update on surviving sepsis 2008

8/2/2019 Update on Surviving Sepsis 2008

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Objectives

Epidemiology of Sepsis

Review Guidelines for Resuscitationx: ac a e, cu ures,

Tx: EGDT, timing/choice of abx, activated

o e


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Epidemiology

In the U.S. Annually:Inci ence of e sis 50 000

160,000 (~20%) are surgical patients

30-40% mortalit des ite abx and source control

~250,000 deaths per year

Cost $17 Billion

Barie, Am J Surg 2004; 188:212-220


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Epidemiology

Compared to medical septic pts, surgical pts:LO + a s

Cost +$10,000

-

Cost 5x higher

Angus, Crit Care Med 2001; 29:1303


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Importance of Severe Sepsis:

Comparison With Other Major Diseases

300

Sepsis

or a y o evere

Sepsis

200

250

00,000

200,000

250,000

r

100

150

Cases/1

100,000

150,000

D

eaths/Ye

0

50

AIDS*Colon Breast CHF Severe0

50,000

* SevereAMIBreast

National Center for Health Statistics, 2001. American Cancer Society, 2001. *American HeartAssociation. 2000. Angus DC et al. Crit Care Med. 2001 (In Press).

Cancer Sepsis SepsisCancer


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Determinants of Mortality

Source control is most vital factor -

Appropriate IV abx in 1 hr


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Definitions


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Systemic Inflammatory Response

Syndrome (SIRS)

Inflammatory response that includes 2 or more

Temp > 38C or < 36 C

RR > 20/min or PaCO2 < 32 mmHg

, ,

Sepsis : SIRS + Infection


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Severe Sepsis

Sepsis with end-organ dysfunctionOli ria

Increase Creatinine

Elevated Lactate


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Definition Summary

SIRS: HR > 90, RR > 20, 12 < WBC < 4,38 < tem


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Pathophysiology

Distributive shock stateaso ilation of arterioles lo R lo BP

Compensate with tachycardia and elevated CO/CI

Pre-ca illar A-V shunts

Low BP bypass capillary resistance beds

Elevated SVO2 Elevated lactate


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Pathophysiology

Classic physiologic derangements mostassociated with LPS

Can be associated with exotoxin from gram

Least associated with fungemia (atypical


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Diagnosing the Septic Pt

Combine clinical exam and labs/imagingEl erl

Cant mount a fever or leukocytosis

Ability to develop bandemia preserved

Immunosuppressed/steroids


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Diagnosing Sepsis

Lab tests: CBC, Chem, CULTURES,lactate SVO2

SVO2 is a measure of O2 extraction (NL 70%)

UNDER-RESUSCITATED se tic ts have a

LOW SVO2

RESUSCITATED septic pts have a HIGH SVO2

Lactate is a measure of the severity of sepsis

Lactate > 4 that does not correct in 6 hrs is bad


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Treatment

Based on Early Goal Directed Therapy , ,

of iv abx

Minimal role for steroids

Surviving Sepsis Campaign: International

guidelines for management of severe sepsis and

septic shock, 2008. Critical Care Med


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=

9% Surgical

u ures

Rivers, NEJM2001; 345:1368


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Treatment

Start with 1-4 liter bolus of saline or LREle ate lactate is not a contrain ication to LR

Pressor if needed to temporize while fluids are

runnin or if unres onsive to fluids alone


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Treatment Fluid Choice

Colloid (Hespan) Starch polymer that cannot cross cap endothelium in non-inflammed state

Mild anti-platelet effects after 1.5-2 liters/dayoss e a verse e ec on rena unc on

Albumin (SAFE Trial)*

Possibly worse in trauma, esp TBI

*NEJM 2004; 350:2247


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Treatment Choice of Fluids

FFP We recommend FFPnot

be used tocorrect laborator clottin abnormalities in

the absence of bleeding or planned

o eration*

Surviving sepsis campaign 2008


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18

16

18

20

12

14

8

66

8

FFP N=380

0

2

4o =

Total FFPTransfused

No FFPTransfused

Sarani Critical Care Med 2008; 36:1114


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OR 95% CI P value

Age 0.994 0.98-1.005 0.27

FFP 1.039 1.013-1.067


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-

MAP > 65 mm Hg, HR < 100 bpmUOP > 0.5 cc/kg/hr

SVO2 70% or more

CVP > 10-15 Higher if known cardiomegaly or intubated

TTE showing cardiac filling

following boluses (concept of volume-responsiveness)

T V


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Treatment - Vasopressors

- 1 2 1

Dopamine 1-5 mcg/kg/min 6-10 mcg/kg/min >10 mcg/kg/min

-

Phenylephrine

(Neosynephrine)

1-300mc /min

+++

Norepinephrine

(Levophed)

1-20 mc /min

+ ++++

Epinephrine

(Gods Pressor)

1-10 mc /min

++++ +++ ++++

Dobutamine (1-10

mcg/kg/min)

+++ ++

Milrinone 0.125- +++ +++

0.5 mcg/kg/min)

Potency + scale is from 1-4


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Treatment

Blood TransfusionRi ers trial transf se for H < 10 if O2

remained low after IVF and after MAP > 65

Role for re-em tive transfusion?

e.g. Hg 10-11 with elevated lactate/shock

Time to replete 2,3 DPG, good colloid resuscitant

Immunosuppressive


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O2 Delivery in Sepsis

Author, Year,

Journal

Population Findings

Dietrich 1990 CritCare Med

N= 32, MICU,se tic RCT

Hg 810.5, nochan e in PAOP

CI, lactate, SVO2

Lorente 1993 Crit N=16, MICU, DobutamineCare Med septic, RCT increases SVO2

but RBC does not

Fernandes 2001

Crit Care

N=15, MICU,

septic, RCT

RBC does not

change gastric

tonometry orlactate


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Consider U/S if too unstable to travel

e s e percutaneous ntervent ons ra ns

Conditions with 100% mortality if notoperated on quickly

Nec fasciitis, non-sealed perforated viscus


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Treatment IV Abx

Mortality increases 7% for every hour delayin antibiotic administration*

)

Minute

Time

eps sBundle at

HUP

unr se*Kumar A. Crit Care Med 2006; 34:

1589-96


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-

Recommended only for shock refractory to pressors

Annane multicenter, European, RCT Pts with vasopressor-resistant hypotension

mprove mor a y r se n cor so o ow ng was9mcg/dL and if baseline cortisol < 21

CORTICUS lar er, Euro ean, RCT All pts with septic shock (regardless of vasopressor response)

No difference in mortality but vasopressor sparing effect with

ACTH stim could not predict who was steroid deficient

Annane 2002; 288:862Insert CORTICUS Reference


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Treatment - Xigris

Activated protein CAnticoa lant inhibits Factors an III

Stop microthrombi formation and prevent end-organ

loss?

Endothelial cell stabilizer (anti-inflammatory)

Stop excessive production of cytokines and

apoptos s


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PROWESS - Limitations

Never replicated

Entr criteria chan ed in the middle of the stud

Study terminated early

Dru a roved for use in a ost-hoc derived

subgroup (APACHE II > 25 or high risk of death

as determined by intensivist)

Higher APACHE II mortality in the control arm

than anticipated

update on surviving sepsis 2008

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