I have just one comment regarding the use of aminoglycoside in ED. IDSA guideline do not recommend the use of aminoglycoside in patients with community acquired abdominal infection e.g. perforated duodenum, complicated appendicitis.etc.. and Aminoglycoside is recommended only in health care associated infection e.g. repeated explorations. So if the patients is presented with septic shock in ED with ?? abdominal infection without history of recent abdominal operation aminoglycoside will not be recommended. Regards Ahmed Mukhtar Assistant professor of anesthesia and critical care Cairo university Cairo, Egypt
On Fri, Sep 20, 2013 at 3:58 PM, < [email protected]> wrote: > Send Sepsisgroups mailing list submissions to > [email protected] > > To subscribe or unsubscribe via the World Wide Web, visit > > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > > or, via email, send a message with subject or body 'help' to > [email protected] > > You can reach the person managing the list at > [email protected] > > When replying, please edit your Subject line so it is more specific > than "Re: Contents of Sepsisgroups digest..." > > > Today's Topics: > > 1. Re: Aminoglycoside dosing in severe sepsis/septic shock > (Moine, Pierre) > 2. Re: Lactic Acid (Theresa Trivette) > > > ---------------------------------------------------------------------- > > Message: 1 > Date: Wed, 18 Sep 2013 19:41:41 -0600 > From: "Moine, Pierre" <[email protected]> > To: "Silvers MD, Jeffrey H" <[email protected]>, > "Harkey,Jessica" <[email protected]>, > "[email protected]" > <[email protected]> > Subject: Re: [Sepsis Groups] Aminoglycoside dosing in severe > sepsis/septic shock > Message-ID: > <114281d08fb17d4087a4b4d60537f599515833b...@steamboat.ucdenver.pvt > > > Content-Type: text/plain; charset="Windows-1252" > > Sorry I do not understand the difference between ICU and ED! > And, in the last 25 years the literature on Aminoglycosides changed! > Thanks > > ________________________________________ > From: Silvers MD, Jeffrey H [[email protected]] > Sent: Wednesday, September 18, 2013 4:39 PM > To: Moine, Pierre; Harkey,Jessica; [email protected] > Subject: RE: [Sepsis Groups] Aminoglycoside dosing in severe sepsis/septic > shock > > We are talking about empiric therapy by ED physicians. Not known > organisms. Patients presenting to the ED with severe sepsis and shock > frequently have unstable renal function. Starting with a higher dose of an > aminoglycoside in that environment is hazardous. This is very different > than ICU or critically ill surgical patients where clearly there are > indications for using aminoglycosides. Dehydration or muscle wasting > decreases the apparent volume of distribution. The latter conditions vary > widely from patient to patient and from hour to hour in critically ill > patients. Hence, it is recommended that a ?peak? serum drug level be > measured after the initial dose or the first maintenance dose. The > following is from the PPID by Mandel. Note that the higher doses of mg/kg > in parentheses are for expanded volume patients, the opposite of severe > sepsis/septic shock. The daily dose depends on the renal function. Note > that Ccr <40 recommends 2.5 mg/kg/day as the dose for euvolemic pat > ients. I suggest 2 mg/kg/day as your first dose in the ED, if used, > because the volume of distribution is significantly less in severe > sepsis/shock. > TABLE 26-12 -- Suggested Once-Daily Dosage Regimens: Gentamicin or > Tobramycin*< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0070&appID=NGE > > > Estimated CrCl[?]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0075&appID=NGE> > (mL/min) > > Dosage Interval (hr) > > Dose[?]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0080&appID=NGE> > (mg/kg) > > [cid:[email protected]] (hr) > > Estimated Serum Level after Drug Administration[?]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0085&appID=NGE> > (?g/mL) > > > > > > > > > > 1 hr > > 12 hr > > 18 hr > > 24 hr > > 100 > > 24 > > 5 (7) > > 2.5 > > 20 (28)[?]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0080&appID=NGE > > > > 1.0 (1.4)[?]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0080&appID=NGE > > > > <1 > > <1 > > 90 > > 24 > > 5 (7) > > 3.1 > > 20 (28)[?]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0080&appID=NGE > > > > 2.0 (2.3)[?]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0080&appID=NGE > > > > <1 > > <1 > > 80 > > 24 > > 5 (7) > > 3.4 > > 20 (28)[?]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0080&appID=NGE > > > > 2.5 (2.9)[?]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0080&appID=NGE > > > > <1 > > <1 > > 70 > > 24 > > 4 (5.5) > > 3.9 > > 16 > > 2.0 > > <1 > > <1 > > 60 > > 24 > > 4 (5.5) > > 4.5 > > 16 > > 3.0 > > 1.5 > > <1 > > 50 > > 24 > > 3.5 (5.0) > > 5.3 > > 14 > > 3.5 > > 1.0 > > <1 > > 40 > > 24 > > 2.5 (3.5) > > 6.5 > > 10 > > 3.0 > > 1.5 > > <1 > > 30 > > 24 > > 2.5 (3.5) > > 8.4 > > 10 > > 4.0 > > 2.5 > > 1.5 > > > > > > > > > > 1 hr > > 24 hr > > 36 hr > > 48 hr > > 20 > > 48 > > 4.0 (5.5) > > 11.9 > > 16 > > 4.0 > > 2.0 > > 1.0 > > 10 > > 48 > > 3.0 (4.0) > > 20.4 > > 12 > > 5.0 > > 3.0 > > 2.0 > > 0 (Hemodialysis)[|]< > http://www.expertconsultbook.com/expertconsult/p/linkTo?type=bookPage&isbn=978-0-443-06839-3&eid=4-u1.0-B978-0-443-06839-3..00026-6--tn0090&appID=NGE > > > > 48 > > 2.0 (4.0) > > 69.3 > > 8 > > 7.0 > > 6.0 > > 5.0 > > Data from Gilbert DN, Lee BL, Dworkin RJ, et al. A randomized comparison > of the safety and efficacy of once-daily gentamicin or thrice-daily > gentamicin in combination with ticarcillin-clavulanate. Am J Med. > 1998;105:182-191; and Gilbert DN, Bennett WM. Use of antimicrobial agents > in renal failure. Infect Dis Clin North Am. 1989;3:517-531. > CrCl, creatinine clearance; [cid:[email protected]] , > half-life. > > Jeffrey Silvers, M.D. > Medical Director of Quality, Eden Medical Center > Infectious Diseases specialist > > From: Moine, Pierre [mailto:[email protected]] > Sent: Wednesday, September 18, 2013 9:46 AM > To: Silvers MD, Jeffrey H; Harkey,Jessica; > [email protected] > Subject: RE: [Sepsis Groups] Aminoglycoside dosing in severe sepsis/septic > shock > > Aminoglycosides should be combined with a betalactam for empiric treatment > of severe sepsis and septic shock, documented Pseudomonas aeruginosa, > Acinetobacter spp, and MDR GNB infections. They should be used high dose > once daily (not the FDA recommendations but at least 7 mg/kg for gentamicin > and tobramycin, and 20-25 mg/kg for amikacin). The use of extended-interval > aminoglycoside dosage regimens in critically ill surgical patients is based > on pharmacodynamic endpoints (probability of attaining the target Cmax). > Administration of aminoglycosides > > with the extended-interval dosing scheme has been associated with a lower > risk for nephrotoxicity. The once-daily dosing schedule provides a longer > time of administration until the threshold for nephrotoxicity is met. This > risk is considered to be even lower when the administration is based on > individualized pharmacokinetic monitoring. The subsequent doses may be > tailored according to measured plasma aminoglycoside concentrations. In > patients with reduced renal function, dosing intervals should be extended > in order to reach low trough levels. Aminoglycosides should be anyway > discontinued at 2-5 days. > > > > Pierre Moine > > Associate Professor > > University of Colorado Denver > > School of Medicine > > Department of Anesthesiology > > ________________________________ > From: [email protected]<mailto: > [email protected]> [ > [email protected]] On Behalf Of Silvers MD, > Jeffrey H [[email protected]] > Sent: Tuesday, September 17, 2013 4:26 PM > To: Harkey,Jessica; [email protected]<mailto: > [email protected]> > Subject: Re: [Sepsis Groups] Aminoglycoside dosing in severe sepsis/septic > shock > I don?t recommend aminoglycosides as empiric therapy in septic shock or > severe sepsis, except in rare circumstances. We have lots of alternatives > and risk of nephrotoxicity in that situation is very high. If for some > reason, that is what the doctor believes should be used, you could give a > loading dose of a maximum of 2 mg/kg but no subsequent doses until level > obtained. I would not use once daily dosing either. The best option would > be to have your infectious disease specialist look at the empiric therapy > regimens that the ED doctors are using and make suggestions for them to use > in general. A good reference for your doctors: The Sanford Guide to > Antimicrobial Therapy 2013. > > Jeffrey Silvers, M.D. > Medical Director of Quality, Eden Medical Center > Infectious Diseases specialist > From: [email protected]<mailto: > [email protected]> [mailto: > [email protected]] On Behalf Of Harkey,Jessica > Sent: Tuesday, September 17, 2013 10:28 AM > To: [email protected]<mailto: > [email protected]> > Subject: [Sepsis Groups] Aminoglycoside dosing in severe sepsis/septic > shock > > Hello there. I have been having some discussion with our pharmacists on > whether or not patients who present to the ED in severe sepsis or septic > shock should receive a full dose of an aminoglycoside (when indicated) > within the first hour regardless of Cr clearance? The practice of our ED > physicians thus far has been to order a full dose, and now we are getting > some feedback from pharmacy to reduce the dose per renal function, which > seems appropriate with consecutive doses along with monitoring drug levels. > I am concerned about delaying administration. For initial empric therapy > what are the rest of you doing in such cases? Any literature available for > me to share with the pharmacy? > Thank you! > > Jessica Harkey, RN, BSN, CCRN > Sepsis Program Coordinator > San Joaquin Community Hospital > 661-869-6874 > [email protected]<mailto:[email protected]> > [cid:[email protected]] > > > > ------------------------------ > > Message: 2 > Date: Wed, 18 Sep 2013 14:52:07 -0400 > From: Theresa Trivette <[email protected]> > To: Jamie Roney <[email protected]> > Cc: "[email protected]" > <[email protected]> > Subject: Re: [Sepsis Groups] Lactic Acid > Message-ID: > <c3a0b1ab-1b63-4e0f-8115-1d33085a5...@georgetownhospitalsystem.org > > > Content-Type: text/plain; charset="utf-8" > > Maybe I didn't ask my question right..... > > We are following the protocol for the whole blood lactic acid > levels----but our physicians and nurses on our team are inquiring regarding > the difference in reference ranges for the istat CG4+ lactic acid levels > and whether other organizations have adapted protocol differences for the > istat level versus the whole blood levels to account for the difference in > reference ranges. > > > > from my iPhone > > On Sep 18, 2013, at 2:24 PM, "Jamie Roney" <[email protected]<mailto: > [email protected]>> wrote: > > That level is not a new level. Elevated is > 2.0 mmol/L; however, > 4.0 > has remained a number that triggers treatment. It is built into our > protocols and is considered the ?critical? alert value triggering physician > notification. > > Jamie > > Jamie Roney, BSN, RN-BC, BSHCM, CCRN > covenant health sepsis coordinator > "Be a yardstick of quality. Some people aren't used to an environment > where excellence is expected." ~Steve Jobs > > 3615 19th Street, Lubbock, TX 79410 > T: (806) 725-4689 C: (806) 773-1914 > www.covenanthealth.org<http://www.covenanthealth.org/> > ????????????????????????????.. > <image008.png><image009.jpg><http://www.facebook.com/CovenantHealth> > <image010.jpg><http://twitter.com/#!/@covhs> <image011.jpg>< > http://www.everymomentmatters.org/> > > > From: [email protected]<mailto: > [email protected]> [mailto: > [email protected]] On Behalf Of Theresa Trivette > Sent: Tuesday, September 17, 2013 5:32 PM > To: [email protected]<mailto: > [email protected]> > Subject: [Sepsis Groups] Lactic Acid > > Severe sepsis in the revised guidelines is 4mmol/L. Has anyone developed > protocol levels for istat or venous blood gas results as an equivalent? > > Thanks. > > > NOTE: > The information contained in this message may be privileged, confidential > and protected from disclosure. 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