surviving sepsis 2008 guidelines early goal directed therapy mazen kherallah, md, fccp infectious...
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Surviving Sepsis 2008 Guidelines
Early Goal Directed Therapy
MAZEN KHERALLAH, MD, FCCPINFECTIOUS DISEASE AND CRITICAL CARE MEDICINE
SepsisSIRS Severe Sepsis Septic ShockInfection
Chest 1992;101:1644
Therapy Across the Sepsis Continuum
A clinical response arising from a nonspecific insult, with 2 of the following: T >38oC or
<36oC HR >90
beats/min RR >20/min WBC
>12,000/mm3 or <4,000/mm3 or >10% bands
Microorganism invading
sterile tissue
SIRS with a presumed
or confirmed infectious process
Sepsis with organ failure
Vascular collapseRenalHemostasisLungLA
Refractoryhypotension
Burns
Trauma
Sepsis Syndromes1992: SCCM/ACCP
Parasite
Virus
Fungus
BacteriaBSI
SevereSepsis
ShockSevereSIRS
Infection SIRSSepsis
Surviving Sepsis Campaign
Launched in Fall 2002 as a collaborative effort of European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine
Goal: reduce sepsis mortality by 25% in the next 5 years
Guidelines revealed at SCCM in Feb 2004 Critical Care Medicine March 2004 32(3):858-87. Website: survivingsepsis . org
THE SEVERE SEPSIS BUNDLES: SSC/IHI
6 Hour Bundle Measure serum lactate Blood Cultures prior to antibiotics Broad spectrum antibiotics within 3
hours of presentation, 1 hour in hospital
Initial fluid resuscitation with 20-40 mL/kg crystalloid (or equivalent colloid) if hypotensive (SBP < 90 mmHg or MAP < 70) or lactate > 4 mmol/L
Vasopressors If septic shock or lactate > 4
mmol/L: CVP and ScvO2 or SvO2
measured CVP maintained 8-12 mm Hg
Inotropes (and/or PRBCs if Hct < 30%) delivered for ScvO2 <70% or SvO2<65% if CVP > 8 mmHg
24 Hour Bundle Glucose control maintained <
150 mg/dL Drotrecogin alfa (activated)
administered in accordance with hospital guidelines
Steroids given for septic shock requiring continued use of vasopressors for > 6 hours
Lung protective strategy with plateau pressures < 30 cm H2O for mechanically ventilated patients
http://www.ihi.org
SCCM 2009: Sepsis Management "Bundles" Boost Guideline Implementation, Reduce
Mortality
15,022 Patients
7% Absolute Risk Reduction19% Relative Risk Reduction
Society of Critical Care Medicine (SCCM) 38th Critical Care Congress. Late breaker. Presented February 2, 2009
SUMMARY: SEPSIS GUIDELINES 2008
Strong Recommendation (1): Recommended
DVT Prophylaxis
H2 Blocker PUD Prophylaxis
No Routine Use of SGC
A DCB
Glycemic Control
Consider Limiting Support
BC prior to Abx
Antibiotics within 1 hr for Septic Shock
EGDT and Protocolized Resuscitation
Antibiotics within 1 hr in No septic Shock Patients
De-escalation Antibiotic Therapy
7-10 day Antibiotic Duration
Source Control
Fluid Challenge
Dopamine or Norepinephrine
Limit P plateau <30 cm H2O
PEEP
Conservative Fluid in ALI with no Shock
No Renal Dose Dopamine
No High Dose Steroids
Weaning Protocol/SBT
Avoid NMB
PPI PUD Prophylaxis
Crystalloid = Colloid
Limited Transfusion
Low VT for ALI
HOB >45
Intermittent = Continuous sedation
No Antithrombin II
No Erythropoietin
SUMMARY: SEPSIS GUIDELINES 2008
Weak Recommendation (2): Suggested
APC in high risk and non-surgical
A DCB
equivalencyof continuous
veno-veno hemofiltrationor intermittent hemodialysis
Wean Steroids
Low dose steroids for septic shock
B/S < 150
APC for high risk and surgical
PRBCs or Dobutamine
ACTH test not to be done
Prone Position in ARDS
NIV for ALI/ARDS mild/moderate
hypoxemia
SepsisSIRS Severe Sepsis Septic ShockInfection
Insulin and Tight Glucose Control
Early Goal Directed Therapy
Steroids
Antibiotics and Source Control
Chest 1992;101:1644
Therapy Across the Sepsis Continuum
*Drotrecogin Alpha
SepsisSIRS Severe Sepsis Septic ShockInfection
Early Goal Directed Therapy
Therapy Across the Sepsis Continuum
Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand: Fluids, Blood, and Inotropes
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001;345:1368.
CVP > 8-12 mm Hg MAP > 65 mm Hg Urine Output > 0.5 ml/kg/hr ScvO2 > 70% SaO2 > 93% Hct > 30%
*
Rivers E, Nguyen B, Havstad S, et al 2001;345:1368-1377.
49.2%
33.3%
0
10
20
30
40
50
60
Standard Therapy N=133
EGDTN=130
P = 0.01*
*Key difference was in sudden CV collapse, not MODS
Early Goal-Directed Therapy Results:28 Day Mortality
Vascular Collapse
21% vs 10%
p=0.02
MODS
22% vs 16%
P=0.27
NEJM 2001;345:1368-77.
Mortality %
Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.
In-hospital mortality
(all patients)
0
10
20
30
40
50
60 Standard therapy
EGDT
28-day mortality
60-day mortality
NNT to prevent 1 event (death) = 6 - 8M
ort
alit
y (%
)
The Importance of Early Goal-DirectedThe Importance of Early Goal-DirectedTherapy for Sepsis-induced HypoperfusionTherapy for Sepsis-induced Hypoperfusion
◦ If venous O2 saturation target not achieved: (2C)
Consider further fluidTansfuse packed red blood cells if required to
hematocrit of ≥30% and/orDobutamine infusion max 20 µg.kg−1 .min−1
Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.
First section screens for SIRS SIRS includes objective vital signs data:
Temperature ≥ 100.4 or ≤ 96.8 F Heart Rate ≥ 90 Respiratory Rate ≥ 20 WBC count ≥ 12,000 or ≤ 4,000, or greater than
0.5K/uL bands If the patient has 2 or more of the above, they
screen positive for SIRS
SIRS Screen
Second section screens for infection The patient is screened for infection if they
have SIRS Does the patient have suspected or
documented infection? Has the patient received antibiotics (not
prophylaxis)? If one of the above is confirmed, the patient
is screened for organ dysfunction
Infection Screen
Third section screens for Organ Dysfunction
Respiratory: SaO2 < 90 % Cardiovascular: SBP < 90 Renal: urine output < 0.5ml/hr; creatinine
increase > 0.5mg/dl from baseline CNS: altered LOC, Glascow coma scale ≤ 5
Any one of the above, in addition to positive results from sections 1 and 2, indicates severe sepsis.
Severe Sepsis Screen
The RN should approache the MD, informing him using SBAR technique, that the patient has screened positive for severe sepsis.
SBAR
SBAR Communication Technique
Situation: RN caring for John Smith Screened positive for severe sepsis
Background: Positive for SIRS (describe) Known or suspected infection Organ dysfunction (describe)
Assessment: Share complete VS and SaO2
Recommendation: I need you to come and evaluate the patient
to confirm if they have severe sepsis. It is recommended that I get an ABG,
lactate, and CBC, Can I proceed and get these?
Any other labs you would like me to obtain? If the pt is hypotensive: Can I start an IV
and give a bolus of NS – 20 ml/kg?
SBAR Communication Technique
Resuscitation Goals (Grade 1C)
Central venous pressure (CVP): 8–12mm Hg
Mean arterial pressure (MAP) ≥ 65mm Hg
Urine output ≥ 0.5mL.kg–1.hr –1Central venous (superior vena cava) or
mixed Venous oxygen saturation ≥ 70% or ≥ 65%, respectively
Hemoglobin >10 mg/dLRivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.
Initiation of Resuscitation (1C)
Begin resuscitation immediately in patients with CVP < 8, hypotension or elevated serum lactate >4mmol/l;
Do not delay pending ICU admission.
Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.
CVP <8 mmHg
Central line placement and CVP monitoring
500 mL 0.9% NaCl bolus every 15 minutes to maintain a CVP goal
Colloids if CVP <4Transfuse 1 unit of PRBC’s if Hg <10
A higher target CVP of 12–15 mmHg is recommended in the presence of
Mechanical ventilationPre-existing decreased ventricular
complianceIncreased intra-abdominal pressure
MAP <65 mmHg
Arterial line placementNorepinephrine 2-20 mcg/minVasopressin 0.04 Unit/minPhenylephrine 40-200 mcg/minHydrocortisone 50 mg IV every 6 hours
ScvO2 <70%
Arterial line placementTransfuse 1 PRBC’s if Hg level <10
mg/dLStart Dobutamine 2.5-20 mcg/kg/min
IV infusionIntubation and ventilation
Critical Care is A Promise
يتقنه أن عمال عمل اذا العبد يحب الله ان
If you are admitted to our ICU with severe sepsis we will:
Obtain blood cultures and lactic acid level Start antibiotics within one hour Target a central venous pressure target to ≥8
mmHg Target a mean arterial blood pressure target
of ≥65 mmHg Target a central venous O2 saturation of ≥
70% Target your urine output to >0.5 mL/Kg/Hour
Thank You
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