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Sepsis Management
Update 2014
Laura J.Moore, MD,FACS
AssociateProessor,Department o
Surger!"#e Uni$ersit! o "e%as&ea't# Science Center,&ouston
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Medica' Director,
S#oc( "rauma)CU
"e%as "rauma
)nstitute, Memoria'&ermann &ospita'
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*+ecti$es
Discuss 2014 Sur$i$ing Sepsis Campaign-uide'ines Sepsis Screening
Use o Proca'citoninorepinep#rine as /rst 'ine$asopressor F'uid resuscitation
e$ie recent'!pu+'is#edProCSS stud!
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e$ision o t#e 2003 Sur$i$ing Sepsis
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Campaign SSC5
-uide'ines
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Si% #our 6resu
Centra' $enous pressure 3712 mm &g
Mean arteria' pressu
Urine output#r 8 0.9 mCentra' $enous or mi%ed $enous
o%!gensaturation :0; or
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normalize lactate
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Surviving Sepsis Campaign Guidelines 2012
Grades of Evidence
Grade 1AGr
a
Glucose protocol(
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!oid phenlephrine S eDe
1
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Surviving Sepsis Campaign Guidelines 2012
Grades of Evidence
Grade 1AGr
a
Glucose protocol(
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!oid phenlephrine S eDe
1
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ationa'e= ar'! inter$ention isdependent upon t#e ear'!identi/cation o sepsis
ar'! initiation o e$idence +ased care#as +een s#on to impro$e outcomes
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and decrease sepsis re'ated morta'it!
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Three Step SepsisScreening Tool
Done Twice Each Day
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Medical School Houston, Houston,
arlScreeni
ngand
$mplementation o"!idenceBased
*are
T/er"ormance$mpro!ement
/ortalit"orSe!ere
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Sepsis,SepticShoc & 2nit
M o r t a l i t y
50.0%2006 Mortality2007 Mortality
40.0%
30.0%
20.0%
10.0%
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0.0%Surg ICU ER CV ICU Med ICU
2006 Mortality 35.1% 25.0% 21.4% 38.0%
2007Mortal
ity23.3
%30.3
%23.5
%37.2%
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Obec!ives
Discuss 201" Surviving SepsisCampaign Guidelines
Sepsis Screening#se of $rocalci!onin
%orepinep&rine as firs! line
vasopressor 'luid resusci!a!ion
(evie) recen!l* publis&ed $roCESS s!ud*
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+&a! is procalci!onin,
116-amino acid pep!ide
.iomar/er !&a! responds !o bo!& infec!ion
inflamma!ionCan i! be used !o differen!ia!e sepsis from
S(S,
Could !&is be of benefi! in sepsisiden!ifica!ion,
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*+ecti$es
Discuss 2014 Sur$i$ing Sepsis Campaign-uide'ines Sepsis Screening
Use o Proca'citoninorepinep#rine as /rst 'ine$asopressor F'uid resuscitation
e$ie recent'!pu+'is#edProCSS stud!
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Surviving Sepsis Campaign Guidelines 2012
Grades of Evidence
Grade 1AGrade1.
G
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Glucose protocol(
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Dellinger ($ e! al3 Crit CareMed.20145 4168-229
1 1
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:asopressors
;arge! mean ar!erial pressure of 68 mmceed 030"
uni!s=minu!eDopamine onl* in &ig&l* selec!ive pa!ien!s
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+&* no! dopamine,
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*+ecti$es
Discuss 2014 Sur$i$ing Sepsis Campaign-uide'ines Sepsis Screening
Use o Proca'citoninorepinep#rine as /rst 'ine$asopressor F'uid resuscitation
e$ie recent'!pu+'is#edProCSS stud!
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Surviving Sepsis Campaign Guidelines 2012
Grades of Evidence
Grade 1A
G
r
a
Glucose protocol(
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!oid phenlephrine S eDe
1
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'luid (esusci!a!ion in Sepsis
Cr*s!alloids are !&e firs! line agen!
?Absence of clear benefi! )i!& colloids
[email protected] s&o)ed improved survival )i!& albuminin sep!ic s&oc/ subgroup
(ecommend 40 cc=/g .+ for s&oc/
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Avoid &*dro>*e!&*l s!arc& solu!ions
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+&* no!
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1919 severe sepsis cases 100 &ospi!als(andomiFed !oalbumin or
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cr*s!alloid
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S!ud* Obec!ives
1
;o de!ermine if earl* goal direc!ed !&erap*BEGD; as described b* (ivers e! al isgeneraliFable
2 ;o de!ermine )&ic& EGD; pro!ocol elemen!s are
necessar*
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Validation Stud/ulticenter Trial
60 sites
roCESS
rotocoli7ed *are "orarl Septic Shoc
N$-sponsored89: /illion
%ere #ngus et al9
2ni!9 o" itts&urgh
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$roCESS
EGD;Similar !o
(ivers pro!ocol
Same goal as(ivers pro!ocol
ScvO2
.lood !> !o /eep
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$ro!ocoliFed
S!andard Care
%o C:$moni!oring
%o cen!ral venous
o>ime!ricca!&e!er
%o ScvO2 goal
S.$=perfusionmoni!oring
;arge!
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%14"1 41 #3S3 Emergenc* Dep!s
rotocol-&ased G%T; n:+=
rotocol-&ased standard therap;n::5
2sual care; n:>5
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Ior!ali!* a! 60 da*srotocol-&ased G%T group (6190?)rotocol-&ased standard-therap group (1896?)2sual-care group (189=?)$ro!ocol-based !&erap* vs3 usual care
? (( 130"5 8 C 0392 !o 13415 $ 0394
$ro!ocol-based EGD; vs3 pro!ocol-based s!andard!&erap*
? (( 13185 8 C 0399 !o 13815 $ 0341
%o significan! differences in0-da* mor!ali!* 1-*ear
mor!ali!* or !&e need fororgan suppor!3
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JAverage amoun! of cr*s!alloids given in firs! 6 &ours b* group
EGD; 239 @i!ers
$SC 434 @i!ers
#C 234 @i!ers
*SS * l ti / t lit
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ro*SS4 *umulati!e /ortalit
'i!ers G%T +09>? in-hospital mortalit
The ro*SS $n!estigators9 Nngl @ /ed 601:A+04158+-15=+
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$roCESS nves!iga!or
Conclusions
$ro!ocol-based resusci!a!ion of pa!ien!sdiagnosed )i!& sep!ic s&oc/ in !&e E( did no!
improve ou!comes3
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$roCESS nves!iga!or
Conclusions
$ro!ocol-based resusci!a!ion of pa!ien!sdiagnosed )i!& sep!ic s&oc/ in !&e E( did no!
improve ou!comes3
S
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mpor!an! Cavea!s
$a!ien!s in all groups received an averageof H 2 li!ers of fluid
H78 of pa!ien!s received an!ibio!ics prior!o randomiFa!ion in!o !&e s!ud*
;&e 19 mor!ali!* ra groups is muc& lo)er!&an !&e sep!ic
s&oc/ mor!ali!* ra!e of "638 repor!ed
in (ivers original !rial;&e maori!* of pa!ien!s &ad cen!ral lines
inser!ed
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S&ould )e abandon EGD;,
Earl* diagnosis and earl* in!erven!ionremain cri!ical
;)o large ongoing !rials ma* clarif*?A(SE BAus!ralian (esuscia!ion in Sepsis
Evalua!ion (C;
?$roISe B$ro!ocolised Ianagemen! in Sepsis
;rial
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Summar*
Sepsis screening aids in earl* recogni!ion
Earl* evidence based care is cri!ical
$rocalci!onin is non-specific no! useful
%orepinep&rine is no) firs! line agen!
'luid bolus 40 cc=/g .+ for sep!ic s&oc/
$roCESS s!ud* &as limi!a!ions
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$roCESS s!ud* &as limi!a!ions
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>US")*
S?