1 / 18

Tools for septic shock

Tools for septic shock. Khanna, Critical Connections 2017, SCCM. SOAP II. Multicenter RCT Randomized >800 patients to each: Norepinephrine Dopamine Inclusion criteria = fluid unresponsive shock Septic – 62% Cardiogenic – 17% Hypovolemic – 16%. DeBacker et al. NEJM 2010. VASST.

kfelt
Download Presentation

Tools for 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. Tools for septic shock

  2. Khanna, Critical Connections 2017, SCCM

  3. SOAP II • Multicenter RCT • Randomized >800 patients to each: • Norepinephrine • Dopamine • Inclusion criteria = fluid unresponsive shock • Septic – 62% • Cardiogenic – 17% • Hypovolemic – 16% DeBacker et al. NEJM 2010

  4. VASST • Multicenter RCT • Randomization (~400 in each): • Vasopressin • Started on 0.03 u/min and titrated to 0.05u/min • Norepinephrine • Started at 5 mcg/min and titrated to 15 mcg/min • Randomized after 12 hours of therapy on average • Patients already on vasopressors • Outcomes: • HR lower in vasopressin group • 90d mortality in “Less severe sepsis” improved with vasopressin (RR=0.78) Russell NEJM 2008

  5. ATHOS-3 • Multicenter RCT • Randomized (150 in each): • Angiotensin II • Dose started at 20 ng/kg/min up to max 300 ng/kg/min • Placebo • Titrated over 3 hours, kept other vasopressors steady • After 3 hours, other vasopressors titrated to goal MAP >65mmHg Khanna NEJM 2017

  6. ATHOS-3 Khanna NEJM 2017

  7. Steroids in Shock • Small studies showing some reduction of vasopressors with steroids • Multicenter RCT, French • Patients refractory to IV fluids, dopamine with low UOP, on ventilator • Enrollment within 8 hours • Randomized (150 in each): • Hydrocortisone 50mg q6hrs + 50mcg fludrocortisone daily x 7 days • Placebo • Divided results based on responders and non-responders • Dose of corticotropin 250mcg • Check at 30, 60 minutes • Increase in cortisol by 9ug/mL or less • Primary outcome - 28d mortality • 53% vs 63% (OR 0.5, p = 0.02) in non-responders • No difference in 1 year mortality • Vasopressors 7 days vs 10 days Annane, NEJM 2002

  8. Steroids in Shock Annane, NEJM 2002

  9. Steroids in Shock • CORTICUS • Some follow up studies suggested increased risk of infection • Enrollment within 72 hours • Less strict inclusion criteria = less sick patients • Randomized (250 in each): • Hydrocortisone x 5 days, taper • Placebo • Responders and non-responders divided the same way • Primary endpoint – 28d mortality • 34% vs 32% (p = 0.51) • No difference in responder/non-responder • Time to reversal of shock: • 3.3d vs 5.8d (p<0.001) • Increased risk of new sepsis or septic shock (OR 1.37) Sprung NEJM 2008

  10. Steroids in Shock Sprung NEJM 2008

  11. Steroids in Shock • ADRENAL • Previously smaller, underpowered trials • Multicenter, international RCT • Inclusion • Ventilator, SIRS, vasopressors • Randomized: (1800 in each) • Hydrocortisone 200mg/d continuous infusion x 7d • Placebo • No ACTH stim testing done • Primary outcome – 90d mortality • 27.9% vs 28.8% (OR 0.95, p=0.5) • Time to shock reversal • 3d vs 4d (HR 1.32, p<0.001) • No increased risk of shock recurrence or new bacteremia • Reduction in time on ventilator Venkatesh, NEJM 2018

  12. Steroids in Shock Venkatesh, NEJM 2018

  13. Vitamin C, Thiamine and Hydrocortisone • Why Vitamin C • Vitamin C is low in sepsis • Vitamin C plays a role in tyrosine hydroxylase function and many other microvascular roles • Tyrosine is an upstream molecule in the synthesis of epinephrine • 47 consecutive patients receiving standard of care • 47 consecutive patients in treatment: • Vitamin C 1500mg IV q6hrs x 4 days • Thiamine 200mg IV q12hrs x 4 days - to prevent kidney stones • Hydrocortisone 50mg IV q6hrs x 7 days • Around 60% patients in the standard of care group were treated with hydrocortisone Marik Chest 2017

  14. Vitamin C, Thiamine and Hydrocortisone Marik Chest 2017

  15. Shock: Tools • Vasopressors • First choice should be norepinephrine • Vasopressin can lower catecholamine dosing • Possibly better in less severe sepsis • Angiotensin II is a promising medication that may be used more in the future • Steroids • Likely no reduction in mortality • Quicker resolution of shock • Vitamin C/Thiamine/Hydrocortisone • Interesting data, no RCT yet • Are you an early adopter?

  16. Objectives: • Identify a patient in shock • Learn the different types of shock and their acute management • With a focus on septic shock, identify best practices • Familiarize yourself with vasopressors and advanced medical therapies

More Related