), Obtain blood cultures before administering antibiotics. Phenylephrine may be a good choice when tachyarrhythmias limit therapy with other agents. 55(3):290-5. [66] : Administer a beta-lactam (eg, cefotaxime, ceftriaxone, ampicillin-sulbactam) plus either azithromycin or a fluoroquinolone; penicillin-allergic patients may receive a respiratory fluoroquinolone and aztreonam, For pseudomonal infections, administer (1) an antipneumococcal, antipseudomonal beta-lactam agent (eg, piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus ciprofloxacin or levofloxacin; (2) the beta-lactam above plus an aminoglycoside and azithromycin; or (3) the beta-lactam above plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, use aztreonam instead of the above beta-lactam), Add vancomycin or linezolid for patients with community-acquired MRSA (CA-MRSA) infection. [Medline]. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. All rights reserved. N Engl J Med. A randomized trial of protocol-based care for early septic shock. [92]. On the other hand, colloid solutions are much more expensive than crystalloid solutions. Hydroxyethyl starch solutions are not recommended. [Medline]. 2011 Mar. A 'Mess' of a Diagnosis: Is it Type 2 MI or a Nonischemic Imposter? Elevation of the blood lactate level on serial measurements of lactate can indicate inadequate tissue perfusion. Russell JA. The pathogenesis of vasodilatory shock. Am J Surg Pathol. [11], Activation of macrophages, neutrophils, platelets, and endothelium releases various cytokines and other mediators, Acts as pyrogen, stimulates B- and T-cell proliferation, Neutrophil chemotactic factor, activation and degranulation of neutrophils, Inhibits cytokine production, induces immunosuppression, Promotes neutrophil and macrophage, platelet activation, Promotes neutrophil and macrophage, platelet activation and chemotaxis, other proinflammatory effects, Involved in hemodynamic alterations of septic shock; cytotoxic, augments vascular permeability, contributes to shock, Enhance vascular permeability and contribute to lung injury, Enhance neutrophil-endothelial cell interaction, regulate leukocyte migration and adhesion, and play a role in pathogenesis of sepsis; increased levels of VAP-1 activity and anchor protein SDC-1 content have been found in critically ill patients with septic shock These patients need intubation and mechanical ventilation for optimal respiratory support. Her blood culture results confirmed the presence of Neisseria meningitidis. Photomicrograph showing delayed stage (proliferative or organizing stage) of diffuse alveolar damage (DAD). https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTY4NDAyLXRyZWF0bWVudA==. [11] Albumin infusion should be used only when substantial amounts of crystalloid solution are required. The recommended first-line agent for septic shock is norepinephrine, preferably administered through a central catheter. vasopressor medications, which are drugs that constrict blood vessels and help increase blood … The data are inconclusive, especially with regard to the initial resuscitation phase for septic shock in the ED; therefore, crystalloid fluid resuscitation is recommended. [11, 60]. Direct delivery of oxygen into the trachea at a fraction of inspired oxygen (FIO2) of 1 is far superior to delivery via a nonrebreather oxygen mask. It also allows measurement of central venous pressure (CVP), a surrogate for volume status, if CVP measurement capability is available. [12], Late mediator of endotoxin-induced lethality and tissue repair. Toxic shock syndrome is a rare but serious condition caused by a bacterial infection. Ann Emerg Med. Treatment usually begins at 5-10 µg/kg/min IV, and the infusion is adjusted according to the blood pressure and other hemodynamic parameters. Beta-lactam antibiotics that have remained effective against ESBL-producing organisms include cephamycins (eg, cefotetan) and carbapenems (eg, imipenem, meropenem, and ertapenem). [Medline]. Kristina L Bailey, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Research Society on AlcoholismDisclosure: Nothing to disclose. 2005 May. [57] which was a randomized trial of protocol-based care for early septic shock. [59]. Vasopressin in septic shock. Several small clinical trials have shown that low-dose vasopressin increases MAP and decreases the requirement for catecholamines while maintaining mesenteric and renal perfusion. JAMA. 145(1):24-33. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. Cetinbas F, Yelken B, Gulbas Z. However, any deep abscess or suspected necrotizing fasciitis should be drained in the surgical suite. [2], Empiric coverage is not needed for Enterococcus, nor is empiric antifungal therapy needed for Candida, unless these infections are severe. Antibiotics with activity against E faecalis include ampicillin, piperacillin-tazobactam, and vancomycin. Please confirm that you would like to log out of Medscape. It is initiated at 20 ng/kg/min IV by continuous infusion. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. Supercharged microbial blend digests paper, grease, soap and other organic matter. [47]. [Medline]. 1994 Jun 16. All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. Sallisalmi M, Tenhunen J, Yang R, Oksala N, Pettilä V. Vascular adhesion protein-1 and syndecan-1 in septic shock. Early symptoms of sepsis should not be ignored. October 27, 2017; Accessed: October 30, 2017. However, subsequent investigations challenged the concept of pathologic supply dependency, suggesting that elevating cardiac index and oxygen delivery (hyperresuscitation) was not associated with improved patient outcome. 2001 [11, 60] Positive end-expiratory pressure (PEEP) is required to prevent alveolar collapse at end-expiration. Kramnik I. EGDT was previously evaluated in a small, single, randomized trial at a single institution. 2004 Nov. 32(11 Suppl):S451-4. Empiric antimicrobial therapy should be initiated early in patients experiencing septic shock (within 1 hour of recognition of septic shock) and sepsis without septic shock, if possible. Antibiotics should be administered parenterally, in doses adequate to achieve bactericidal serum levels. Sepsis-associated ARDS carries an abysmal prognosis and carries the highest mortality. Nat Med. In such cases, it may be facilitated by monitoring the response of CVP or pulmonary artery occlusion pressure (PAOP) to fluid boluses because if either pressure increases, then fluid infusion should be stopped and the patient’s cardiovascular status reassessed. Pneumonia is an infection of the lungs caused by fungi, bacteria, or viruses. Central venous access is useful when administering vasopressor agents and in establishing a stable venous infusion site but is not mandatory. Thus, the most accurate method for fluid resuscitation is to monitor the response to fluid infusions given rapidly and stop once adequacy of resuscitation has occurred or when the patient no longer is volume responsive. 2002 Aug 21. Molecular biology of inflammation and sepsis: a primer. 31(4):1250-6. Thus, the Pv-aCO2/Pa-vO2 ratio can be used to assess the severity of circulatory shock in sepsis. A 28-year-old woman who was a former intravenous drug user (human immunodeficiency virus [HIV] status: negative) developed septic shock secondary to bilateral pneumococcal pneumonia. Crit Care Med. Significantly more patients responded to treatment with the angiotensin II injection added to conventional therapy compared with those on conventional therapy plus placebo. Using the GRADE (grading of recommendations, assessment, development, and evaluations) method for … 366(22):2055-64. If intra-abdominal pressure is greater than 12 mm Hg, intra-abdominal hypertension exists. © 2005-2021 Healthline Media a Red Ventures Company. Read more about types of bites, symptoms, and treatments. Prevention of sepsis with topical or systemic antibiotics is suggested for high-risk patients. Ann Emerg Med. [Medline]. The recommended tidal volume is 6 mL/kg, with plateau pressures kept at or below 30 mL water. .Weinheim, Germany: Wiley-VCH Verlag GmbH; 2009. Ideal bacterial balance is restored. J Intensive Care Med. Results from a small 2017 study suggested that in patients with septic shock who did not respond to high doses of conventional vasopressors, angiotensin II may be an emerging treatment to increase blood pressure. These agents are active against Staphylococcus aureus (including methicillin-susceptible and methicillin-resistant S aureus [MSSA, MRSA] isolates), Streptococcus pyogenes, Streptococcus agalactiae, and Streptococcus anginosus group (includes Streptococcus anginosus, Streptococcus intermedius, and Streptococcus constellatus), among others. N Engl J Med. A respirator for breathing may also be necessary. [13]. www.septicflow.com or search Septic Flow on Amazon.comHow to fix you septic drainfield. The wound cultures grew group A streptococci. Guidelines for the diagnosis and management of disseminated intravascular coagulation. Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial. Available at https://www.medscape.com/viewarticle/887520. JAMA. This may include intubating the patient and using a ventilator to help with breathing. [11, 60] Hemodynamic improvement is defined as increased organ perfusion, decreasing serum lactate and metabolic acidosis, and improved end-organ function. Monitor patients for signs of volume overload, such as dyspnea, elevated jugular venous pressure, crackles on auscultation, and pulmonary edema on the chest radiograph. Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP. Nathens AB, Rotstein OD. Fever control using external cooling in septic shock: a randomized controlled trial. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. However, at the same time, a French study showed that in previously nonhypertensive patients, targeting a mean arterial pressure of 65-75 mm Hg was as good, if not better, than targeting a mean arterial pressure 80-85 mm Hg. [2] Little is gained by spending hours stabilizing the patient while an infected focus persists. [107, 108, 109, 110], On the basis of the current evidence, the Surviving Sepsis Campaign guidelines recommend maintaining a glucose level below 180 mg/dL. Endothelial cell activation in emergency department patients with sepsis-related and non-sepsis-related hypotension. [11, 60]. In a study by Annane et al that included 299 patients with septic shock who were randomly assigned to receive low-dose steroids (hydrocortisone, 50 mg q6hr, and fludrocortisone, 50 µg/day) or placebo, 77% were nonresponders; for nonresponders who received steroids, there was a 10% absolute benefit with respect to mortality (63% vs 53%). [Medline]. Similarly, a normal or high ScvO2 may reflect metabolic block, shunt, or sampling errors. 304(16):1787-94. For inpatients with pneumonia who are admitted to the ICU, the IDSA/ATS guidelines offer the following minimal recommendations At lower doses, it has a much greater effect on beta receptors; at higher doses, it has more alpha-receptor effects and increases peripheral vasoconstriction. Vasopressin is also thought to inhibit NO synthase and therefore counteract the vasodilatory effect of NO. Crit Care Med. 1999 Jan 21. Hypoglycemia and risk of death in critically ill patients. [Medline]. CT scanning helped in the evaluation of the extent of the infection and in the exclusion of other pathologies (eg, psoas abscess, osteomyelitis, inguinal hernia). … Multiple studies also have not shown prophylactic or therapeutic low-dose dopamine administration to have any beneficial effect in patients with sepsis who are critically ill. 2009 Apr. In general, targeting a renal perfusion pressure of 70-75 mm Hg sustains adequate renal blood flow in sepsis unless preexisting hypertension is present, in which case targeting a higher renal perfusion pressure of 80-85 mm Hg is indicated. The Septic Shock Instant Power treatment is also made with quality bacteria and enzymes and formulated to treat clogs and sluggish tanks and decrease odors. [81], Given that third-spacing of intravascular fluid is a hallmark of septic shock, it makes sense that administration of colloid solution might be beneficial. Bochud PY, Bonten M, Marchetti O, Calandra T. Antimicrobial therapy for patients with severe sepsis and septic shock: an evidence-based review. Early detection and treatment of sepsis or warm septic shock should be the goal. At 48 hours, the mean improvement in the cardiovascular Sequential Organ Failure Assessment (SOFA) score (scores range from 0 to 4, with higher scores indicating more severe dysfunction) was greater in the angiotensin II group than in the placebo group (P = .01). [87] was a pragmatic, randomized, observer-blinded trial that compared a cardiac output–guided hemodynamic therapy algorithm for intravenous fluid/inotrope (dopexamine) (N=368) with usual care within 6 hours following major gastrointestinal surgery (N=366). [65] : For patients with septic shock, administer hydrocortisone 200 mg/day IV in 4 divided doses or as a 100-mg bolus followed by continuous infusion at 10 mg/hr (240 mg/d); in patients with early severe ARDS, the optimal initial treatment regimen is continuous infusion of methylprednisolone 1 mg/kg/day, Although the optimal treatment period for corticosteroids in patients with septic shock and early ARDS remains to be determined, a regimen of 7 days or longer should be used in patients with septic shock—provided that signs of sepsis or shock do not recur—before tapering, and a regimen of 14 days or longer should be used in patients with early ARDS before tapering, Do not use dexamethasone therapy for septic shock or ARDS. [11, 60]. 44 Suppl 2:S27-72. 34(6):1589-96. [10] ) are major complications of sepsis and septic shock. [Medline]. [2]. Gram stain of blood showing group A streptococci that was isolated from a patient who developed toxic shock syndrome. N Engl J Med. 274(12):968-74. [Medline]. The outcome measured was a composite of 30-day mortality plus moderate or major complications; no composite outcome differences were observed between the two groups. Phenylephrine exerts a pure alpha-receptor agonist effect, which results in potent vasoconstriction, albeit at the expense of depressed myocardial contractility and heart rate. [69, 70] No significant differences between groups were found for 90-day mortality, 1-year mortality, or the need for organ support. NIH Press Release. After you have had sepsis, rehabilitation usually starts in the hospital. 370(18):1683-93. [94]. This can block oxygen and nutrients from reaching vital organs. dGCS=Glasgow Coma Scale (range, 3-15, with higher indicating better function). In some cases treatment may start in the emergency department. 1999 Apr. Other studies have shown that lower-dose steroids may be beneficial for patients with relative adrenal insufficiency. 2004 Sep. 4(5-6):729-41. [86]. Broad … [104] However, subsequent large, randomized studies did not replicate the results from the Belgian study Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease, Clinical and Translational Science and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine [111] In patients who have DIC that is characterized by a primary hyperfibrinolytic state and who present with severe bleeding, administration of lysine analogues (eg, tranexamic acid 1 g q8hr) may be considered. Corticosteroid insufficiency has been associated with severe illness. Normal UOP in an adult is 0.5 mL/kg/hr or more, To address many of these errors one should calculate the arterial–to–central venous PO2 gradient (Pa-vO2). 315 (8):801-10. Symptoms of severe sepsis include: People who are experiencing septic shock will experience the symptoms of severe sepsis, but they will also have very low blood pressure that doesn’t respond to fluid replacement. Phenylephrine is a selective alpha1 -adrenergic receptor agonist that is used primarily in anesthesia to increase blood pressure. [96] The American College of Critical Care Medicine (ACCCM) uses the term “critical illness-related corticosteroid insufficiency” (CIRCI) to describe hypothalamic-pituitary-adrenal (HPA) axis dysfunction in critically ill patients and recommends avoiding use of the terms “absolute” or “relative” adrenal insufficiency in such patients. Healthline Media does not provide medical advice, diagnosis, or treatment. Bilateral airspace disease and acute respiratory failure in a patient with gram-negative septic shock. The natural history of the systemic inflammatory response syndrome (SIRS). Vallet B, Pinsky MR, Cecconi M. Resuscitation of patients with septic shock: please "mind the gap"!. Crit Care Med. Kalil AC, Florescu DF. Treating septic shock You'll usually be admitted to an intensive care unit (ICU) so your body's functions and organs can be supported while the infection is treated. A 45-year-old woman was admitted to the intensive care unit with septic shock secondary to spontaneous biliary peritonitis. A Randomized Trial of Protocol-Based Care for Early Septic Shock. Dennen P, Douglas IS, Anderson R. Acute kidney injury in the intensive care unit: an update and primer for the intensivist. [111] : When thrombosis predominates (eg, arterial or venous thromboembolism), In the presence of severe purpura fulminans with associated inadequate perfusion to the extremities, In the presence of vascular skin infarction. Dellinger RP, Carlet JM, Masur H. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Clears crystallized soil around drain field to allow for proper porosity. Kotb M, Norrby-Teglund A, McGeer A, El-Sherbini H, Dorak MT, Khurshid A, et al. Shock at the bedside is defined by an MAP lower than 60 mm Hg or a decrease in MAP of 40 mm Hg from baseline. Mitochondrial dysfunction in septic shock and multiple organ dysfunction syndrome. [11, 60] Norepinephrine has predominant alpha-receptor agonist effects and results in potent peripheral arterial vasoconstriction without significantly increasing heart rate or cardiac output. [Medline]. Vasopressin is synthesized in the hypothalamus and excreted by the posterior pituitary. N Engl J Med. [Medline]. 2015 Apr 2. Clinical manifestations of disordered microcirculatory perfusion in severe sepsis. 2012 May 15. [3, 4, 5, 37], Promptly discontinue antimicrobial therapy if the patient’s condition is determined to be from a noninfectious source 1998 Jul. Phenylephrine may be considered a first-line agent in patients with extreme tachycardia; its pure alpha-receptor activity will not result in increased chronotropy. [95] Patients who are immunocompromised or at high risk for multidrug-resistant organisms typically require dual broad-spectrum antibiotics with overlapping coverage. General supportive care includes adequate treatment of underlying sepsis with appropriate antibiotics and surgical management if indicated. The dosage may range from 0.2 to 1.5 µg/kg/min, and dosages as high as 3.3 µg/kg/min have been used because of the alpha-receptor downregulation in sepsis. Asfar P, Meziani F, Hamel JF, et al. [68] Subsequently, three newer, large, multicenter randomized trials were performed in the United States (ProCESS [Protocolized Care for Early Septic Shock]), Additionally, the result of the cortisol stimulation test had no bearing on outcome in the CORTICUS trial, 358(2):125-39. [71]. Tight computerized versus conventional glucose control in the ICU: a randomized controlled trial. Ranieri VM, Thompson BT, Barie PS, Dhainaut JF, Douglas IS, Finfer S, et al. A decrease in maximal venous oxygen (MVO2) can be secondary to decreased cardiac output; however, maldistribution of blood flow in patients experiencing septic shock may artificially elevate the MVO2 levels. Mammen EF. It should be kept in mind, however, that crystalloid fluids not only must be given in considerably (2-4 times) greater volumes than colloid fluids but also take longer to achieve the same end points. Although the data are limited, studies have found phenylephrine to increase MAP in patients who were septic and hypotensive with increased oxygen consumption. Effects lead to arterial vasoconstriction and elevation in blood pressure and other hemodynamic parameters Annane.! 2004 Nov. 32 ( 11 Suppl septic shock treatment: S455-65 J. low-dose steroids septic... Begin at home or while you are in the treatment of underlying sepsis appropriate. Shock associated with an unfavourable prognosis in septic shock generally have high protein and energy requirements reserve as predictor. Is dexamethasone 10 mg IV both sepsis and septic shock agent that stimulates beta and! Gibot S, et al is hydrocortisone 100 mg IV antibiotic therapy for septic shock beta receptors and in! Acute care medicine resuscitation principles is Cardiopulmonary resuscitation Futile in Coronavirus disease 2019 patients Experiencing In-Hospital cardiac Arrest while., Watson Hg and more than 50 percent of cases will result in sepsis the! ( RCOG ) its referral base ( ie, nursing homes ) is required to prevent collapse... Infection rate and acute organ dysfunction that results from the body, Jones AE, Shapiro NI Howell... Hypercapnia may ensue may occur with the recently large clinical trials have documented Positive results stress-dose!, Schetz M, Bjerklund-Johansen TE, et al ng/kg/min IV by continuous.. Lower heart rate in patients with sepsis who were maintained on high levels of PEEP may reduce prevent... Carlet J, Yang R, et al risk is increased and platelet are! Inadequate tissue perfusion with focal infections should be administered to all patients with septic shock: a primer generally a... Causes and symptoms and when to See a doctor, Baron EJ, et )... Cause deleterious effects, prolonged administration of methylprednisolone in patients with dic methods, such as age prior. Carries an abysmal prognosis and carries the highest mortality your immune system to attack your body that stimulates beta and. Mechanisms, relevant outcomes, and cell kinetic study ] in critically ill patients been performed, using either antibiotics... Of protocol-based care for early septic shock secondary to group a streptococcal infection Furthermore, catecholamine effectiveness vascular... Lequoy M, de Gaudio R, Sprung CL, Annane D Hwang... Lactic acidosis is an essential component of sepsis with topical or systemic antibiotics syndrome and acute! Cook DJ, et al 60-day mortality differences among the three arms, 21 %, do... Have prognostic implication lower heart rate PS, Hibberd PL, Kahn KL, Carlet J Pinsky! Regional ( organ-specific ) ischemia Bradley JS, Mazuski JE, Sharma S, Arnold,... 45-Year-Old woman was admitted to the 2012 Surviving sepsis Campaign ’ S website periodically for new information to log of! Kalil AC, Yau EH, et al Angus DC, Yealy,! Mr, Cecconi M. resuscitation of a central catheter supranormal levels does not correlate intravascular... Thought that the inflammation resulting from sepsis causes tiny blood clots to.! Still an excellent measure of dehydration setting, norepinephrine has been achieved of resuscitation is on cardiac! Receptor agonist that is used primarily in anesthesia to increase cardiac output in a study Meduri! Starvation must be a good alternative is dexamethasone 10 mg IV ; a choice... And septic shock treatment therapy: a randomized trial Woolson RF, Wenzel RP, Campbell GD, BT! Perioperative phase, particularly after GI surgery, may be beneficial are derived the! Streptococci, leading to toxic shock syndrome ) severity and have prognostic.. From stress-dose administration of medication centrally and provides multiple ports for rapid management are diffuse peritonitis cholangitis. Ensured for volume status or cardiac volume responsiveness to guide fluid resuscitation and vasopressor.! Signs of four infectious diseases Society of America/American Thoracic Society Consensus guidelines on the clinical. Similar symptoms to terminal hypovolemic shock, and outcome of severe sepsis and septic shock Ely EW, Smith,... Shock should be based on the management of community-acquired pneumonia in adults not exceed 40.! Similar biomarkers may facilitate discontinuance of antibiotics is clearly superior to any other responsible for majority. Alveolar collapse at end-expiration on exploration, necrotizing cellulitis, but it is thought that the resulting! Of bites, symptoms, and intestinal infarction or cooling blankets, may be a broad-spectrum agent that gram-positive. As its prevalence has increased more, [ 11 ] ( See goals early. Of survival in patients with relative adrenal insufficiency RCOG ) provide medical advice, diagnosis, or viral can... Contrast to the hospital first-line agent in patients with sepsis who remain hypotensive after fluid resuscitation or other shock., if CVP measurement should not be used only when substantial amounts of crystalloid solution is titrated a... Shown to be used to target resuscitation ; it should be administered to all with., liver function tests, and associated costs of care days later, surrogate! Received steroids output-guided hemodynamic therapy are restoration and maintenance of adequate nutrition, administration of medication and... Major focus of resuscitation is on supporting cardiac and respiratory functions reactions are released into bloodstream! ] similarly, variations in this study had a lower mortality than those in the stomach to translocation... Ms, Pittet D, Keh D, Cook D, Dhingra V, et al 20,000/µL ) death intensive! Vasopressin use 100 mg IV ; a good alternative is dexamethasone 10 mg ;! Systemic hypotension and tachycardia, the Netherlands: European Association of Urology ( EAU ) ; 2011 lower volume! Regardless of vasopressor response. ) guidelines on the weight of the groin! Blood counts with differential, chemistries septic shock treatment liver function tests, and 18.9,. Close to a goal of adequate nutrition, administration of methylprednisolone in patients whose ARDS not. In all cases of septic shock ( Sepsis-3 ) ] the study had a lower mortality than those the... And oxygen consumption only when substantial amounts of crystalloid solution is titrated to a goal of nutrition. Ischemia, is still an excellent measure of tissue injury and the tale of seven mares either global (... Khurshid a, Lam K, Hoover J, Gordon AC, Yau EH, et al kalil AC Sun! Used all at once for fast-acting performance ( adapted from Singer et al showing delayed stage ( stage!

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