1 / 50

SEPSIS ,SEVERE SEPSIS AND SEPTIC SHOCK

SEPSIS ,SEVERE SEPSIS AND SEPTIC SHOCK. 2008 UPDATE J.TAVARES,MD,FCCP,FAASM. Protocol for Early Goal-Directed Therapy. Rivers E et al. N Engl J Med 2001;345:1368-1377. SEPSIS RESUSCITATION BUNDLE: 1-Serum Lactate 2-Blood Cultures 3-Antibiotics within 3 hours/1 hr 4-IVF

jerry
Download Presentation

SEPSIS ,SEVERE SEPSIS AND SEPTIC SHOCK

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. SEPSIS ,SEVERE SEPSIS AND SEPTIC SHOCK 2008 UPDATE J.TAVARES,MD,FCCP,FAASM

  2. Protocol for Early Goal-Directed Therapy Rivers E et al. N Engl J Med 2001;345:1368-1377

  3. SEPSIS RESUSCITATION BUNDLE: • 1-Serum Lactate • 2-Blood Cultures • 3-Antibiotics within 3 hours/1 hr • 4-IVF • 5-CVP 8-12 or 12-15mmHg • 6-Scv02>70%

  4. LACTIC ACID • High Lactate levels due to liver failure. • Cutoff value still 4mmol/L . • Rapid turnaround time (ABG analyzer).

  5. SEPSIS RESUSCITATION BUNDLE: • 1-Serum Lactate • 2-Blood Cultures • 3-Antibiotics within 3 hours/1 hr • 4-IVF • 5-CVP 8-12 or 12-15mmHg • 6-Scv02>70%

  6. FLUID MANAGEMENT • 1-Crystalloids comparable to Colloids(SAFE Trial:NEJM,2004) • 2-May use Albumin in individuals with Albumin less than 4. • 3- ?Hydroxyethyl starch(HES )

  7. PENTASTARCH • NEJM(358;2; jan 10/08) • Ringer’s Lactate vs Pentastarch • Mortality: no diference at 28 days(24.1% vs 26.7%) ; higher in the Pentastarch group at 90 days(33.9% vs 41.0%; P=0.09)

  8. PENTASTARCH • MORBIDITY: • Higher rate of acute renal failure(22.8% vs 34.9%) • Lower platelets count • More PRBC transfusions

  9. Kaplan-Meier Curves for Overall Survival Brunkhorst F et al. N Engl J Med 2008;358:125-139

  10. SEPSIS RESUSCITATION BUNDLE: • 1-Serum Lactate • 2-Blood Cultures • 3-Antibiotics within 3 hours/1 hr • 4-IVF • 5-CVP 8-12 or 12-15mmHg • 6-Scv02>70%

  11. CVP 8-12:?for how long • Comparison of 2 fluid mngt strategies in ALI(nejm;354,2006 • 1000 Pts(500 conservative fluid mangt;497 liberal) • No difference in 60 day mortality,but less lung injury, faster weaning and fewer days in ICU for conservative.

  12. Protocol for Early Goal-Directed Therapy Rivers E et al. N Engl J Med 2001;345:1368-1377

  13. RBC Transfusion • Controversies in RBC transfusion in the critically ill(chest/131/5/may,2007) • TRICC trial(NEJM 1999;340) • Lack of benefit of RBC transfusions:1-immune suppression(leukocytes);2-prolonged RBC storage

  14. RBC TransfusionClinical Recommendations) • 1-general critically ill:Hb=7g/dl • 2-critically ill with septic shock(<6h):8-10 • 3-critically ill with septic shock(>6h):7g/dl • 4-critically ill with chronic cardiac disease:7g/dl • 5-critically ill with acute cardiac disease:8-10g/dl

  15. Sepsis management bundle • 1-Tightbloodsugarcontrol • 2-Low dose steroids • 3-Drotrecogin alfa • 4-Plateau pressures<30cm H2O • 5-Extubation readiness.

  16. Intensive insulin therapy in the ICU • Leuven study(nejm;nov2001) • 1-BG<110 2-mortality reduced from 8% to 4.6% • 3-Severe hypoglycemia(<40): 0.8% in the conventional group and 5.1% in the intensive treatment group. • 4-Surgical ICU patients.

  17. Kaplan-Meier Curves Showing Cumulative Survival of Patients Who Received Intensive Insulin Treatment or Conventional Treatment in the Intensive Care Unit (ICU) Van den Berghe G et al. N Engl J Med 2001;345:1359-1367

  18. IIT in the ICU • Leuven 2(nejm 2006;354) • 1-Blood glucose 80-110 • 2- patients staying in ICU for 3 or more days: mortality decreased from 52.3% to 43% • 3-Severe hypoglycemia(<40): 3.1% in the conventional group and 18.7% in the treatment group. • 4-medical IICU patients.

  19. IIT in the ICU • VISEP studies and Glucocontrol studies both in Europe(stopped because of increased risk of hypoglycemia). • Both criticized for not having enough number of patients. • Ongoing clinical trial by NIH(NICE-SUGAR) trial may have sufficient statistical power to address the above issues.

  20. Kaplan-Meier Curves for Overall Survival Brunkhorst F et al. N Engl J Med 2008;358:125-139

  21. ITT in the ICU • Glycemic control needs to be done safely. • Use of computerized systems: • Glucommander(can be loaded in a bedside computer,hanheld computer or nursing station computer

  22. Glucommander • 5 parameters: • 1-low end of target range for blood glucose • 2-high end of target range for glucose • 3-the initial multiplier(adjusted for insulin sensitivity) • 4-the maximum time interval between measurements • 5-the insulin concentration

  23. Sepsis management bundle • 1-Tight blood sugar control • 2-Low dose steroids • 3-Drotrecogin alfa • 4-Plateau pressures<30cm H2O • 5-Extubation readiness.

  24. Adrenal Insufficiency • 2002:Annane et al(JAMA;288):299 patients-76% of nonresponders to cosyntropin stimulation test,on ventilator were randomized to hydrocortisone plus fludrocortisone for 7 days:13% reduction in mortality for those treated

  25. Adrenal Insufficiency • The CORTICUS trial(double-blinded,randomized,placebo-controlled multicenter European trial)( Goal:800 patients): • Comparing hydrocortisone(50mg IV q6h for 5 days,taper to 50mg IV q12h for 3 days,then 50mg daily for 3 days)with placebo in septic shock.

  26. Adrenal Insufficiency • The retrospective Corticus cohort study(Critical Care Medicine:Volume 35(4) April 2007pp 1012-1018) • Total of 562 patients(after exclusion:477pts were left)

  27. Enrollment and Outcomes Sprung C et al. N Engl J Med 2008;358:111-124

  28. CORTICUS • 1-Hydrocortisone did not improve survival or reversal of shock even in patients who did not respond to Cosyntropin test • 2- Hydrocortisone hastened reversal of shock.

  29. Sepsis management bundle • 1-Tight blood sugar control • 2-Low dose steroids • 3-Drotrecogin alpha • 4-Plateau pressures<30cm H2O • 5-Extubation readiness.

  30. Proposed Actions of Activated Protein C in Modulating the Systemic Inflammatory, Procoagulant, and Fibrinolytic Host Responses to Infection Bernard G et al. N Engl J Med 2001;344:699-709

  31. Drotrecogin Alfa • 1-PROWESS trial:NEJM 2001;344:699-709. • 2-ADDRESS trial:(APACHE<25 or only one organ dysfunction at baseline)-NEJM 2005;353:1332-1341.:no significant reduction in 28-day mortality. • 3-ADDRESS one year follow-up(critical care medicine 2007;35:1457-1463):no increased risk of death or evidence of harm at 1 year.

  32. Kaplan-Meier Estimates of Survival among 850 Patients with Severe Sepsis in the Drotrecogin Alfa Activated Group and 840 Patients with Severe Sepsis in the Placebo Group Bernard G et al. N Engl J Med 2001;344:699-709

  33. Incidence of Serious Adverse Events Bernard G et al. N Engl J Med 2001;344:699-709

  34. How do I do it(Resuscitation Phase) • Septic shock: • 1-IVF (up to 20cc/kg bolus to keep MAP>=65 • 2-if unable to achieve above,place central line for CVP monitoring:keep CVP 8-12mmHg(12-15 if PPV). • 3-If CVP goal achieved but MAP<65,start vasopressors

  35. How do I do it(Resuscitation Phase) • 4-NE,DA,PE,Vasopressin • 5-follow serial lactate levels 6-If MAP>65,check ScVo2(goal is ScVo2>70%). 7-If ScVo2<70% and Ht<30%,transfuse PRBC

  36. How do I do it(Resuscitation Phase) • 9-If Ht>30% and ScVo2 still <70%,start Dobutamine. If ScVo2>70%,goal achieved

  37. FLUIDS • Normal Saline:500 cc boluses • Albumin:25g iv x 3 doses • Avoid Hespan

  38. Vasopressin • 0.01-0.04 units/mn IV • Do not titrate.

  39. How do I do it(Management Phase) • STEROIDS • 1-No need for baseline cortisol level or Cosyntropin test: If BP is not responding to IVF and Vasopressors after 1 to 2 hours,start HYDROCORTISONE at 50mg IV every 6 hours for 5 days(do not taper)

  40. How do I do it(Management) • ACTIVATED PROTEIN C • 2-APACHE>25 or at least two organs failure,start drotrecogin alpha. • 3-If APACHE<25 or only one organ failure,may consider drotrecogin.

  41. How do I do it(management) • BLOOD GLUCOSE • 4-Tight Blood Sugar control: use hospital protocol). Acceptable to keep blood sugar less than 150.

  42. How do I do it(Management) • Mechanical ventilation • 5-keep plateau pressure below 30 cmH20 • 6-Spontaneous Awakening Trials • 7-Spontaneous Breathing Trials

  43. Antibiotics • USE HOSPITAL PROTOCOL

  44. Goal for 2009 • DECREASE SEPSIS MORTALITY BY 25%

  45. Material for Research • 1-Procalcitonin • 2-C Reactive Protein • 3-Statins

More Related