ARDS trial
A fresh trial shows considerable efficacy of dexamethasone in ARDS. This may come as a bit of a surprise, but it’s actually entirely consistent with prior evidence. To understand the study, we need to start with previous data… Part I: Background: The Rabbit hole of ARDS, pneumonia, and septic shock We often think about ARDS, […]
EM Nerd-The Case of the Temporal Fallacy
Inadvertent catastrophes are often hidden just beneath good intentions. Such is the case with the most recent iteration of the Surviving Sepsis Campaign’s treatment bundle. Published in Intensive Care Medicine by Levy et al, this special editorial includes the Surviving Sepsis Campaign’s most recent recommendations for the early and aggressive treatment of sepsis (1). Most […]
Understanding lactate in sepsis & Using it to our advantage
Introduction with a case 0 Once upon a time a 60-year-old man was transferred from the oncology ward to the ICU for treatment of neutropenic septic shock. Over the course of the morning he started rigoring and dropped his blood pressure from 140/70 to 70/40 within a few hours, refractory to four liters of crystalloid. […]
Toxic Shock Syndrome (TSS)
CONTENTS Rapid Reference 🚀 Pathophysiology Epidemiology Clinical presentation Lab tests Diagnosis Differential diagnosis Overall approach to diagnosis CDC diagnostic criteria Treatment Basic sepsis resuscitation Antibiotics Source control Intravenous immunoglobulin (IVIG) Purpura fulminans Preventing nosocomial transmission Podcast Questions & discussion Pitfalls pathophysiology Some Streptococcus and Staphylococcus species secrete superantigens that causes widespread activation of T-lymphocytes (figure […]
PulmCrit- Epinephrine challenge in sepsis: An empiric approach to catecholamines
A 55-year-old woman was admitted with toxic shock syndrome. Her norepinephrine requirement was labile, fluctuating between 15 mcg/min and 30 mcg/min. Bedside echocardiogram showed a dilated inferior vena cava without respiratory variability, and a normal ejection fraction. On examination her extremities were cool and her urine output was marginal.
Early suspicion of toxic shock syndrome
0 Introduction 0 Toxic shock syndrome (TSS) is critical to recognize because it can be rapidly lethal and yet is usually treatable. TSS is a relatively new disease, first described in 1978. The prevalence has increased over the last few decades due to shifts in the circulating strains of Group A streptococcus (Low 2013). However, […]
PulmCrit- WHO guidelines regarding fluid administration for coronarvirus are dangerously misguided
The Surviving Sepsis Campaign is a blight on modern, evidence-based medicine.1 It’s been clear for some years that its fundamentals were flawed (centering around rapid, large-volume fluid resuscitation). Rather than adapt guidelines to modern evidence, the campaign recently doubled down on immediate administration of fluid and antibiotics within one hour. This provoked widespread protest, including […]
PulmCrit- APROCCHSS vs. ADRENAL: Are we asking the right question?
ADRENAL and APROCCHSS were both designed with mortality as a primary endpoint. They reached opposite conclusions: steroid had no effect on mortality in ADRENAL, whereas it improved mortality in APROCCHSS. Why?
EMCrit 241 – Sepsis Update 2019
New stuff on sepsis resuscitation for 2019
PulmCrit: Myth-busting the fluid bolus
For centuries, medical experts practiced bloodletting for a variety of ailments. This was widely believed to rid the body of evil humors. When patients didn’t respond well, this was believed to reflect an inadequate or delayed bloodletting. Practitioners competed to see who could partake in the most rapid and aggressive bloodletting.
EM Nerd-The Case of the Tardy Delegate
We have discussed the dangers of surrogate outcomes at length, but none are more evident to an Emergency Physician than the time-based metrics we are subjected to on a daily basis. The latest of these temporal surrogates forced upon us is the 3-hour bundle of care in patients presenting to the Emergency Department with symptoms […]
Pulmcrit – Renoresuscitation, vasopressin, vepinephrine, and VANISH
My goals during sepsis resuscitation focus largely on preservation of renal function and maintence of a reasonable fluid balance (renoresuscitation). The kidney is one of the most fragile organs, which may be rapidly injured by hypoperfusion. Renal failure correlates closely with mortality, participating in a vicious spiral of multi-organ failure. Alternatively, if you can save the kidneys, you’re likely to save the patient too. In this context, any beneficial effect of vasopressin on renal function could be helpful.
The Case of The Dying Detective…
…and his missing lactate I am, as I am sure many of you are, a big fan of using lactate to guide my resuscitative efforts in my critically ill septic patients. You would pour fluids into your large bore catheters, infuse pressors through your ultrasound guided central lines and revel in how quickly you […]
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