Septicemic Shock in ED - Race against time

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[00:00:04]Okay, I think good there is one screen is there. So I think everyone will see.

[00:00:09]Uh firstly uh congratulations to Sir Indian Reliance Foundation Hospital uh for organizing such a beautiful CM on golden hour uh and it's it's my pleasure to come here. I thank to Dr. Pit, Dr. Nita, Dr. Chetan and entire HL foundation hospital team for hosting me here and hosting this pre-conference workshop um on acute care medicine where we will be discussing on acute care aspects of various clinical elements.

[00:00:47]So today uh when I talk I saw the schedule I I I made one presentation but I saw the schedule the schedule was that I I had 30 minutes generally in conferences they give 20 minutes and here 30 minutes. So I thought I should be talking like a master's class on safety shock uh management. So I'll be talking a little bit detail here but it's very important and it's a very much time bound emergency.

[00:01:16]When we go through the statistics in Indian ICUs, one study shows that there is mortality of 66% in sepmic shock patients. Okay. As compared to steaming as compared to active stroke, the mortality is quite high. But sensitivity sensitivity to a septic shock is not as high as we do with the ST segmentation infection or stroke. So it's very essential to emphasize a time bound care in safety centric shock and uh early intervention in emergency department will decide one of the outcomes either patient will survive or patient will uh will have prolonged ICU state or patient will die. So these these things so emergency department is not just first point of contact it's the most decive point of uh point of contact in modern healthcare. Okay. So what today I'll be discussing. So today we'll be discussing basic pathophysiology here because it's very important because safety semic shock pathophysiology is very important.

[00:02:25]Unless we understand that we will not able to deal or we will not able to intervene properly or we will not able to resuscate properly unless we understand how things go wrong in the safety semi shop.

[00:02:40]So here I'll be talking about the most recent evidence all of you are you read the surviving safety guidance I'll be talking on that some insights which we have learned in safety semic shock management over the years that I will also uh we'll share and the class format will be the mechanism science and management okay the five bedside things we have to learn and understand first is recognize before DP Bulbs give antimicrobial fast because every 1 hour delay in anti antimicrobials antibiotics will increase mortality by 10%.

[00:03:19]Restored preload and vascular tone. We have to give adequate fluid and vascular tone is important because in 17 shock patient goes in vasopllesia mean peripheral vascular vascular plasia will be there and peripheral vascular dilation will be there. So warm shock phase will be there. So we have to deal that bossia by starting thoroughly anotropic supports then control the source of course unless we control the source and we address that thing will not giving the full system and reassess the tissue and not just just the treatment.

[00:03:55]So we have to deal in three ways. Okay.

[00:04:02]uh so high yield message is that infection triggers vascular failure, microirculatory collapse and cellular dysfunction. So our management should be aimed to these three things.

[00:04:15]So uh I think slides are visible visible. Yeah. So this syndrome why this syndrome particular matters what is the current definition of safety syndrome shock? If you requireic support to keep map more than 65 mmg and if lactic is more than two in that case that is called as shock so that that we have to understand okay and it's a life-threatening thing and it's due to the disregulated immune response of the body. So when we go for the surviving sepsis guidelines what is there in the there are 129 statements and 46 new recommendation.

[00:04:56]So what all these things say just say in I'll do a simple bed slide translation of that 129 stateways and 46 new update is that uh uh think of septmic shock as a three failures happening one as infection trigger any infection pneumonia pylonritis uh urinary tract infection that trigger we have to identify then vascular or microirculatory failure Because vascular failure is there, glycoal damage will cause the capillary leak that will be there and cellular energy failure means it's difficult to deliver oxygen at cellular level. That's why lactate increases. So these things we have to understand and our treatment should be targeted to all these things. Okay.

[00:05:49]So important thing this slide is very important. Huh? everyone. One is PA.

[00:05:58]What is the PAP? Pam pathogen activated molecular patterns.

[00:06:05]This is very important understand if you are you write down and read on this thing. This is very important. Pathogen activated molecular patterns that what that patterns they do that patterns mean whenever there is any infection happens that will activate pathogen activated molecular patterns and that will lead to the immune system activation that will be tumor meosin factor alpha interlucan one interlucan 6 complement luccoy activation and that will and all these things will make a damage to the tissue damage to cellular tissue and that damage damage will what will do that damage activated molecular patterns. So that will again aggravate this imunological response. So this VCS circle will happen and patient rapidly deteriorates. Okay. So first pathogen activates the molecular factor then tissue damage happen the damage associated molecular factor will happen and there will be the aggravated immune response. What that will do that immune response will do the endothelial failure. Glycoalixial shedding, vasoplesia is loss of peripheral vascular tone capillary leak and due to the endothelial damage. Whenever there is there are endothelial damage, it will cause a micro throi and patient will go into the DIC. Okay. Then uh cellular dysfunction yes patient is mean oxygen will not get delivered properly to the oxygen level. What will happen if due to all these things microirculatory damage and cyclopesia vascular shunts will happen. So in some tissues will peruse more and some tissues will peruse less. So even if you see BP is normal but lactate is fine. Why that lactic is five? Because microus shunts are happen.

[00:07:52]So due to that thing due to cyclophasia blood is moving on one side more of the tissue and one side of tissue is got deprived of from the oxygen and that will give rise to the lactate. So this this concept that is called as cryptic shock and that concept we have to understand because we can say BP2 normal but lactate is fine. Yes because BP normal head but of tissue level is not getting perfused that is unevenly getting perfused. So we have to manage that particular patient aggressively and that particularly finally leads to multiorgan dysfunction shock ARDS or similar type of okay are you with me the p damp immune system activation glycoal damage microari okay so this this and how the concept of cryptic shock do you understand that that is very important because uh due to this cyclopia and due to endothelial damage some mean there will uneven distribution of the blood so sh will happen so one part of of tissue will not get perusable other hyper peruse so that hyper there lactate will increase so we'll see that initial stage that lactate is high but BP is normal so we see that machine problem that is not a problem in machine that is a problem in patients so we have to be very aggressive while dealing such cryptic shock patients okay so that uh therefore particular thing I have explained uh in our previous slide itself and uh uh this uh patient may look stable and lactate is high that patient we have to be very much precisely and we have to treat them equally aggressive and if patient of BP of suppose 128 lactate is six you do research and see the lactate if it is reduced then you know that this patient is getting respon getting response to your treatment so lactate is a new vital parameters while doing in emergency department in our department I think last 10 years we keep that BBP pulse oxygen saturation and lactate also so that gives that not only help us to giving idea about tissue perfusion but that will help us to prognosticate patient also so that lactate is very important in all cases mean we have done one study so high lactate is associated with high mortality irrespective of underlying cause. Maybe it's a trauma, maybe an estis, maybe it may be congestive cardiac failure, maybe it acquid my heart infection, maybe safety semicolon is associated with high mortality.

[00:10:35]Now clinical signs and symptoms. Sometimes we say that here a patient safety semic but there is no history of fever. What happens? the cytoine reset the hypothalammic uh temperature. So uh temperature center. So that will what will happen in that situation that patient patient will not get cure and patient will be the hypo hypothermic even hypothermia. So that is more dangerous that gives explanation of hypothermia in safety in short teicardia. Yes it's a response because peripheral loss of peripheral ocular is there. So to compensate that teicardia will be there. Techipnia to compensate the metabolic acidosis warm.

[00:11:17]Initially the shock will be warm because spirical oasilation will be there. Then patient will go in go into the safety cardopathy and then it becomes the cold shock and altermentation due to low perision and due to safety semic and there will be allergy area and uh modeling. Okay. So lactate again I'm taking lactate it matters because lactate guided research station is the key uh key new guidance also and we have observed in our clinical practice also. So practical target range we can see that 1.5 to 1.5 to 1.5 is normal historically more than four is considered as something dangerous and that should be concerning.

[00:12:07]So any patient with more than lactate four we have to aggressively find out the cause which is what is be behind that and occurred and cryptic shock normal VP and lactate is more than two.

[00:12:17]So we have to be careful in this patient how we should be looking at the how the patient give response to the uh initial research station. Why lactate four cut off because in earlier guidelines all studies are made lactate more than four or more than less. But what is current statement? Safety semic shock. What is current state matters? If you require more anotroic support to keep map 65 m of mercury and lactate is more than two patient is in safety semic shock. So this matters today. Okay. So cryptic shock everybody got the concept of cryptic shock.

[00:12:54]>> BP is normal but lactate is high. So we should not be get deceived by normal beauty and that lactate is increased due to the microscular shedding which are >> which are which is happened at the tissue level >> because some vessels are hyper focused some got holistic shut down and there the anorobic pathway will shut and lactate will get increased okay everybody's with me okay now biomarkers which biomarkers CRP best for galactate Again I'm telling that lactate is best for perfusion and stress. Yes it's like vital parameter treat lactate as a vital parameter in emergency department then CRP CRP will increase in any inflammation. But if we want to be more specific and we want to find out whether it's a bacterial or not then proacetone high the sepsis is due to the bacterial.

[00:13:50]So it has good role in roll in and roll out. And one more uh biomarker is rapidly evolving. We are doing a pilot study on that particular thing sorry.

[00:14:10]So, so we are doing a pilot study um on on that the precepts. Okay, precepts means it arises within 2 hours and it's very specific to the bacteria and uh it can be a very useful tool in emergency department though it doesn't came into the mean standard recommendation but uh uh we are doing a pilot study of couple of our purchase hospitals and data is quite ensuring and I'm I'm seeing in next items the place will be the ideal biomarker for emergency medicine uh doctors while resusating the safety semi shock patient or while evaluating the safety segment that may come on and this is another homework and go and read all about the precepts and it's a it's just available in India and pilot is going on in this thing so but it is very promising uh thing to diagnose and uh risk stratify as well as uh to prognosticated patient highps more more infection and it is more specific about bacterial thing and it rises within 2 hours proc may take 12 to for 24 hours but it gives it start rising within 2 hours of the infection.

[00:15:24]So it's very sensitive and specific.

[00:15:28]So in emergency department workup what workup should have two blood cultures.

[00:15:33]Why two blood cultures?

[00:15:36]Why two blood cultures?

[00:15:40]What?

[00:15:42]Why two blood cultures?

[00:15:45]So yeah guess you will get two blood cultures. So generally how much mean 30 to 40% culture fully composite. So if you get to chances of mean you will get get more another thing is that one pragmatic point is that if one sample get contaminated so you will get something different micro but other that that will help to the contamination should not happen but a microbiologist perspective that is very important unusual pathogen growing one and one set it's a contaminated sample so and that will change entirely. So two blood cultures are very much essential from two other side otherwise two blood culture blood culture that should not happen. It should be taken from the two two sides.

[00:16:26]Okay. And then during school and if any or is there then that culture should happen then imaging we have to find a patient is in safety semic shock there should be some underlying focus.

[00:16:40]Okay. So we have to find out that focus unless we get the focus then we will not suppose the patient having some liver access we have to read that or sometimes uh sometimes we have seen um mean very different when we find out pometra mean uterus filled with pract like that you have to find out if patient in safety semic shock unless and until you don't get safety semic focus you should not get to so you have to scan patient and you have to find out the reason for that thing. Then elected I talked lot about lactate in blood gas analysis will give idea about the uh metabolic status of the patient.

[00:17:21]Capillary refill they have emphasized on capillary refill don't go by everybody while the blood test capillary refill is equally important. Survival ses guidance has given lots of emphasized by capillary refill time checking the capillary refill time while resuscitating the patient. Then complete blood counts, platelets, complete metabolic panel, creatinine electronic.

[00:17:44]Why hydrogen? Why fibroin? Because I told endothelial damage, glycoal disruption microi that will absorb the coation parameters and patient go. So that's why PT AP and hydrogen level is very important and in selected cases we can go for troponine and BP. Okay. So far everyone is with me. So we have discussed the pathophysiology why we have discussed why the concept of cryptic shock why lactate raises and what is the triggers for the safety shock pathogen activated molecular patterns that will make a damage to the tissue and then again that will damage associated molecular pattern and then moving rapidly this is a circle and patient spiral down into the safety shop. Okay.

[00:18:43]So first hour in emergency department what must happen? What should we have in first hour in emergency department?

[00:18:49]First recognize a patient in safety section emergency patient should be able to recognize that suspicion of infection organ dysfunction. Lactate the lactate will tell you about the organ dysfunction or hypoporusion and then it's a medical emergency. Then we have to take the IV fluids, take a check the lactate, take the blood culture and then we should be starting IV fluids and after culture we should be giving the broad spectrum antibiotic empiric antibiotic start IV fluid plan source control and start nor okay nor when we are giving fluid simultaneous you are giving 500 ml fluid you are giving so that time you are giving or occurring to deal with the cycle of DGR.

[00:19:38]Okay. So in new guidance they are saying that while doing the fluid resistation no don't don't get that 3 hours you have given optimal fluid resistation and then you are thinking for pressure here you have to go for early pressure suppose because you are you have to deal with the cyclopsia. Okay.

[00:20:03]Soap, antimicrobial and source control.

[00:20:05]This is the framework. They have defined three things. Safety saving shop within 1 hour. Sepsis uh is possible then we should be giving uh means there are three sepsis probable sepsis possible sepsis unlikely sepsis. So if sepsis is definite and probable we should be delivering first dose of antibiotic within 1 hour and if it is possible then after evaluation within 3 hours we can do but if we are strongly suspecting the patient is in a shock and we are the same is probable then we should be giving first dose of antibiotic within first 1 hour of arrival fluid resusation this initially the last guideline they say that we should be giving 30 ml per kg over first 3 hours but what they have recommended that we should be doing the personalized research station okay we should be giving bers give 500 ml bas look the patients patients uh patients fluid status patients fluid responsiveness and based upon that we should be giving the fluids so you should be checking the injection factor looking at the IVC and then you should be keep on giving fluids this gradually and we can give up to 30 ml per after that also if IC is collapsed hyperdamic circulation is there then you can give further fluid but that should be the personalized fluid therapy okay what fluid we should be given the crystallites they have recommended normal or ring like and balanced crystallite they recommended that will work better and in certain liver failure cases we can think for aluminina also key mistake that it's not rule that every patient should receive 30 ml per kg. If patient's ejection fraction is low, you can't flood that patient. So based upon we have to that 30 ml per kg that should be the standard but we have to personalize uh the fluid administration plan for irrigation and then when we are doing this thing fluid responsiveness I think you have people have attended last focus workshop what we did we have emphasized on to check the LOVI that will give us idea about the fluid responsiveness if LOTVI is in in increase after 500 ml of fluid suppose.

[00:22:30]So this fluid patient is fluid responsive. So we can give more fluid.

[00:22:34]We have given 500 ml and loot is the same that fluid is not fluid responsible. Then we have to deal with other things cyclopenegia and uh septic cardiamathy. So that that is very important. So personally so uh we have to uh incorporate resistive focus skills while resuscitating CPH patient and of course low fluid also can damage and if you give more fluid that can that can also damage to the patient. Suppose a patient coming from all the hospital he has fluid and you have seen IVC is dilated. So whether to give fluid or not that will be discussed or that decision will be taken on the nexus. Okay. So based upon basis we can take whether fluid should be given flu should be a lot of fluid should be removed that is also important thing. So that that skill emergency medicine doctor we should again and uh and learning curve is very long. I think some of your colleagues were there. I think within 3 days we have given hands-on training for everyone for a vtd and tap map in all these things. So I think uh emergency medicine has has evolved to a resus research station speciality but we have to do the research station with precision and that precision will be by point of katrasam and point of test and judiciously use using um these two element in emergency department.

[00:24:02]So osopressor first line osop pressure norepinephrine root peripherally because don't wait for center line we can start this nor adrenaline from peripheral line and it helps especially masoplesia directed vessels okay okay and then target should be mapped map should be more than 65 mm of mercury but that should not be last target again we have to put the serial lactate and we should make that tissue getting perus lactate should get Okay.

[00:24:34]Now adjun. So there are lots of adjuns mean this uh in 201 16 they removed steroids again they bought steroids like they are like a Bollywood fashion some some bell bottom in narrow bottom bottom. So sometimes I they removed in 2016 they show hydro is not there. How hydrocortisone came back? If I hydrocortisone uh when muscle pressure required persistent despite adequate period and anotropic support if hypotension is there then we can use hydrocortisone. So that is recommendation.

[00:25:08]Yes low tidal volume metilation they recommend glucose there should not be tight glycemic. Initially it was concept gly glycemic control sugar should be between 140 to 180. No it should we start insulin only when patients glucose go above 180. Renal replacement therapy, diialysis and CR. So that decision will be taken. Diialysis indication you know Aeio who will say what is AIO acidosis.

[00:25:36]Huh?

[00:25:37]Huh?

[00:25:40]>> Hyper calmia acidosis. Okay. Fluid overload. Okay. And the CRT patient is hemodynamically unstable. Refractory acidosis. Electric is more than 10 to 12. Um ania rising react inducting in hemodynamically unstable CR hemodynamically unstable we can go for hemoilysis. So that procedure should happen based upon patients physiology biarbonate is not mis bicarbonate is what is we should not be giving routinely so after optimal resistation if required and if patient is in renal acute renal period in that condition we should be using and then v propylaxis should be there uh internal nutrition within 72 hours because nutrition is very important component what genuinely new. Genuinely new. So that is a new thing because that recommendation came this thing. What is genuinely new that they should that we should be maintaining safety dashboard at what time patient came to at what time first dose of antibiotic happened? Uh how much flu we are given and what is the outcome of the patient and uh the monthly review of the data. So that is new recommendation that we have been doing since last three four years but that is that that officially came from the surviving sis guidance antibiotic antibiotic timing initially up to 3 hours no but in safety semicop first do should happen within 1 hour okay and then initially they thought that give all cover means antifungal also no we should be giving the first dose of antibiotic with local understanding the local microbial pattern and antibiotics stewardship program of particular hospital and that good and then further we can select not that uh um uh rifle approach is not good some some three four uh pellets will go and one of that will hit so we have to be uh that uh uh pistol approach mean single bullet okay so peripheral pressures age adjusted map yes peripheral means uh initially give adequate fluid and Again look for anotropic support. No while doing giving the fluid you should be giving the osopresses because that will help to deal with the ooplesia.

[00:28:01]Okay. Post resisation fluid strategy if you think that fluid is overload is there then you have to remove that fluid. Okay. So if patient is fluid overload then it so we have to dial and remove that fluid. So we can't go with this thing. So flute overload sometimes giving sometimes 30 ml per kg 3 liter 4 lit we have given the patient patient will go in fluid over and he will not able to get ventilated optimally. So if excessive fluid is that remove that and there is called as terminology called as fluid overload nephropathy just there a low preal low volume will damage the kidney post renal means uh when we give a fluid overload that will also damage the kidney so that important concept is there no value of they have removed vitamin C no value I gave This is very trendy that I that is that is not that we should not be using the filters cytoine because cytoines happen you know that pathogen activated molecular patterns damage activated molecular pattern that will lead to interlucan stimulus factors so that cytoines and there they use the cytoines filters to remove that thing hoping that that will reduce the further dime but now they they they told that this there is no mortality benefit with this thing. So rather than going doing that thing, we should be doing the source control more and choosing the appropriate antibiotics. Okay.

[00:29:36]Now common fit wall reassured by uh normal BP lactate suppose lactate is five but DP is normal machine don't get reassured with normal BP. This is important thing waiting for perfect culture. If you are not getting culture or you are getting culture don't delay in safety semicopure is taking time more than 1 hour don't wait for that give antibiotic first but you should be optimally take a blood culture and do this things equating high lactate with hypoxia h this is very deceptive because we use lactate for prognosticating the patient but suppose a patient with liver acute hepatitis or acutely hepatitic 20 because lactate mechanism It happens it's a liver means whatever this thing so so liver damage will raise deceptively very high but that will not correlate its outcome. So we have to think that that lactate will not reflect the lact rate of safety semic shock.

[00:30:33]that is due to the liver that that is due to the uh damage to the liver and that uh uh that high lactate will not correlate with the hypogly and same possible in this patient who comes to emergency caesar that may have high and some somebody who who are on very high metmorphine dose 1 g or two or 2 g per day like that they may have some electric acidosis don't give blindly 30 ml per kg uh treating map 65 You have to go mapping one goal achieved but our target is that lactate should come down. Okay.

[00:31:11]And don't over interpret the novel biomarkers actively black is there everything is there but they are all adjunct. We have to see the patient and based upon uh the patient's condition we have to take certain decisions. So bed bedside algorithm suspect sepsis organ dysfunction lactate elevation start resuscitation oxygen blood culture possess of antibiotic IV fluids restore perfusion and reassess dynamically while giving the fluid we have to look at for the point of resus point of care ultrasound and we have to escalate individually. So what we have done new beyond surviving sepsis guidance in last 3 to four years in 2003 we saw some sepic shock mortality around 35%. When we did two two three two new things in our department research focus while giving fluid focus guided fluid resistation and individual fluid plan look for the IBC look for the ejection fraction and based upon that thing we should give you a you should be using the LVOT VTI while resistation the first thing then arter line this makes your stress less a patient with systolic comes to you put arter line and based upon that thing that will give real time blood pressure so you can give fluid and you can see the BP is riding some sometimes if patients BP is calling you can actively intervene so that RTL line in emergency department will make wonderful I'm sure you start doing it will reduce your stress and it will improve patient outcome also so uh that is very important so unnecessary sometimes you may not get BP and sister will not check BP every half an hour is continuously these things or any pattern suddenly drop or suddenly raise you can try to diotropic support and that gives a real time uh idea about the blood And you can see the real time reversal of the disease process BPA and it is happening 120. It will give you the satisfaction test in the patient and it will again reduce your stress and when patient we are all hardcore emergency medicine doctors. We are assess any patient who responds to our research station give us a rewarding experience. So that that that that that real time rewarding experience will get there. Precision research stationation means focus and realtime human dynamic that two things we have done and our mortality from 30 to 40% we have reduced to 20% in 2024 and that case uh that data we have publish uh we have presented in 10th international conference of quality summit and we we have won the first prize in that uh we have won the clinical excellence award in the 10th IHS quality summit at Hong Kong in that particular. So it it rewards and patient outcome one where when we do the resistation our patient gets saved that is that is a reward but when we generally research the patient and if we keep the data of what we are doing what will happen even system also recognize mean system means universe will recognize you are this thing and that will also rewards. So I think this I think this is uh this is the first inter big international award. I think we I got through the safety semic shock.

[00:34:19]So this particular topic is very close to my heart and safety semic shock is very important and we should be dealing it with very aggressive resuscitation with precision is the key.

[00:34:31]So finally I'll uh people may know I will be talking about MCON a lot but yes I have to talk because organizing chairman you don't know it's like a daughter's marriage 10 daughters marriage at a time. So now nowadays there is a problem with sons daughter also. So I can say this since five sons and five daughters marriage I am doing at a time in one day. So this uh particular conference it's India's first international conference in emergency medicine. We got registration from every continent of the globe.

[00:35:03]Uh Royal College of uh president of Royal College of Emergency Medicine, you must have seen he has given the video message and he personally coming.

[00:35:11]President of American College of Emergency Medication, he he is personally coming. He has also given a video message. President of International Federation of Emergency Medicine. She also commented this thing and importantly president of Win Focus recently I shared the video focus is uh the AEX body of point of care ultrasound on this planet. The president of that win focus is also coming here. She has given the video message and she will be giving the keynote address.

[00:35:37]So this has evolved to international conference. Uh I can say this is India's first international conference on emergency medicine and I assure you it will be the unprecedented event and those who are not registered please register be the part of the movement that will define future of emergency medicine India. The concept of this particular conference is innovation collaboration and excellence in emergency medicine and uh I again say that excellence in emergency medicine begins with excellence in research. Many say that who are we masters of? We are masters of this.

[00:36:14]Thank you.