Recent Advances in Sepsis Management12

8/22/2019 Recent Advances in Sepsis Management12

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Recent Advances in Sepsis

Management


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Golden Hours


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What do u think of pre hospital

empiric antibiotic therapy


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2,154 septic shock

patients

Received antibiotics

after the onset ofrecurrent or persistent

hypotension

Each hour of delay

over 6 hrs wasassociated with 7.6%

decrease in survival.


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Lactate clearance and repeating it in 4 hours

Initial lactate- later lactate

Initial lactate


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Early lactate clearance

Debaker,2006

53

42

29

16

0

10

20

30

40

50

60

1 2 3 4


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Goal Directed

Septic

Shock

DO2

- PaO2

-Hemoglobin

- Cardiac Output

CNS and Systemic VO2

- Stress

- Pain

- Hyperthermia

- Shivering

- Work of breathing Cardiac Optimization

- Preload (CVP)

- Afterload (MAP, SVR)

Contractility (SV)

- Heart Rate (BPM)

- Coronary Perfusion Pressure

Microcirculation

Endpoints of Resuscitation


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Sepsis is a Spectrum of Disease

MAP

SVR

Volume

CVP,

SVV

Flow

CO,

ScvO2

Lactate Treatment and

Comments

Hypovolemia Variable Volume

Compensated

and vasodilatory

Normal Variable Vasopressors

Adrenal Dysf.

Myocardialsupression

Variable Correct anemiaInotropic

Therapy

Impairment of

O2 utilizationVariable Normal Vasodilators


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Fluid Responsiveness

Marik meta-analysis from Chest 2008


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No outcome difference


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Mortality Prediction at 48 hours


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SAFE trial provides enough data to suggest using

albumin?


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Mechanical ventilation


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Use of low dose vasopressin in moderate

to severe sepsis to replenish the reserves?


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Steroids in shock?


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Effect of Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients

with Septic Shock(Annane JAMA 2002)

Design: Randomized, double-blind,

multi-center

Patients: Septic shock

Intervention:Hydrocortisone (50 mg every six

hours)

Fludrocortisone (50 ug once per day)

Main Outcome: 28-day survival in

nonresponders to CST

229 Non-responders Randomized

115 Treatment & 114 controls

10% decrease in 28-day mortality

17% reduction in vasopressors use


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Now what should I do about steroids?

The Original Trial

8 hour time frame

Minimal steroid use

56% mortality

The Corticus Trial

72 hour time frame

Excluded patientstreated over 50%

Less severe patients

30 - 40% mortality

Similar benefit with higher mortality


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14.5% Reduction in

VasopressorUse if Optimized

with EGDT

Hold steroiduse

until the

patient

has beenresuscitated

and

endpoints met

(6-8 hours)


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Timing of echo

Global Tissue

Hypoxia

Inflammatory

Mediators


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Early Goal-Directed Therapy for Sepsis in Patients With Pre-

existing Left Ventricular Dysfunction:

A Retrospective Comparison of Outcomes

Based Upon Protocol Adherence

Shah S, Ouellette DR. Chest 2010;138:897A.


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Sepsis Data Base of 1287 Patients

183 with echo documented systolic dysfunction (EF< 50%)

135 patients did not meet EGDT 48 patients met EGDT

Mortality 36.3%Mortality 17%


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Mrs S

Suspected sepsis

Lactate of 10 & oligouric

BNP-4324

BUN- 77 Creatinine-3.2

CXR

ECHO


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Future of sepsis management


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Recent Advances in Sepsis Management12

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