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Approach in the Management of Septic Shock Esteban Osorio Salazar Resident of Anesthesiology HUAV July -2012 The sick girlby Gabriel Metsu (1658)

Management of septic shock

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Una breve revisión sobre la estrategia adecuada para el manejo del shock séptico... ojala nos sirva a todos....

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Page 1: Management of septic shock

Approach in the Management of Septic Shock

Esteban Osorio SalazarResident of Anesthesiology

HUAV

July -2012

“The sick girl” by Gabriel Metsu (1658)

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Questions/objectives.1. Introduction.2. Definition.3. Pathophysilogy of sepsis.4. Management of septic shock.

1. Stabilize respiration.

2. Therapeutic priorites (monitoring andr initial resuscitation)

3. Diagnosis-AB therapy- Source Control.

4. Fluid Therapy.

5. Vasopressors and Inotropic Therapy.

6. Additional therapies.

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1. Introduction.

450.000-500.000 cases of sepsis/year in EU.80.000 cases in SPAIN.Mortality Index 4-5 deaths/100.000/year.Hospital admission of sepsis : 3.4-28

cases/1000 admission. Incidence of Severe sepsis in ICU.

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2. Definition.Septic Shock Severe sepsis +:

*SMBP of <60 mm Hg (<80 mm Hg if hypertension) after 20 to 30 mL/kg starch or 40 to 60 mL/kg saline solution.*PCWP between 12 and 20 mm Hg +*Dopamine of >5 mcg/kg/min *Norepinephrine or epinephrine of <0.25mcg/kg/min.

Refractory Septic Shock

*Dopamine at >15 mcg/kg/min *Norepinephrine or epinephrine at >0.25 mcg/kg/min

Mean BP at >60 mm Hg (80 mm Hg if previous hypertension

Schmidt Gregory A, MD, Mandel Jess, MD. Management of severe sepsis and septic shock in adults.Wolters Kluwer Healt and Uptodate, May 2012.

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3. Pathophysiology of Sepsis.

Richard S. Hotchkiss, M.D., and Irene E. Karl, Ph.D.The Pathophysiology and Treatment of Sepsis. N Engl J Med 2003 348;138-150.

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3. Pathophysiology of Sepsis.

Richard S. Hotchkiss, M.D., and Irene E. Karl, Ph.D.The Pathophysiology and Treatment of Sepsis. N Engl J Med 2003 348;138-150.

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3. Pathophysiology of Sepsis

Emanuel P. Riversa, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010,16:001–012.

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3. Pathophysiology of Sepsis

Emanuel P. Riversa, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010,16:001–012.

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Supplemental oxygen to all patients and monitored continuously with pulse oximetry.

Intubation and mechanical ventilation (may be required). Chest Rx Sedative and induction agents.

4. Management of Septic Shock.4.1.Stabilize respiration

Target in Mechanical ventilation of sepsis-induced ALI/ARDS

*Tidal volume of 6 mL/kg (predicted).*Initial upper limit plateau pressure <30 cm H2O.*PEEP for prevent lung collapse in ALI/ARDS.*Prone position for ARDS patients with max FiO2/Pp? (2C)*Mild to moderate hypoxemic respiratory failure: NIMV.*

Target in sedative, inductive agents and NMB in sepsis

*Sedation protocols.*Intermittent bolus sedation or continuous infusion sedation (1C).*Avoid NMB where possible. Train-of-four when using continuous infusions(1B).

*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.*Schmidt Gregory A, MD, Mandel Jess, MD. Management of severe sepsis and septic shock in adults.Wolters Kluwer Healt and Uptodate, May 2012.

 

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4. Management of Septic Shock.4.1.Stabilize respiration

Murray MJ, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscularblockade in the adult critically ill patient. Crit Care Med 2002; 30:142-156.

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4. Management of Septic Shock.4.2.Therapeutic PrioritiesMonitoring and Initial Resuscitation

MonitoringAssess perfusion: *Arterial catheter.*Signs of Hypoperfusion (cold, VC skin, olig/anuria and

lactate>4mmol/l.

Catheters:*Central venous catheter

*Avoid PACs (SvO2 = ScvO2) + PAOP

*Radial artery pulse pressure

*Aortic blood flow peak velocity

*brachial artery blood flow velocity

x Static Hemod. Measures

Dynamic Hemod.Measures

Schmidt Gregory A, MD, Mandel Jess, MD. Management of severe sepsis and septic shock in adults.Wolters Kluwer Healt and Uptodate, May 2012.

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4. Management of Septic Shock.4.2.Therapeutic PrioritiesMonitoring and Initial ResuscitationInitial Resuscitation

Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis and Septic Shock. Infect Dis Clin N Am 23 (2009) 485–501.

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4. Management of Septic Shock.4.2.Therapeutic PrioritiesMonitoring and Initial Resuscitation

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4. Management of Septic Shock.4.3. Diagnosis-AB therapy- Source Control.

Diagnosis*Obtain ≥ 2 BCs one drawn percutaneosuly.*Obtain ≥1 BCs of vascular access devices.*Obtain culture of other sites clinically indicated

Antibiotics therapy

1º Appropiate antibiotics

Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis and Septic Shock. Infect Dis Clin N Am 2009;23:485–501.Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327. 

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4. Management of Septic Shock.4.3. Diagnosis-AB therapy- Source Control.

Antibiotics therapy

Anand Kumar, MD; Daniel Roberts, MD; Kenneth E. Wood, DO; Bruce Light, MD; Joseph E. Parrillo, MD; Satendra Sharma, MD; Robert Suppes, BSc; Daniel Feinstein, MD; Sergio Zanotti, MD; Leo Taiberg, MD; David Gurka, MD; Aseem Kumar, PhD; Mary Cheang, MSc. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006 ;34:1589-1596.

2º Early therapy (First hour of onset the hypotension)

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4. Management of Septic Shock.4.3. Diagnosis-AB therapy- Source Control

Antibiotics therapy

3ºApproach of antibiotics therapy

Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis and Septic Shock. Infect Dis Clin N Am 2009;23:485–501.

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4. Management of Septic Shock.4.3. Diagnosis-AB therapy- Source Control.

Source Control*the drainage of infected fluids.*Removal of infected devices.*Debridement of infected soft tissues. *Definitive measures to correct anatomic derangement resulting in ongoing antimicrobial contamination.

*Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis and Septic Shock. Infect Dis Clin N Am 2009;23:485–501.*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327. 

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4. Management of Septic Shock.4.4. Fluid Therapy 1000 mL of crystalloids or 300–500 mL of colloids

over 30 mins.

More rapid and larger volumes in tissue hypoperfusion.

If there are not improvement in the hemodinamics paramethers, the rate of fluid administration should be reduced.

*Emanuel P. Rivers, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010;16:001–012.*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.

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4. Management of Septic Shock.4.4. Fluid Therapy Target a CVP of 8 mm Hg (12mmHg MV).

John H. Boyd, MD, FRCP(C); Jason Forbes, MD; Taka-aki Nakada, MD, PhD; Keith R. Walley, MD, FRCP(C); James A. Russell, MD, FRCP(C).Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011 Vol. 39, No. 2

Design: Retrospective review of the use of intravenous fluids during the first 4 days of care.Setting: Multicenter randomized controlled trial.Patients: The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were receiving a minimum of 5 ug NA/minThe VASST patient database included daily fluid intake and urine output for the first 4days of treatment, CVP and (APACHE) II score.

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Target a CVP of 8 mm Hg (12mmHg MV).

4. Management of Septic Shock.4.4. Fluid Therapy

John H. Boyd, MD, FRCP(C); Jason Forbes, MD; Taka-aki Nakada, MD, PhD; Keith R. Walley, MD, FRCP(C); James A. Russell, MD, FRCP(C).Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011 Vol. 39, No. 2

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Colloids vs Crystalloids??

4. Management of Septic Shock.4.4. Fluid Therapy

Emanuel P. Rivers, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010;16:001–012.

Colloids versus crystalloids for fluid resuscitation in critically ill patients.Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G.Update in Cochrane Database Syst Rev. 2007;(4):CD000567. “There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids”

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4. Management of Septic Shock.4.4. Fluid Therapy

Anders Perner, Nicolai Haase, Anne B. Guttormsen, Jyrki Tenhunen, Gudmundur Klemenzson, Anders Åneman, Kristian R. Madsen, Morten H. Møller, , Jeanie M. Elkjær, Lone M. PoulsenAsger BendtsenRobert WindingMorten SteensenPawel Berezowicz, Peter Søe-JensenMorten BestleKristian StrandJørgen Wiis, Jonathan O. White, Klaus J. Thornberg, Lars Quist, Jonas Nielsen, Lasse H. Andersen, Lars B. Holst, Katrin ThormarAnne-Lene Kjældgaard, Maria L. Fabritius., Frederik Mondrup, Frank C. PottThea P. MøllerPer Winkel, Jørn Wetterslev.Hydroxyethyl Starch 130/0.4 versus Ringer's Acetate in Severe Sepsis. N Engl J Med 2012 .

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4. Management of Septic Shock.4.5.Vasopressors and inotropes therapy

Alpha 1 Receptor stimulation px VC Alpha 2 Receptor stimulation px VD by endothelial NO production

Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056. Timothy J. Ellender,MD, Joseph C. Skinner,MD.The Use of Vasopressors and Inotropes in the Emergency Medical Treatment of Shock. Emerg Med Clin N Am 26 (2008) 759–786.

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Beta1 receptor produces inotropic and chronotropic effect by sinoatrial nodal conduction. Also Dromotrophic effect (A/V nodal conduction)

Beta2 receptor px relaxation of smooth muscle and VD

4. Management of Septic Shock.4.5.Vasopressors and inotropes therapy

Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056. Timothy J. Ellender,MD, Joseph C. Skinner,MD.The Use of Vasopressors and Inotropes in the Emergency Medical Treatment of Shock. Emerg Med Clin N Am 26 (2008) 759–786.

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4. Management of Septic Shock.4.5.Vasopressors and inotropes therapyNOREPINEPHRINE

•NT and potent alpha 1 adrenergic receptor agonist.•Modest beta agonist effect.•Powerful VC •Increase systolic and diastolic pressures (coronary flow).•Direct toxicity in continue infusion (apoptosis)

•NE doesn´t improve sublingual microcirculatory perfusion, intestinal [pCO2] or arterial lactate levels.

*E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018.*Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.

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4. Management of Septic Shock.4.5.Vasopressors and inotropes therapy

Critical Care 2008, 12:R143 (doi:10.1186/cc7121)

n?

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4. Management of Septic Shock.4.5.Vasopressors and inotropes therapy

DOPAMINE

•Inmediate precursor to NE•Low doses * D1: renal, coronary, mesenteric, cerebral beds * D2: vasculature and renal tissues.(natriuretic effects). RENAL DOSE???•Medium doses * B1: inotropy and chronotropy effect with mild VC•High doses * A1:VC

*E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018.*Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.

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4. Management of Septic Shock.4.5.Vasopressors and inotropes therapy

*E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018.

•58 RCTs studies (2,149 patients)/ 33 years. •Dopamine did not prevent mortality, the onset of acute renal failure, or the need for dialysis.•Sufficient statistical power to exclude any large effect of dopamine on the risk of acute renal failure or the need for dialysis. •“There is no evidence to support the use of low-dose dopamine to prevent or treat acute renal failure, and, therefore, dopamineshould be eliminated from routine clinical use for this indication.”

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4. Management of Septic Shock.4.5.Vasopressors and inotropes therapyDOBUTAMINE

•Beta1: Beta2 (3:1).•Low doses (<5 ug/kg/min): * VD(beta2) vs VC(alpha1)•High doses (>15ug/kg/min): * VC>VD.•Increase myocardial oxygen consumption.

*E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018.*Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.

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4. Management of Septic Shock.4.5.Vasopressors and inotropes therapy

Vasopressors therapy•Maintain MAP 65 mm Hg.•NE and DO are the initial vasopressors of choice (1C)•Epinephrine, phenylephrine, or vasopressin should not be administered as the initialvasopressor in septic shock . •Use epinephrine if blood pressure is poorly responsive to norepinephrine or dopamine. •Do not use low-dose dopamine for renal protection.

Inotropes therapy•Dobutamine is the firstchoice inotrope for patients low cardiac output in adequate left ventricular filling pressure and adequate mean arterial pressure.

*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.*Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis and Septic Shock. Infect Dis Clin N Am 2009;23:485–501.

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CORTICOIDS Consider intravenous hydrocortisone for adult septic shock when hypotension

responds poorly to adequate fluid resuscitation and vasopressors. ACTH stimulation test is not recommended. Hydrocortisone is preferred to dexamethasone. Fludrocortisone (50 g vo/d) if an alternative to hydrocortisone (IF lacks

significant mineralocorticoid activity.

4. Management of Septic Shock.4.6.Additional Therapies

*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.

Kaufman, David,MD, Mancebo, Jordi,MD.Corticosteroid therapy in septic shock . Wolters Kluwer Healt and Uptodate, April 2012.

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METHODS Muticenter RCT, double-bind, placebo-controlled. 250 pts to receive 50 mg HCT ev and 248 pts to receive placebo every 6

hours for 5 days. At 28 days: primary outcomes were death among patients who did not have

response to corticotropin test.

RESULTS At 28 days, there was no significant difference in mortality between patients

in the two study groups who did not have a response to corticotropin (39.2% HCT vs 36.1% PCB,P=0.69).

CONCLUSIONS Hydrocortisone did not improve survival or reversal of shock in patients with

septic shock.

4. Management of Septic Shock.4.6.Additional Therapies

Charles L. Sprung,Djillali Annane,Didier Keh,Rui Moreno,Mervyn Singer, Klaus Freivogel,Yoram G. Weiss,Julie Benbenishty,Armin Kalenka, Helmuth Forst,Pierre-Francois Laterre, Konrad Reinhart,Brian H. Cuthbertson,Didier Payen,Josef Briegel for the CORTICUS Study Group.Hydrocortisone Therapy for Patients with Septic Shock.N Engl J Med 2008;358:111-24.

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Thanks!!