|
|
| Line 1: |
Line 1: |
| ==Definition==
| |
|
| |
|
| '''Sepsis''' is a [[systemic inflammatory response syndrome]] (SIRS) following an infection, and it is manifested by multi-system organ dysfunction in addition to [[hypotension]] that is not readily reversible with fluid resuscitation.
| |
|
| |
| '''Systemic inflammatory response syndrome (SIRS)''' is the occurrence of at least two of the following criteria:<ref name="Levy-2003">{{Cite journal | last1 = Levy | first1 = MM. | last2 = Fink | first2 = MP. | last3 = Marshall | first3 = JC. | last4 = Abraham | first4 = E. | last5 = Angus | first5 = D. | last6 = Cook | first6 = D. | last7 = Cohen | first7 = J. | last8 = Opal | first8 = SM. | last9 = Vincent | first9 = JL. | title = 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. | journal = Crit Care Med | volume = 31 | issue = 4 | pages = 1250-6 | month = Apr | year = 2003 | doi = 10.1097/01.CCM.0000050454.01978.3B | PMID = 12682500 }}</ref>
| |
|
| |
| :* Fever > 38.0°C or hypothermia < 36.0°C,
| |
| :* [[Tachycardia]] > 90 beats/minute
| |
| :* [[Tachypnea]] > 20 breaths/minute or PaCO<sub>2</sub> lower than 32 mm Hg.
| |
| :* [[Leucocytosis]] > 12,000/mm<sup>3</sup> or [[leucopoenia]] < 4,000/mm<sup>3</sup>
| |
|
| |
| '''Septic shock''' is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation (infusion of 30 mL/kg of [[crystalloids]]/albumin equivalent).
| |
|
| |
| ==Diagnostic Criteria For Sepsis==
| |
| (Documented/Suspected Infection plus some of the following:)<ref name="Dellinger-2013">{{Cite journal | last1 = Dellinger | first1 = RP. | last2 = Levy | first2 = MM. | last3 = Rhodes | first3 = A. | last4 = Annane | first4 = D. | last5 = Gerlach | first5 = H. | last6 = Opal | first6 = SM. | last7 = Sevransky | first7 = JE. | last8 = Sprung | first8 = CL. | last9 = Douglas | first9 = IS. | title = Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. | journal = Crit Care Med | volume = 41 | issue = 2 | pages = 580-637 | month = Feb | year = 2013 | doi = 10.1097/CCM.0b013e31827e83af | PMID = 23353941 }}</ref>
| |
|
| |
| :'''General variables'''
| |
| :* Fever > 38.3°C
| |
| :* [[Hypothermia]] (core temperature < 36°C)
| |
| :* Heart rate > 90/min–1 or > 2 Standard deviation (SD) above the normal value for age
| |
| :* Tachypnea
| |
| :* Altered mental status
| |
| :* Edema
| |
| :* Positive fluid balance ( > 20 mL/kg over 24 hr)
| |
| :* Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
| |
|
| |
| :'''Inflammatory variables'''
| |
| :* Leukocytosis (WBC count > 12,000 µL–1)
| |
| :* Leukopenia (WBC count < 4000 µL–1)
| |
| :* Immature WBCs forms are > 10% with normal count
| |
| :* Plasma [[C-reactive protein]] > 2 SD above the normal value
| |
| :* Plasma [[procalcitonin]] > 2 SD above the normal value
| |
|
| |
| :'''Hemodynamic variables'''
| |
| :* Arterial hypotension after 30 ml/kg fluid bolus (Systolic blood pressure (SBP) < 90 mm Hg, mean arterial pressure (MAP) < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or < 2 SD below normal for age)
| |
|
| |
| :'''Organ dysfunction variables'''
| |
| :* Arterial [[hypoxemia]] (Pao2/Fio2 < 300)
| |
| :* Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
| |
| :* Creatinine increase > 0.5 mg/dL or 44.2 µmol/L
| |
| :* Coagulation abnormalities (INR > 1.5 or aPTT > 60 Sec)
| |
| :* Ileus (absent bowel sounds)
| |
| :* Thrombocytopenia (platelet count < 100,000 µL–1)
| |
| :* Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 µmol/L)
| |
|
| |
| :'''Tissue perfusion variables'''
| |
| :* Hyperlactatemia > 1 mmol/L
| |
| :* Decreased capillary refill or mottling
| |
|
| |
| ==Severe Sepsis==
| |
|
| |
| Severe sepsis refers to sepsis-induced tissue hypoperfusion or organ dysfunction with one of the following, due to infection:<ref name="Dellinger-2013">{{Cite journal | last1 = Dellinger | first1 = RP. | last2 = Levy | first2 = MM. | last3 = Rhodes | first3 = A. | last4 = Annane | first4 = D. | last5 = Gerlach | first5 = H. | last6 = Opal | first6 = SM. | last7 = Sevransky | first7 = JE. | last8 = Sprung | first8 = CL. | last9 = Douglas | first9 = IS. | title = Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. | journal = Crit Care Med | volume = 41 | issue = 2 | pages = 580-637 | month = Feb | year = 2013 | doi = 10.1097/CCM.0b013e31827e83af | PMID = 23353941 }}</ref>
| |
| <ref name="Levy-2003">{{Cite journal | last1 = Levy | first1 = MM. | last2 = Fink | first2 = MP. | last3 = Marshall | first3 = JC. | last4 = Abraham | first4 = E. | last5 = Angus | first5 = D. | last6 = Cook | first6 = D. | last7 = Cohen | first7 = J. | last8 = Opal | first8 = SM. | last9 = Vincent | first9 = JL. | title = 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. | journal = Crit Care Med | volume = 31 | issue = 4 | pages = 1250-6 | month = Apr | year = 2003 | doi = 10.1097/01.CCM.0000050454.01978.3B | PMID = 12682500 }}</ref>
| |
|
| |
| :* Sepsis-induced hypotension - systolic blood pressure (SBP) <90 mmHg or mean arterial pressure (MAP) <70 mmHg or a SBP decrease >40 mmHg or less than two standard deviations below normal for age in the absence of other causes of hypotension
| |
| :* Lactate above upper limits laboratory normal
| |
| :* Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
| |
| :* [[Acute lung injury]] with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
| |
| :* [[Acute lung injury]] with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
| |
| :* [[Creatinine]] > 2.0 mg/dL (176.8 μmol/L)
| |
| :* [[Bilirubin]] > 2 mg/dL (34.2 μmol/L)
| |
| :* Platelet count < 100,000 μL
| |
| :* [[Coagulopathy]] (international normalized ratio > 1.5)
| |
|
| |
| ==Causes==
| |
|
| |
| ===Life Threatening Causes===
| |
|
| |
| :*Bacteremia: 95% of positive blood cultures were associated with sepsis, severe sepsis, or septic shock.<ref name="Jones-1996">{{Cite journal | last1 = Jones | first1 = GR. | last2 = Lowes | first2 = JA. | title = The systemic inflammatory response syndrome as a predictor of bacteraemia and outcome from sepsis. | journal = QJM | volume = 89 | issue = 7 | pages = 515-22 | month = Jul | year = 1996 | doi = | PMID = 8759492 }}</ref>. However septic shock can occur without bacteremia "viable bacteria in the blood". In fact, septic shock is associated with culture-positive bacteremia in only 30-50% of cases.<ref name="Brun-Buisson-1995">{{Cite journal | last1 = Brun-Buisson | first1 = C. | last2 = Doyon | first2 = F. | last3 = Carlet | first3 = J. | last4 = Dellamonica | first4 = P. | last5 = Gouin | first5 = F. | last6 = Lepoutre | first6 = A. | last7 = Mercier | first7 = JC. | last8 = Offenstadt | first8 = G. |last9 = Régnier | first9 = B. | title = Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. | journal = JAMA | volume = 274 | issue = 12 | pages = 968-74 | month = Sep | year = 1995 | doi = |PMID = 7674528 }}</ref><ref name="Sands-1997">{{Cite journal | last1 = Sands | first1 = KE. | last2 = Bates | first2 = DW. | last3 = Lanken | first3 = PN. |last4 = Graman | first4 = PS. | last5 = Hibberd | first5 = PL. | last6 = Kahn | first6 = KL. | last7 = Parsonnet | first7 = J. | last8 = Panzer | first8 = R.| last9 = Orav | first9 = EJ. | title = Epidemiology of sepsis syndrome in 8 academic medical centers. | journal = JAMA | volume = 278 | issue = 3 | pages = 234-40 | month = Jul | year = 1997 | doi = | PMID = 9218672 }}</ref><ref name="Kumar-2006">{{Cite journal | last1 = Kumar | first1 = A. | last2 = Roberts |first2 = D. | last3 = Wood | first3 = KE. | last4 = Light | first4 = B. | last5 = Parrillo | first5 = JE. | last6 = Sharma | first6 = S. | last7 = Suppes |first7 = R. | last8 = Feinstein | first8 = D. | last9 = Zanotti | first9 = S. | title = Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. | journal = Crit Care Med | volume = 34 | issue = 6 | pages = 1589-96 | month = Jun |year = 2006 | doi = 10.1097/01.CCM.0000217961.75225.E9 | PMID = 16625125 }}</ref><ref name="Bernard-2001">{{Cite journal | last1 = Bernard | first1 = GR. |last2 = Vincent | first2 = JL. | last3 = Laterre | first3 = PF. | last4 = LaRosa | first4 = SP. | last5 = Dhainaut | first5 = JF. | last6 = Lopez-Rodriguez |first6 = A. | last7 = Steingrub | first7 = JS. | last8 = Garber | first8 = GE. | last9 = Helterbrand | first9 = JD. | title = Efficacy and safety of recombinant human activated protein C for severe sepsis. | journal = N Engl J Med | volume = 344 | issue = 10 | pages = 699-709 | month = Mar | year = 2001 |doi = 10.1056/NEJM200103083441001 | PMID = 11236773 }}</ref>
| |
|
| |
| ===Common Causes===
| |
|
| |
| :*Community acquired pneumonia: 48% develop severe sepsis.<ref name="Dremsizov-2006">{{Cite journal | last1 = Dremsizov | first1 = T. | last2 = Clermont |first2 = G. | last3 = Kellum | first3 = JA. | last4 = Kalassian | first4 = KG. | last5 = Fine | first5 = MJ. | last6 = Angus | first6 = DC. | title = Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course? | journal = Chest |volume = 129 | issue = 4 | pages = 968-78 | month = Apr | year = 2006 | doi = 10.1378/chest.129.4.968 | PMID = 16608946 }}</ref>
| |
| :*Diabetes and renal disease may explain the higher rates of infection related septic shock.
| |
| :*Immunosuppression
| |
|
| |
| ==Management==
| |
|
| |
| The following guidelines are based on 'Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012'.<ref name="Dellinger-2013">{{Cite journal | last1 = Dellinger | first1 = RP. | last2 = Levy | first2 = MM. | last3 = Rhodes | first3 = A. | last4 = Annane | first4 = D. | last5 = Gerlach | first5 = H. | last6 = Opal | first6 = SM. | last7 = Sevransky | first7 = JE. | last8 = Sprung | first8 = CL. | last9 = Douglas | first9 = IS. | title = Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. | journal = Crit Care Med | volume = 41 | issue = 2 | pages = 580-637 | month = Feb | year = 2013 | doi = 10.1097/CCM.0b013e31827e83af | PMID = 23353941 }}</ref>
| |
|
| |
| {{familytree/start}}
| |
| {{familytree | | | | | | | | | A01 | | | | | | | | | | |A01=<div style="float: left; text-align: left "> ''' Characterize the symptoms:''' <br> ❑ Fever <br> ❑ [[Hypothermia]] <br> ❑ Altered mental status <br> ❑ [[Mottling]] <br> ❑ [[Ileus]] <br> ❑ [[Oliguria]] </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | B01 | | | | | | | | | | |B01=<div style="float: left; text-align: left "> '''Examine the patient:''' <br> ❑ Tachycardia <br> ❑ Tachypnea <br> ❑ Edema <br> ❑ Hyperglycemia <br> ❑ Hypotension after an initial 30 ml/Kg bolus <br> ❑ Decreased capillary refill </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | C01 | | | | | | | | | | |C01=<div style="float: left; text-align: left "> '''Order labs:''' <br> ❑ Random blood sugar (RBS) <br> ❑ Complete blood count (CBC) <br> ❑ [[C-reactive protein|Plasma C reactive protein (CRP)]] <br> ❑ [[Procalcitonin|Plasma procalcitonin]] <br> ❑ Pulse oximetry <br> ❑ Urinalysis/Renal function tests <br> ❑ PT/INR <br> ❑ Liver function tests <br> ❑ Serum lactate <br> ❑ Central venous pressure (CVP) </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | D01 | | | | | | | | | | |D01=<div style="float: left; text-align: left "> '''Consider alternative diagnosis:''' <br> ❑ Infections <br> ❑ [[Acute pancreatitis]] <br> ❑ [[Diabetic ketoacidosis]] <br> [[Lower gastrointestinal bleeding]] <br> [[Myocardial infarction]] </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | E01 | | | | | | | | | | |E01=<div style="float: left; text-align: left "> '''Initial resuscitation: Goals to achieve in first 6 hours''' <br> ❑ Central venous pressure (CVP) 8-12 mm Hg <br> ❑ Mean arterial pressure (MAP) ≥ 65 mm Hg <br> ❑ Urine output ≥ 0/5 mL/Kg/hr <br> ❑ Central venous O<sub>2</sub> sat. 70% <br> ❑ If lactate levels elevated, target is normalization </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | F01 | | | | | | | | | | |F01=<div style="float: left; text-align: left "> '''Diagnosis:''' <br> ❑ Perform 2 sets of blood cultures (aerobic and anaerobic) atleast, before starting antibiotics <br>
| |
| :# Drawn percutaneously <br>
| |
| :# Drawn through each vascular access device present for > 48 hours <br>
| |
| ❑ Perform 1,3 beta-D-glucan assay, mannan, anti-mannan antibody assay if available <br> ❑ Perform imaging studies as appropriate to locate a source </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | G01 | | | | | | | | | | |G01=<div style="float: left; text-align: left "> '''Antimicrobial therapy:''' <br> ❑ Initiate within 1st hour of diagnosis <br> Reassess regimen daily <br> ❑ Use low procalitonin levels for prognosis <br> ❑ Usual duration of therapy 10 days <br> ❑ Longer in neutropenics, slow responders, undrainable foci, immunologically compromised </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | H01 | | | | | | | | | | |H01=Choice of antibiotics }}
| |
| {{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | }}
| |
| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | }}
| |
| {{familytree | I01 | | I02 | | I03 | | I04 | | I05 | | |I01='''Unknown organism''' <br> ❑ Empiric therapy with broad spectrum antbiotic with good tissue penetrance |I02= '''[[Neutropenic]] pt with severe sepsis (goal is to cover [[Acinetobacter]] & [[Pseudomonas]] spp)''' <br> ❑ Use combination empirical therapy |I03='''Severe infections + resp failure + septic shock''' <br> ❑ Extended spectrum [[Beta-lactam antibiotic|beta lactam]] and [[aminoglycoside]]/[[fluoroquinolone]] |I04= '''[[Streptococcus pneumoniae]]''' <br> ❑ [[Beta-lactam antibiotic|beta lactam]] + [[macrolide]] |I05='''Culture specific organism''' <br> ❑ Shift to appropriate anti-bacterial, antiviral or antifungal }}
| |
| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | }}
| |
| {{familytree | |`|-|-|-|^|-|-|-|+|-|-|-|^|-|-|-|'| | | }}
| |
| {{familytree | | | | | | | | | J01 | | | | | | | | | |J01=<div style="float: left; text-align: left "> '''Remove source/foci of infection:''' <br> ❑ Use minimally invasive process <br> ❑ Source removal best done in first 12 hours <br> ❑ Remove intravascular access devices if they are a possible source
| |
| ----
| |
| ❑ Oral [[chlorhexidine gluconate]] to reduce oral contamination as a risk factor for [[ventilator associated pneumonia]] </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | K01 | | | | | | | | | |K01=<div style="float: left; text-align: left "> Hemodynamic support <br> '''Fluid therapy:''' <br> ❑ Administer [[crystalloids]], use albumin when demand for fluids is too high <br> ❑ Use dynamic variables (change in pulse pressure, stroke volume) and static variables (arterial pressure,heart rate) to assess status
| |
| ----
| |
| '''[[Vasopressors]] (to achieve target MAP ≥ 65 mm Hg):''' <br> ❑ Place [[arterial line]] as soon as feasible <br> ❑ Administer [[norepinephrine]] as 1st choice drug <br> ❑ Use [[epinephrine]] - when additional agent needed <br> ❑ Use [[vasopressin]] 0.03 units/minute to raise MAP or decrease norepinephrine usage <br> ❑ Selective [[dopamine]] (absolute or relative bradycardia) and [[phenylephrine]] usage
| |
| ----
| |
| '''Inotropic therapy:''' <br> ❑ Trial of [[dobutamine]] infusion 20 μg/Kg if cardiac output low with elevated cardiac filling pressure </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | L01 | | | | | | | | | |L01=<div style="float: left; text-align: left "> '''Corticosteroids:''' <br> ❑ Use continuous flow IV [[hydrocortisone]] 200 mg/day if shock doesn’t improve with fluids & vasopressor <br> ❑ Taper when vasopressors no longer required </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | M01 | | | | | | | | | |M01=<div style="float: left; text-align: left "> '''Blood products:''' <br> ❑ Transfuse blood when hemoglobin < 7.0 g/dL <br> ❑ Transfuse platelets if < 10,000/mm<sup>3</sup> or < 20,000/mm<sup>3</sup> in those with high risk </div> }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | N01 | | | | | | | | | |N01=<div style="float: left; text-align: left "> '''Mechanical ventilation for sepsis induced ARDS':''' <br> ❑ Target tidal volume of 6 mL/Kg <br> ❑ Target plateau pressure ≤ 30 mm Hg <br> ❑ Use PEEP (positive end expiratory pressure) to avoid alveolar collapse <br> ❑ Raise patients bed to 30-45° <br> ❑ Attempt weaning when all foll. criteria are met: <br>
| |
| :# ❑ Pt arousable
| |
| :# ❑ Hemodynamics stable
| |
| :# ❑ No new complications
| |
| :# ❑ Low ventilatory/fiO<sub>2</sub> requirements <br>
| |
| ❑ Extubate when weaning successful </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | O01 | | | | | | | | | |O01=<div style="float: left; text-align: left "> Other supportive therapy <br> '''Sedation & neuromuscular blockade:''' <br> ❑ Use minimal sedation/[[Neuromuscular-blocking drugs|neuromuscular blockade]] in mechanically ventilated patients
| |
| ----
| |
| '''Glucose control:''' <br> ❑ Blood glucose target value should be ≤ 180 mg/dL <br> ❑ Use insulin infusion and 1-2 hourly monitoring to achieve target
| |
| ----
| |
| '''Renal replaement therapy:''' <br> ❑ May be used for management of fluid balance in hemodynamically unstable patients <br> ❑ Use for septic patients with [[acute renal failure]]
| |
| ----
| |
| '''DVT prophylaxis:''' <br> ❑ Do pharmacoprophylaxis with [[low molecular weight heparin]] (LMWH), if no contraindications present <br> ❑ Use [[Intermittent pneumatic compression|pneumatic compression devices]] whenever possible
| |
| ----
| |
| '''Stress ulcer prophylaxis''' <br> ❑ Consider prophylaxis if risk factors are present
| |
| ----
| |
| '''Feeding:''' <br> ❑ Enteral & oral feeding preferred over total parenteral feeding (TPN) <br> ❑ Adjust calorie requirement in subsequent days, as tolerated
| |
| ----
| |
| '''Goals of care:''' <br> ❑ Discuss goals or care, patient aspirations and future directives with family with 72 hours of admission </div>}}
| |
| {{familytree | | | | | | | | | | | | | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | | | | | | | | | | | | | }}
| |
| {{familytree/end}}
| |
|
| |
| ==Do's==
| |
|
| |
| * Patients who are suspected of being severely infected, should be routinely screened for sepsis.
| |
|
| |
| * Administer antimicrobial therapy within 1 hour of diagnosis of sepsis.
| |
|
| |
| * Delay intervention, if source/foci of infection is peri-pancreatic necrosis.
| |
|
| |
| ==Dont's==
| |
|
| |
| * Do not use empiric combination therapy for more than 3-5 days.
| |
|
| |
| * Do not use antimicrobial agents in severely inflamed patients, from a non-infectious cause.
| |
|
| |
| * Do not use [[hydroxyethyl starch]] for fluid therapy resuscitation of severe sepsis and septic shock.
| |
|
| |
| * Do not use low dose vasopressin/dopamine/phenylephrine as monotherapy.
| |
|
| |
| * Do not use low dose dopamine for renal protection.
| |
|
| |
| * Do not use [[corticosteroid]]s in the absence of shock.
| |
|
| |
| * Do not use [[erythropoietin]] as a specific treatment of anemia associated with sepsis.
| |
|
| |
| * Do not use antithrombin.
| |
|
| |
| * Do not use fresh frozen plasma to correct clotting abnormalities in the absence of bleeding or planned invasive procedure.
| |
|
| |
| * Do not use following supportive therapies as their role is not clear:
| |
|
| |
| : IV [[immunoglobulin]]s
| |
|
| |
| : IV selenium
| |
|
| |
| * Do not routinely use pulmonary artery catheters.
| |
|
| |
| * Do not use bicarbonate therapy as prophylaxis of hypoperfusion induced [[lactic acidosis]] if pH > 7.15.
| |
|
| |
| ==References==
| |
| {{Reflist|2}}
| |
|
| |
| [[Category:Help]]
| |
| [[Category:Projects]]
| |
| [[Category:Resident survival guide]]
| |
| [[Category:Templates]]
| |
|
| |
| {{WikiDoc Help Menu}}
| |
| {{WikiDoc Sources}}{{familytree/start |summary=DKA}}
| |