We're going to start out with a set of questions. And we have Drs. Balk and Patel here to help us run through sepsis, infections, pneumonia, and shock. And I think, yes. So why don't you step up and join. Well, this can be you, but I think I was supposed to do it. So no, we'll go ahead. And if I get anything wrong, you tell me what I did wrong and why it's wrong. So you've got a gentleman who has emergent surgery, perforated diverticulum, develops shock, multisystem organ failure. And he's on the vent. He's on a lot of oxygen. And his CT post-op doesn't show any problems. But it turns out that he's got infiltrates, increasing secretions. He's got a high white count. His platelet count is low. And he's developing some kidney injury. And the question is, which of the following treatments should be eliminated for consideration from this patient? Yes. Well, so there's a QR code that they. Oh, so I have to hit the start? Show the correct answer. So I have to do this from here? You'll have to do this one. OK. So you show the correct answer. And when you go to the next one, you'll have to hit Start again, because that will change the question on their phone. OK, great. So it looks like we have a preponderance of people who agree with each other. So we're going to move on. So why am I not so I've hit the next one should it not just move forward But it looks like the Yeah, I thought I did but Okay Okay So it looked like most people noticed the low platelets and decided that lanazulid was Something that they would be uncomfortable giving and I think that's probably even though it's not the answer that they wanted I think it's probably reasonable to To do that So I'm not moving forward which means that probably I'm not qualified to operate this I Apparently I'm under caffeinated this morning, which which I apologize for So We may need lots of remedial help so so this patient has MRSA pneumonia, he doesn't have a belly problem and the Again it's reasonable to to treat with with for a MRSA pneumonia You can use vancomycin. You can use lanazulid in theory. You can use clindamycin. Although I'm gonna ask our Pharmacist here whether or not they would ever use clindamycin for that. He shakes his head. No But but adaptomycin is probably not a drug that you should use for a lung infection So anything you would add My son has a inducible resistance to MRSA so oftentimes Ironically enough and coincidentally enough you'll you may start it and then for whatever reason somebody sends another aspirate culture and Then days later it actually becomes resistant. So it's inducible and it's pretty quick. It can actually be while they're on therapy So we generally just avoid it But sometimes you use it for antitoxin effects, correct? Yeah Yeah, if it's a shock, yeah Okay So following along the MRSA infection theme You've got somebody with coronary artery disease They've got a soft tissue infection They're hypotensive tachycardic they're given volume Somebody decided that they need to place a central line early, which we don't do so much anymore and they start vasopressors and She's on a high dose of vasopressors And the question is when would you think about giving IV hydrocortisone for somebody with on two vasopressors So, it looks like there's not much controversy over here. The correct answer is patients with persistent shock, despite adequate volume resuscitation on vasopressors. There's reasonably good evidence that steroids in septic shock does not improve mortality, at least short-term mortality. There are a couple of systematic reviews and meta-analyses suggesting that there may be a long-term mortality benefit. When you look at the confidence intervals on these systematic reviews and meta-analyses, they don't cross one for long-term mortality. But for short-term mortality, 10,000 patients, lots of trials, it doesn't work. So if there is a mortality effect, it's probably pretty small, but it clearly does get people off pressors faster and probably off the ventilator faster, at the cost of raising your sodium a bit and causing a 20 or so percent increased risk of critical illness weakness. OK. Following, and you'll hear more about this from Steve Pastore later today, but checking for cosentropin, short cosentropin tests, it gives you something to do. But it doesn't help figure out whether or not you're going to treat the patient, since that doesn't seem to help with response of whether or not somebody is going to respond to steroids. So that's not something that we routinely do. And how you diagnose, again, you'll hear from Steve a little later today, how to think about corticosteroid-induced endocrineopathy. And I believe I'm going to pass the baton now to two of my colleagues. Perhaps. This one, this case, it's a 50-year-old, 4-year-old patient with ventilator-associated pneumonia, complications in his ICU stay, empiric treatment, broad spectrum, piperacillin-tazobactam, levofloxacin, and vancomycin. Several days later, you get information back that the aspirate culture is E. coli, and it's sensitive to piperacillin-tazobactam. The team discontinues vancomycin and levofloxacin. The patient's deferred vest, a count of 18,000, WBC is down to 8,000, and it's asking what your selection, best choice is for duration of therapy. So you have 8 days, 10 days, 14 days, and 21 days. All right, very good. Let's see. It doesn't say anything. That's interesting. The correct duration is the one chosen by everyone. Yeah, that is good. Eight days and let me see. There we go. Yeah, true. So the rationale, the Chastry study, which is fairly old now, I think almost coming on a decade. If I remember right, it was in 2015, but it looked at the eight versus the 15-day model for duration of therapy for non-fermenters. We'll get to that in the next lecture in terms of once you identify a bacterial isolate with sensitivities. All right. This next one, it's a 60-year-old male with MRSA, bacteremia, endocarditis, without endocarditis. Actually, that's one of the keys. Despite seven days of vancomycin therapy, which is probably universally empiric, empiric started almost everywhere for MRSA cultures. On day six, patient's still positive. The MRSA, the information you're getting back, of course, resistant to penicillin and oxacillin, now resistant to vancomycin, lenazolid intermediate, and daptomycin intermediate. Which of the following is the most appropriate? To start for this patient in terms of once you get this information back, you can continue vancomycin for four to six weeks, daptomycin, sulfamethoxazole, trimethoprim, or colistamate. All right, split between sulfomythoxazole, I'm sorry, daptomycin and looks like callisomate. And daptomycin would still, even though you're seeing intermediate, and the reason is it's actually concentration dependent. So there are studies where you can utilize 6, 8, and 10. Normally you'll see 10 milligram per kilogram, a little bit more for enterococcal infections, but it is concentration dependent. So you can always give more, where it's actually concentration dependent killing. So that one actually is acceptable. They're pointing away, trying to get you away from the sulfomythoxazole trimethoprim due to the reaction. There was prior drugs available like quinupristin, delfopristin, but it actually, the company stopped making it. Pfizer did in 2022, but that was an option prior. If they had ceftaroline on there, would that be something that you would think about? Yeah. Ceftaroline could be another one for either the bacteremia or pneumonia. If I remember correctly, some of the original trials were probably more with pneumonia, but yeah, that could be an acceptable option as well. It does, yeah. So you actually can utilize it, but I would say the literature for MRSA bacteremia is probably going to be the strongest with daptomycin. And I believe they moved it years ago, actually in the endocarditis guidelines, and finally moved away from genomycin therapy synergy. I need somebody else to do this. Oh, you don't even have to. You could use it with this or advance it. Advance it here? Yep. You have to push something there? Yeah, it's a touch screen too. Oh, okay. Well, good morning. I have the privilege of going over a couple of controversial questions for you. So I'm all prepared to hear some discussion. So this is a 55-year-old man admitted to the ICU with community-acquired pneumonia. He's hypoxemic. He's on high-flow nasal cannula, and it's a FiO2 of one, 60 liters per minute of flow. He's on broad-spectrum antibiotics. He's continuing to deteriorate. He's worsening tachypnea, hypoxia. He's in respiratory distress. No-brainer, we want to intubate the guy. So the question is, let's evaluate for how easy or hard it's gonna be. It turns out that we look at his mouth, and he's got a mouth opening greater than three centimeters. His neck mobility is normal. Thyromental distance is greater than six centimeters, and a Malampati score of one. Sounds pretty easy, right? So then the question is, what do we expect to be the difference between video laryngoscopy as compared to direct laryngoscopy? So here are our choices. And I push this little button. How do you push that little button? Oh. Sometimes it's easier just to do it with a mouse. Oh, okay. So please vote on whether you think that the video laryngoscope is going to increase our likelihood of a successful intubation on the first attempt, improve glottic view, reduce post-intubation complications, or reduce time to successful intubation. And you've all used these devices, and you know, probably the right answer is it depends on the, actually, skill of the operator, right? But most will, how do I know when they're done? Most of you say it will increase the likelihood of successful intubation on the first attempt, which in some studies is true, but most would say you're gonna get an improved glottic view. So this, I think, is one of those controversial questions. Oh, I moved this down to here. No. Oh gosh, it's more complicated than I think. So you see we have some trials show improved glottic view. Others show that, like the device trial, in the New England Journal showed benefit to video laryngoscopy by allowing for first attempt success. So I think this is a difficult question for people to figure out what is the test writer thinking of, and I would say both of those could be correct answers. The other two are not good answers. And feel free to bring up any discussion. So let's move to more controversy. Especially when you think about if you're preparing for a test, then all of the new information that may be included in these slides may not be of any help to you. In fact, it may confuse you. If you're actually wanting to do state-of-the-art, let's see what's going on, then the new information we're gonna tell you may be quite beneficial to help your current practice. So here's a 55-year-old man admitted to the ICU with septic shock secondary to viral pneumonia. He's on mechanical ventilation. His medical history is remarkable for chronic low back pain, type 2 diabetes. Home medications are tramadol and metformin. And we're gonna ask you who should get stress ulcer prophylaxis, and what are the benefits in this patient? So we're gonna talk about, you can read that while I try and hit the button with the right part of this. Well, did I do that correct? Okay. Good. So we're gonna see is stress ulcer prophylaxis going to increase nosocomial pneumonia? Are we more likely to reduce mortality using proton pump inhibitors than H2 receptors? Did I go too far? Stress ulcer prophylaxis associated with crostidium difficile, diarrhea, and is it even mentioned in the surviving sepsis campaign? So if you've read your critical care medicine, you know we have some new guidelines that have come out on when to use stress ulcer prophylaxis. It wouldn't be for people on just mechanical ventilation anymore. We would be saying, this guy has shock, so he would very much, septic shock, so he would qualify for that. And it looks like most of you have gone with stress ulcer prophylaxis has been associated with C. diff, diarrhea. It turned, as it turns out, the guidelines actually don't support that anymore. So it is mentioned in the surviving sepsis campaign. Nosocomial pneumonia risk does not increase with stress ulcer prophylaxis, and proton pump inhibitors are not more likely to reduce mortality than H2 receptor blockers. In fact, there was a past study that actually showed that there wasn't a potential trend for increased mortality with the use of PPI versus H2 receptor antagonists. So I think this is another one of these controversial areas. Most of you have said, yeah, it's associated with C. diff, diarrhea, and I think that was the thinking before we got into the new guidelines. So I hope you don't see this on the boards. It is the, it's the C. diff, diarrhea. Yeah, the new guidelines just came out one month ago. So it should not be on the boards. Okay, so on the boards, this is what you're doing. In real life, you don't now have to worry about C. diff, diarrhea. Okay, and I think we change. And here's the rationale. Do they get a copy of all these? Okay, and I even threw in some of those new studies for you. And then this is, I think this is mine too, right? So this is a 49-year-old woman admitted to the ICU two days ago for septic shock, secondary to a urinary tract infection. She's responded well to antibiotics, has remained hemodynamically stable off vasopressors for 24 hours. We'd like to evaluate to see if it's appropriate to wean and extubate this patient. She's been on propofol, and according to the bedside nurse, she opens her eyes to voice but does not make eye contact. To optimize facilitating extubation of this patient and her ability to pass a spontaneous breathing trial, which of the following Richmond agitation sedation scale score goals should be achieved while receiving sedation? And hopefully, you're on the least amount of sedation. Oh, go ahead. So you can choose A as minus one to plus one, B as plus three to plus four, C as minus five to minus four, and D as minus three to minus two. And I expect you all to probably get close to 100% on this one. So an A is the correct answer. And I don't know if we need any discussion on that. This is pretty general, and everybody is not gonna argue about this. Okay. Well, thanks, and I will pass the baton. That's it, yeah, thanks. Next case is a adult patient, goes into the ICU after an X lab. Within the operating room, they find an abscess, it's strained, vancomycin and meropenem are initiated as empiric therapy. You get cultures, data back with an isolate of E. coli. It's susceptible to cephalosporins, which is good, unusual sometimes, but good. And also mixed anaerobes. So the question's asking kind of what's your next steps? You can continue triple antimicrobial therapy for 10 days, 10 days of meropenem, change the antibiotics to cefazolin metronidazole for four days, or change the antibiotics to cefepime and clinda for five days. No, thank you. Okay. Okay, I'm assuming everyone's familiar with the STOP-IT trial then. Very good, so it's four days of therapy narrowed to cefazolin and metronidazole based on your microbial data and the STOP-IT trial from the New England Journal of Medicine. Next patient, a 46-year-old male presents to the emergency department, febrile, tachycardic, and lethargic. He can move all four extremities, but then has a generalized tonic-clonic seizure lasting about approximately three minutes. Upon getting a CSF sample, you have WBCs at 33,000, RBCs, elevated protein levels, WBCs, elevated protein, glucose at 90 with the serum at 120. So the question's asking which of the medications that you could initiate could actually improve mortality for this patient. So you have acyclovir, amfotericin B, aspirin, ceftriaxone, or dexamethasone. All right, we have almost a split between acyclovir and and dexamethasone So let's go let's go through each one of these in terms of possibilities You can show the credits yeah, it's a cycle here So for HSV encephalitis Which is what the question is trying to portray is the patients presenting with some key factors We'll start with the dexamethasone have been shown very good outcomes in terms of mortality and morbidity actually in bacterial meningitis Not so much in viral meningitis the other options Ceftraxone would be helpful. Of course again if you're targeting more empiric bacterial type meningitis presentation and And the other one I believe was aspirin, of course more standard of care therapy for a CVA type presentation Correct yeah Yeah that data is just With strep, although the interesting thing with the bacterial meningitis Unless you have an isolate if you're empirically treating it what I have seen it likely is that the team is starting Dexamethasone earlier than latter. But yeah, that's correct

critical care

sepsis

antibiotic therapy

MRSA pneumonia

STOP-IT trial

sedation management