0071598626.pdf

Fever Answers 191

with potential sepsis in the ED, early broad-spectrum antibiotics, and a
rapid crystalloid fluid bolus, followed by goal-directed therapy for those
patients who remain hypotensive or severely ill after this initial therapy.
Those patients who did not respond to an initial fluid bolus and antibiotics
received a central venous catheter in the internal jugular or subclavian vein
to measure CVP and an arterial catheter to directly measure arterial BP.
EGDT is basically a three-step process, aimed at optimizing tissue
perfusion:

• The first step involves titrating crystalloid fluid administration to CVP, or
  administering 500-mL boluses of fluid until the CVP measures between
  8 and 12 mm Hg. CVP is a surrogate for intravascular volume, as excess
  circulating blood volume is contained within the venous system.


• The second step, if the patient has not improved with fluid alone, is to
  administer vasopressors to attain a mean arterial pressure (MAP) greater
  than 65 mm Hg.


• The third step is to evaluate the central venous oxygen saturation
  (SvO 2 ). This is obtained from the central venous line, which, in turn, is
  a surrogate for peripheral tissue oxygenation and cardiac output. A cen-
  tral venous saturation of less than 70% is considered abnormal and
  indicative of suboptimal therapy. In this case, the hematocrit is checked
  and blood is transfused until a hematocrit greater than 30% is attained.
  Once this is attained and the central venous saturation is still low, dobu-
  tamine is initiated to increase cardiac output.

Systemic

Inflammatory

Response Severe Septic

Syndrome (SIRS) Sepsis Sepsis Shock

Two or more of the

following criteria:

HR > 90 SIRS Sepsis Sepsis

Temperature > 100.4°F + + +

or < 96.8°F Suspected or Acute organ Refractory

RR > 20, or PaCO 2 < 32 proven dysfunction hypotension

WBC >12,000 cells/mm^3 , infections

or < 4000 cells/mm^3 ,

or > 10% band forms