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SEPSIS: THE PAST, PRESENT & FUTURE

SEPSIS: THE PAST, PRESENT & FUTURE. Bravein Amalakuhan, MD Pulmonary Medicine General Critical Care Medicine Cardiac Surgical Critical Care Medicine. OUTLINE. PART 1. OVERVIEW Basics Pathophysiology, Etiology Epidemiology DEFINITIONS/DIAGNOSIS Pre-2016 [Sepsis -1 and -2 Guidelines]

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SEPSIS: THE PAST, PRESENT & FUTURE

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  1. SEPSIS: THE PAST, PRESENT & FUTURE Bravein Amalakuhan, MD Pulmonary Medicine General Critical Care Medicine Cardiac Surgical Critical Care Medicine

  2. OUTLINE PART 1 • OVERVIEW • Basics • Pathophysiology, Etiology • Epidemiology • DEFINITIONS/DIAGNOSIS • Pre-2016 [Sepsis -1 and -2 Guidelines] • SIRS • Sepsis • Severe Sepsis • Septic Shock • Post-2016 [Sepsis -3 Guidelines] • Sepsis • Septic Shock

  3. OUTLINE PART 2 • TREATMENT • The Rivers’ Approach • Key Components - Updated • CONTROVERSIES • Code Sepsis & Sepsis Alerts: • Sepsis + Heart Failure: • CMS/JOINT COMMISSION SEPSIS CORE MEASURES • FUTURE DIRECTIONS EFFECTIVE? WHAT DO WE DO? WHAT’S IMPORTANT TO THE GOVERNMENT?

  4. OVERVIEW THE BASICS PART 1 PART 1

  5. THE BASICS WHAT IS SEPSIS? HISTORICALLY: GREEK ORIGIN “To Decay” or “To Rot” “A life-threatening organ dysfunction caused by a dysregulated host response to infection” MODERN TIMES: SCCM / SURVIVING SEPSIS CAMPAIGN AN UNCONTROLLED INFLAMMATORY RESPONSE

  6. PATHOPHYSIOLOGY Immune cells, Cytokines/Chemokines (IFN’s, TNF’s, IL’s) A TIDAL WAVE OF INFLAMMATION!!!!

  7. PATHOPHYSIOLOGY INFLAMMATION ON HYPERDRIVE !!!!

  8. DIC DISSEMINATED INTRAVASCULAR COAGULATION

  9. EPIDEMIOLOGY • Mortality: • 250,000 Americans die from it each year • 1/3rd of in-hospital deaths • Mortality rates: 20-50% • Hospital Admissions: • > 1.5 million cases/year • 10% of all ICU admissions • Longer LOS ~4-days compared to other diagnoses • Financial Burden • The single most expensive condition to treat in the hospital • >$20 Billion Dollars/yr

  10. OUTLINE

  11. OUTLINE WE’RE DOING A BETTER JOB !!!!!’ % MORTALITY TIME

  12. QUESTION • Sepsis is a dysregulated and uncontrolled host T or F response to infection • Sepsis causes vasoconstriction and decreased T or F permeability • DIC occurs in early stages of sepsis T or F • DIC causes both thrombosis & hemorrhage T or F • Sepsis is no longer a serious health threat T or F

  13. THE BASICS DEFINITIONS/ DIAGNOSES PART 1 PART 1

  14. PRE-2016 SEPSIS-1 & -2 GUIDELINES BP CORRECTS WITH FLUIDS REQUIRES VASOPRESSORS

  15. SEVERE SEPSIS SIGNS OF ORGAN DAMAGE

  16. POST-2016 SEPSIS-3 GUIDELINES

  17. OUTLINE

  18. QUESTION • 75yo male, weighing 50kg’s, with history of DM, HTN, HLD, presents to the local ER with worsening weakness, confusion and SOB. Upon arrival to the ER, patient had the following vitals: BP 60/30, HR 105, temp 102 deg. F, RR of 34, 02 saturation of 85% of room air. Lactate =4, WBC’s 30, Chest X-ray with bilateral infiltrates. He is started on 02 NC. Despite fluids he remains hypotensive. • Q1: What score would you calculate? • Q2: Does he have Sepsis, Severe Sepsis or Septic Shock • Q3: What is the likely source/etiology of the infection?

  19. TREATMENT OUTLINE PART 2

  20. EARLY GOAL DIRECTED THERAPY • Within 6-hrs of presentation to the ER, the following parameters should be achieved via the following interventions: Parameters: • CVP 8-12 • MAP 65-90 • Uout >0.5 ml/kg/hr • Scv02 >70% • HCT >30% Interventions: • Early Mechanical Ventilation • Fluid Resuscitation • Vasoactive agents • Transfusions • Antibiotics OUTDATED APPROACH

  21. THE RIVERS’ APPROACH

  22. KEY TRIALS – THE TRILOGY

  23. TREATMENT COMPONENTS CURRENT GUIDELINES: THE NEW STANDARD OF CARE - ’SEPSIS-3’ • Source Control • Early administration of Antibiotics (Goal: <1-hour) • Broad spectrum initially • Early Administration of Fluids (Goal: <3-hrs) • 30ml/kg of IV Crystalloids • Target MAP >65 • No need to target CVP, Scv02 or urine output • Norepinephrine is the 1st line Vasopressor • Add Vasopressin or Epinephrine

  24. TREATMENT COMPONENTS CURRENT GUIDELINES • Normalize lactate levels with resuscitation efforts • Stop antibiotics early if procalcitonin low (< 0.5 ug/L) • Hydrocortisone 200mg/day if vasopressors and fluid resuscitation are not able to normalize hemodynamics • Blood Glucose Control: 140-180 (mg/dl) • Nutrition: • Start TPN only after day #7/8 • Early enteral nutrition • Do not check gastric residuals

  25. ANTIBIOTICS ARE KEY !!!!!

  26. QUESTION • 75yo male, weighing 50kg’s, with history of DM, HTN, HLD, presents to the local ER with worsening weakness/ confusion/SOB. Vitals upon arrival to ER: BP 60/30, HR 105, temp 102 deg. F, RR of 34, 02 saturation of 85% of room air. Lactate =4, WBC’s 30, Chest X-ray with bilateral infiltrates. He is started on 02 NC. Despite fluids he remains hypotensive. • Q4: How much fluids should he have been given? • Q5: What is your first, second and third line vasopressors? • Q6: He is on moderate doses of 2 vasopressors. Next step?

  27. CONTROVERSIES PART 2

  28. CODE SEPSIS / SEPSIS ALERTS • Improves mortality when baseline mortality rates >30% !!!! • Improves PROCESSES and ensures we don’t get complacent • However its criteria are non-specific  SIRS SEPSIS • It should simply prompt a discussion with the involved physicians • IS THERE AN INFECTION? • SHOULD WE GIVE ABX AND FLUIDS? • NO MANDATORY ORDERS! – DISCUSS • Post-op Patients ????

  29. SEPSIS AND CHF PATIENTS • Complex • Hard to tease out the predominant contributor to a patient’s hemodynamic instability • Get more info!!!! • MAP, CO (4-6), CI, SVR (800-1200), Cardiac Echo • Arterial line • Vigeleo, EV1000-FloTrac, LiDCO • Cardiogenic Shock: Low MAP, Low CO, High SVR • Septic Shock: Low MAP, High CO, Low SVR

  30. SEPSIS AND CHF PATIENTS • In-hospital Mortality from Septic Shock: 50% • In-hospital Mortality from Cardiogenic Shock: 50% • Frequency: Septic Shock >>>>> Cardiogenic shock • Any difference in treatment in someone with chronic CHF and septic shock?

  31. QUESTION • 75yo female, weighing 50kg’s, with history of DM, HTN, HLD, CAD s/p stents, EF 30%, presents to the local ER with worsening weakness, confusion and SOB. Upon arrival to the ER, patient had the following vitals: BP 60/30, HR 105, temp 102 deg. F, RR of 34, 02 saturation of 85% of room air. Lactate =4, WBC’s 30, Chest X-ray with bilateral infiltrates. He is started on a 60% venturi mask. • Q1: Do you give fluids or start on vasopressors right away? • Q2: What is the predominant form of shock? And how do you determine it? • Q3: What vasopressor is your first choice?

  32. CMS Core Measures SEPSIS AND CHF PATIENTS PART 2 • Septic patients with pre-existing systolic or diastolic dysfunction have increased mortality!!! • Robust Data • Fluids have not been shown to adversely impact Pa02/Fi02 ratios or intubations rates • Uoellette et al. Critical Care 2014 • Really difficult to get pulmonary edema in a truly septic patient even if pre-existing LV dysfunction with just 2L of crystalloids!!!!

  33. CMS CORE MEASURES • Mandatory Reporting of Sepsis Bundle Compliance (2015) • Goal: 100%/”All or Nothing” Score • Complete the following within 3-hrs of presentation: • Measure lactate • Obtain blood cultures • Administer broad spectrum antibiotics • Admin 30cc/kg of crystalloids for low BP or lactate>4 • Complete the following within 6-hrs of presentation: • Re-measure lactate • Start vasopressors if warranted

  34. SEVERE SEPSIS

  35. SEPTIC SHOCK

  36. FUTURE DIRECTIONS IN SEPSIS TREATMENT SEPSIS AND CHF PATIENTS PART 2 • Septic patients with pre-existing systolic or diastolic dysfunction have increased mortality!!! • Robust Data • Fluids have not been shown to adversely impact Pa02/Fi02 ratios or intubations rates • Uoellette et al. Critical Care 2014 • Really difficult to get pulmonary edema in a truly septic patient even if pre-existing LV dysfunction with just 2L of crystalloids!!!!

  37. Novel Antibiotics • Increasing incidence and prevalence of multi-drug resistant organisms • Research into the development of antibiotics with novel mechanisms of action MORE EFFECTIVE ANTIBIOTICS

  38. IMMUNE THERAPY • Sepsis is a balance between “Hyperinflammation” (SIRS) and “Antinflammation” (CARS) at the cellular level • Targeting specific inflammatory/immune mediators associated with poor outcomes • Blocking vs. Promoting certain Biomarkers • Eg. HLA-DR, IL-10, IL-6, IL-3, CCL4, GM-CSF • CHEST 2017: Vitamin C + Thiamine + Hydrocortisone ? IMMUNOMODULATION

  39. REFERENCES • Singer, M., Deutschman, C.S., Seymour, C.W. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315: 801–810 • Seymour, C.W., Liu, V.X., and Iwashyna, T.J. Assessment of clinical criteria for sepsis for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315: 762–774 • Levy, M.M., Rhodes, A., Phillips, G.S. et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Crit Care Med. 2015; 43: 3–12 • Kaukonen, K.-M., Bailey, M., Pilcher, D., Cooper, D.J., and Bellomo, R. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med. 2015; 372: 1629–1638 • Rhodes, A., Phillips, G., Beale, R. et al. The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intens Care Med. 2015; 41: 1620–1628 • Rhee, C., Seymour, C.W., Iwashyna, T.J. et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. JAMA. 2017; 318: 1241–1249 • Sprung, C.L. and Trahtemberg, U. What definition should we use for sepsis and septic shock?. Crit Care Med. 2017; 45: 1564–1567 • Liu, V.X., Fielding-Singh, V., Greene, J.D. et al. The timing of early antibiotics and hospital mortality in sepsis. Am J Respir Crit Care Med. 2017; 196: 856–863 • Rhodes, A., Evans, L.E., Alhazzani, W. et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017; 43: 1–74 • Dellinger RP, Levy MM, Rhodes A, et al: Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580–637 • Centers for Medicare & Medicaid Services: CMS to Improve Quality of Care during Hospital Inpatient Stays. 2014. Available at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact- • sheets/2014-Fact-sheets-items/2014-08-04-2.html. • Poutsiaka DD, Porto M, Perry W, et al. Comparison of the Sepsis-2 and Sepsis-3 Definitions of Sepsis and Their Ability to Predict Mortality in a Prospective Intensive Care Unit Cohort. Open Forum Infect Dis. 2017; 4(Suppl 1): S602. Published 2017 Oct 4. doi:10.1093/ofid/ofx163.1579

  40. drbravein@gmail.com

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