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Jay Green, PGY-4Dr. Jason Lord
August 20, 2009
Dr. Jason Lord Dr. Dan Howes Dr. Trevor Langhan Dr. Aric Storck
Case Definitions Keys to sepsis management
Why is sepsis important?
SIRS (2 of)T<36 or >38HR>90RR>20, pCO2 < 32WBC<4, >12 or >10% bands
SIRS Sepsis Severe sepsis Septic shock
Sepsis Management
SIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
Mortality: 46%
SEVERE SEPSIS
SEPTIC SHOCK
SEPSIS
SIRS
Mortality: 10%
Mortality: 16%
You think he’s septic ?Pulmonary source?
Sepsis Management
1. RecognitionSIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
#1 priority in sepsis?
Kumar et al. Crit Care Med 2006;34(6):1589
Kumar et al. Crit Care Med 2006;34(6):1589
Abx keys• Get them in fast!• Culture first• Source control• ?MRSA/
pseudomonas
Chest Levo + ceftriaxone Azithro + ceftriaxone Tazo/Cipro (nursing home, etc)
Abdo Pip/tazo or AGF or ceftriaxone/Flagyl
GU Gent or ceftriaxone
Skin Ancef +/- vanco
Head Ceftriazone + vanco + dex
Surviving Sepsis Campaign• Crit Care Med 2008;36(1):296
CAEP• CJEM 2008 Sept;10(5):443
Sepsis Management
1. Recognition
2. ABX!
SIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
What does our patient have?
Investigations? Initial management priorities?
Reassess our patient Why is lactate important?
Mortality: 46%
SEVERE SEPSIS
SEPTIC SHOCK
SEPSIS
SIRS
Mortality: 10%
Mortality: 16%
EGDT Mortality: 30%
EGDT
In-hospital mortality• 46.5% vs 30.5% (NNT = 6!)
60-day mortality• 56.9% vs 44.3%
EGDT got more early fluid, pRBC, inotropes
Hinshaw & Cox. The Fundamental Mechanisms in Shock. Plenum Press, New York. 1972. Hypovolemi
c Distributive Cardiogenic Obstructive
✓✓✓
✗
Hypovolemic
Distributive
Cardiogenic
Why are patients in hypovolemic shock?• Venodilation• 3rd spacing• Losses (vomiting, diaphoresis)• Recent poor PO intake
Crystalloid vs colloid?
BMJ 1998;316:961
NEJM 2004;350:2247
Cochrane review, 2005 VISEP. NEJM 2008;358:125-39 NS – cheap, available – USE IT
Surviving Sepsis Campaign• Colloid or crystalloid
CAEP• Colloid or crystalloid
Crit Care Med 2008;36(1):296
Voluven• Lu et al. 2009 Mar;21(3):143-6
?lung-protective in rabbits• Palumbo et al. 2006;72(7-8):655
Improved hemodynamics and APACHE-II score• Franziska et al. 2009;35(9):1539
Similar rates of ARF as albumin in surgical ICU pts
Sepsis Management
1. Recognition (lactate, u/o)
2. ABX
3. EGDT (NNT=6)
SIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
EGDTCVP 8-12 Crystalloid (1L q30min)
Distributive
Should we use vasopressin in sepsis?
NEJM 2008;358(9)
Sepsis Management
1. Recognition (lactate, u/o)
2. ABX
3. EGDT (NNT=6)
SIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
EGDTCVP 8-12 Crystalloid (1L q30min)
MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min
Cardiogenic
EGDT• If ScvO2<70% and hct<0.30
TRICC • If Hb > 70g/L
How does this help?
O2 content = (1.34 x Hb x SaO2) + (0.0031 x PO2)
NEJM 1999;340:409
Results• No difference in 30 or 60 day mortality• Restrictive group
• Lower in-hospital mortality 22.2% vs 28.1% (p=0.005)
• Less sick pts (APACHE II score <20) did better• ARR 7.4% (95%CI 1.0 – 13.6%)
• No difference in mortality in sepsis sub-group
EGDT• Hypovolemic ED patients• Actual measurement of suboptimal O2
delivery TRICC
• Euvolemic pts enrolled within 72 hours of ICU admit
• 6% sepsis, 27% had any infection
Sepsis Management
1. Recognition (lactate, u/o)
2. ABX
3. EGDT (NNT=6)
SIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
EGDTCVP 8-12 Crystalloid (1L q30min)
MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min
ScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/min
Absalom 1999, Malerba 2005, Vinclair 2007• Single dose inhibits cortisol synthesis for 24-48h
Mohammed 2006, Ray 2007, Riche 2007• Studies designed for etomidate vs no etomidate• No increase in mortality
CORTICUS (2008)• >28d mort with one dose (OR 1.53 (1.06-2.26)) • Etomidate non-randomized, post-hoc analysis
Bottom line• Avoid in sepsis
NEJM 2000;342(18)
Sepsis Management
1. Recognition (lactate, u/o)
2. ABX
3. EGDT (NNT=6)
4. ARDS vent settings (NNT=11)
SIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
EGDTCVP 8-12 Crystalloid (1L q30min)
MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min
ScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/min
ARDSNetTV 6cc/kgPEEPPplateau<30
Early studies - no benefit NEJM 1987; 317: 659-65, NEJM 1987; 317: 653-58
Increased mortality at higher doses Crit Care Med. 1995; 23: 1430-39
Annane – benefit in non-responders JAMA 2002;288(7)
CORTICUS – no benefit NEJM 2008;358(2)
Annane - benefit in subgroup JAMA 2009 June;301(22)
Sepsis Management
1. Recognition (lactate, u/o)
2. ABX
3. EGDT (NNT=6)
4. ARDS vent settings (NNT=11)
5. ?Hydrocortisone 50mg q6h -vasopressor-unresponsive pts
SIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
EGDTCVP 8-12 Crystalloid (1L q30min)
MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min
ScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/min
ARDSNetTV 6cc/kgPEEPPplateau<30
Van den Berghe et al. NEJM 2001;345(19)• Overall mortality benefit
Glucontrol. Presented Oct 2007 • Stopped early, hypoglycemia, protocol violations
VISEP. NEJM 2008;358:125-39• Stopped early, hypoglycemia concerns
Guidelines• SSC – Glucose management in ICU• CAEP – Reasonable to target glu 4-8mmol/L
Sepsis Management
1. Recognition (lactate, u/o)
2. ABX
3. EGDT (NNT=6)
4. ARDS vent settings (NNT=11)
5. Hydrocortisone 50mg q6h -vasopressor-unresponsive pts
6. ?Insulin (ICU unless v. high)
SIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
EGDTCVP 8-12 Crystalloid (1L q30min)
MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min
ScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/min
ARDSNetTV 6cc/kgPEEPPplateau<30
PROWESS. NEJM 2001;344(10)• Improved survival, NNT = 6
Post-hoc PROWESS. Int Care Med 2003;29• PROWESS benefit only in very sick
ADDRESS. NEJM 2005; 353:13• Stopped early, no effect, increased bleeding
RESOLVE. Lancet 2007;369:836• Peds, no difference in any outcome
Cochrane review 2008 BOTTOM LINE: Not for ED use
Sepsis Management
1. Recognition (lactate, u/o)
2. ABX
3. EGDT (NNT=6)
4. ARDS vent settings (NNT=11)
5. ?Hydrocortisone 50mg q6h -vasopressor-unresponsive pts
6. ?Insulin (BG~10)
7. ?APC (maybe in ICU)
SIRST<36 or >38HR>90RR>20, pCO2<32WBC<4, >12 or >10% bands
EGDTCVP 8-12 Crystalloid (1L q30min)
MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min
ScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/min
ARDSNetTV 6cc/kgPEEPPplateau<30
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