2014 Sepsis Management (1)

7/25/2019 2014 Sepsis Management (1)

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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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Grades of Evidence

Grade 1AGr

a

Glucose protocol(


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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





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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





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Grades of Evidence

Grade 1A

G

r

a

Glucose protocol(


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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?

2014 Sepsis Management (1)

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