Sepsis Guidelins and STOP SEPSIS

download Sepsis Guidelins and STOP SEPSIS

of 55

Transcript of Sepsis Guidelins and STOP SEPSIS

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    1/55

    Sepsis Guidelines,and The

    STOPSepsis(Strategies to Timely Obviate

    the Progression of Sepsis )

    Basrul Hanafi

    Division Of Digestive SurgeryHasan Sadikin General Hospital

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    2/55

    Sepsis Guidelines

    I. Background

    Mortality rate of peritonitis with concomitantseptic shock, more than 60%

    If More than 4 MOFS already occured,

    mortality rate nearly 100 % (Baue,2000).

    Early Tratment of MODS and Preventing the

    MOFS, mortality rate are able to reduce

    (1995., Boyd, 1993., Flemming, 1992., Yu, 1993).

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    3/55

    Sepsis:

    A Major Cause of ICU Death

    More than 750,000 cases of severe sepsis in the

    US each year

    Mortality about 20% (recent decline)Economic cost of $17 billion each year

    Incidence is projected to increase by 1.5% yearly

    Although prognosis has improved, because ofincreased incidence, actual deaths will increase

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    4/55

    SIRS

    Pancreatitis

    BurnsTrauma

    Others

    Bacteremia

    Fungemia

    Parasitemia

    viremia

    Infection

    Sepsis

    Relation between infection, sepsis, SIRS and MOF

    The systemic

    inflammatory

    response syndrome

    (SIRS) produces aclinical reaction that

    is indistinguishable

    from sepsis in the

    absence of an

    infecting organism

    Timothy W Evans, Mark Smithies: Organ dysfunction,

    Clinical review. BMJ VOLUME 318 12 JUNE 1999

    Local

    inflamation

    Distantinjury

    Multi-Organ

    failure

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    5/55

    The Sepsis Continuum

    A clinical responsearising from anonspecific insult, with2 of the following:

    T >38oC or 90 beats/minRR >20/minWBC >12,000/mm3or

    10% bands

    SIRS = systemic inflammatoryresponse syndrome

    SIRS with a

    presumed

    or confirmed

    infectiousprocess

    Chest 1992;101:1644.

    SepsisSIRSSevere

    Sepsis

    Septic

    Shock

    Sepsis with

    organs failure

    Refractory

    hypotension

    Lactat 2-4, >4mmol/L

    Low, HightRisk

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    6/55

    Comparison With

    Other Major Diseases

    National Center for Health Statistics, 2001.American Cancer Society, 2001. *American Heart Association.2000.Angus DC et al. Crit Care Med.2001;29(7):1303-1310.

    AIDS* Colon Breast

    CancerCHF Severe

    Sepsis

    Cases/100,0

    00

    0

    50

    100

    150

    200

    250

    300

    Incidence of Severe Sepsis Mortality of Severe Sepsis

    0

    50,000

    100,000

    150,000

    200,000

    250,000

    Deaths/Year

    AIDS* Severe

    SepsisAMIBreast

    Cancer

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    7/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    8/55

    Grading of Recommendations

    Supported by at least two level I investigations

    Supported by one level I investigation

    Supported by level II investigations only

    Supported by at least one level III investigation

    Support by level IV or V evidence

    Guidelines :

    Based Medicine(EBM)Grading System

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    9/55

    I. Large randomized trials with clear-cut results; low risk offalse-positive (alpha) error or false-negative (beta) error

    II. Small randomized trials with uncertain results; moderate-to-high risk of false-positive (alpha) and/or false-negative (beta)error

    III. Nonrandomized, contemporaneous controlsIV. Nonrandomized, historical controls and expert opinion

    V. Case series, uncontrolled studies, and expert opinion

    Grading of Evidence

    Grading System

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    10/55

    1. Initial Resuscitation

    2. Diagnosis

    3. Antibiotic Therapy

    4. Source Control5. Fluid Therapy

    6. Vasopressores

    7. Inotrophic Therapy

    8. Steroid

    9. Recombinant HumanActivated Protein C(rhAPC) [drotrecoginalfa (activated)]

    10.Blood Product Administration

    11.Mechanical Ventilation

    12.Sedation, Analgesia, and Neuromuscular

    Blockade in Sepsis

    13.Glucose Control

    14.Renal Replacement

    15.Bicarbonat Therapy

    16.Deep Vein Thrombosis Prophylaxis

    17.Stress Ulcer Prophylaxis

    18.Limitation of Support

    Establish EBM on Sepsis

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    11/55

    Summary of SSC Guidelines

    Initiative GradeDVT prophylaxis with low dose heparins or

    mechanical devicesA

    Stress ulcer prophylaxis, preferably with H2blockers ADo not use more then 300 mg/day hydrocortisone A

    Weaning protocol with spontaneous breathing trials A

    Do not increase cardiac index to supranormal

    AEarly initial resuscitation to goals B

    Red blood cell transfusion/dobutamine to goals B

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    12/55

    Summary of SSC Guidelines

    Initiative GradeDo not use low dose dopamine for renal protection B

    rh Activated Protein C [drotrecogin alfa(activated)] in patients with high risk of death

    B

    RBC transfusion if hemoglobin

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    13/55

    Target Resusitasi pada

    Tingkat Seluler

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    14/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    15/55

    Cellular metabolism in the shock state

    Respiratory

    Enzyme

    Chain

    Citric

    Acid

    Cycle

    GlycolysisGlucose Pyruvate

    Lactate

    NAD+

    NADH

    ANAEROBIC

    AEROBIC

    CO2

    Oxygen

    2ATP

    36ATP

    H2O

    NAD+

    NADH

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    16/55

    Aerobic Metabolisms

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    17/55

    Anaerobic Metabolisms

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    18/55

    Target Pada Tingkat

    Mikrosirkulasi

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    19/55

    Microcirculatory System

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    20/55

    Rheology of Erythrocyt

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    21/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    22/55

    Shock state

    DIVERTED BLOOD FLOW

    HEART & BRAIN

    Control ofCV system

    Spinchterclosed

    Vasoconstriction

    NORMAL

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    23/55

    DISTAL ILEUM SECTION

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    24/55

    Target on Macrosirculation :Hemodynamic, Oxygen Transport

    Parameters

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    25/55

    DO2 and VO2 on Severe Shock

    Riverss Concepts (2002) Balanced DO and VO through

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    26/55

    Riverss Concepts(2002) Balanced DO2and VO2through

    Balancing Cardiac Preload, Contractility, and Afterload

    Cardiac preload

    (EDI)

    Cardiac after load

    (SVR)

    Cardiac contractility

    (CI)

    Balance between DO2 and VO2

    SvO2 Lactate Base deficit pH

    Resuscitation end points

    Target forhemodynamic

    Surrogate forcardiac index

    V l f S O2

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    27/55

    Value of SvO2

    SvO2

    Low SvO2

    SvO2 < 50%

    Poor tolerated

    Below 30%

    Anaerobic Metabolism

    Lactic Acidosis

    Emergency

    High SvO2

    Have enough O2 available

    to the cells but the cells

    cannot extract it

    Shunt, intracardiac or

    systemic vascular

    shuntHb failed to unload O2

    (leftward shift in ODC)

    Interstitial edema

    Toxic, Dying or Necrotic

    Tissue hypoxia

    Acute DO

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    28/55

    O2ER = 25%

    Acute DO2

    VO2O2ER = 50%

    O2return

    500SvO2 50%

    Anemia

    CO

    Hypoxemia

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    29/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    30/55

    Pencegahan & Pengelolaan

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    31/55

    Initial

    physiologiccondition

    I st Initial StagesOf PhysiologicDerangement

    CNSCardiovascular

    HormonalMetabolic

    Immune system

    and mediators

    NewEquilibrium:II nd or rd etc

    (New Stages of

    physiologicDerangement)

    Death ?Sequels?

    Phi losophy of Phys io log ic

    Derangement

    2ndHIT

    Goals

    DirectedResuscitation

    Supportive Th/1stHIT

    Insult/Injury

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    32/55

    Introduction

    The Management of Sepsis and Trauma

    Source Control

    Nutrition / MetabolicSupport

    Resuscitation &

    Physiologic Support1. Minimize flow-dependent

    oxygen consumption

    2. Minimize flow-dependent

    lactate clearance

    3. Restore Microcirculation

    1. Remove / Treat Infection2. Remove / Treat Inflammation

    3. Remove Dead Tissue

    4. Stabilization Injured Tissue

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    33/55

    P i P it iti U

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    34/55

    Prognosis Peritonitis Umum e.c

    Perforasi Ileum demam tifoid

    (Hanafi, 1979)

    Keadaan Umum Pre Op (Setelah Resusitasi)

    i. KU baik, Mortality < 5 %

    ii. KU sedang Mortality 25 %

    iii. KU tetap buruk pasca Resusitasi, Mortalitymendekati 100 %

    Upayakan KU Baik, EGDT Pola Kita Sejak1979

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    35/55

    Numerik Asli TKF vs TKU

    Analisis Multivariet Numerik AsliTingkat Kekacauan Fisiologik (Gabungan)

    Antar Kelompok RTNI vs RTSK

    =.00729

    CIEDISSVRILactateCCr

    Kelompok RTNI

    Resus

    Jam 00

    Jam 12

    Jam 24

    Jam 48-50

    0

    50

    100

    150

    200

    250

    300

    Kelompok RTSK

    Resus

    Jam 00

    Jam 12

    Jam 24

    Jam 48

    Analisis Multivariet Numerik AsliTingkat Keadaan Umum (Gabungan)

    Antar Kelompok RTNI vs RTSK

    p=.91224

    HRMAPS st BP

    Kelompok RTNI

    Resus

    Jam ke 00

    ke 12

    ke 24

    ke 4870

    80

    90

    100

    110

    120

    130

    140

    150

    Kelompok RTSK

    Resus

    Jam ke 00

    ke 12

    ke 24

    ke 48

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    36/55

    Numerik Asli RTNI vs RTSKKelompok Heart Rate MAP Syst BP

    Jam ke 0 12 24 48 0 12 24 48 0 12 24 48

    RTNI 106 95 94 87 87 83 82 87 116 111 113 121

    RTSK 106 100 94 103 92 91 90 97 125 124 123 131

    Kelompok CI EDI SSVRI

    Jam ke 00 12 24 48 00 12 24 48 00 12 24 48

    RTNI 3.9 4.0 3.8 3.9 63.0 68.9 67.9 73.4 200.3 159.8 174.7 151.0

    RTSK 3.9 4.7 3.6 3.1 64.3 71.3 63.8 56.4 198.6 172.6 183.9 230.5

    Kelompok Lactate CCr

    Jam ke 00 12 24 48 00 12 24 48

    RTNI 1.7 1.6 1.4 1.3 43.1 60.0 83.3 98.0

    RTSK 1.9 1.5 1.4 1.3 72.0 58.9 55.1 52.7

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    37/55

    KU Konvensional vs TKF

    KU Konvensional RTNI vs RTSKp=.91224

    Kelompok RTNIKelompok RTSK

    1 2 3 4

    Resusitasi

    0.5

    1.0

    1.5

    2.0

    2.5

    3.0

    3.5

    4.0

    4.5

    KU

    KF Antar Kelompok RTNI vs RTSKp=.13144

    Kelompok RTNIKelompok RTSK

    Jam ke 00

    Jam ke 12

    Jam ke 24

    Jam ke 48

    Resusitasi

    0.8

    1.0

    1.2

    1.4

    1.6

    1.8

    2.0

    2.2

    2.4

    KF

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    38/55

    Kelompok RTNI lebih baik dari RTSK dalam

    memperbaiki KF (Kekacauan Fisiologik)

    Analisis Multivariet KF Antar Kelompok RTNI vs RTSK

    p=.04604

    CI

    EDI

    SSVRI

    Lactate

    CCr

    Kelompok RTNI

    ResusJam ke 00

    Jam ke 12Jam ke 24

    Jam ke 48-0.5

    0.0

    0.5

    1.0

    1.5

    2.0

    2.5

    3.0

    3.5

    4.0

    4.5

    Kelompok RTSK

    ResusJam ke 00

    Jam ke 12Jam ke 24

    Jam ke 48

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    39/55

    RTNI lebih baik daripada RTSK dalam

    memperbaiki Hemodinamik Sistemik, Fungsi

    Ginjal, Status Metabolik

    Analisis Waktu ke waktu Kekacauan Fisiologik

    Antar Kelompok (WW*Kel.RTNI vs RTSK)

    Wilks lambda=.38699, F(15, 21)=2.2176, p

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    40/55

    - Central Venous Pressure 8-12 mm Hg (12-15 in ventilator pts)

    - Mean arterial pressure > 65 mm Hg

    - Urine output > 0.5 mL/kg/hr

    - ScvO2or SvO2 70%;

    if not achieved with fluid resuscitation during first 6 hours:

    - Transfuse PRBC to hematocrit > 30% and/or

    - Administer dobutamine (max 20 mcg/kg/min) to goal

    Resuscitation should begin as soon as severe sepsis or sepsis

    induced tissue hypoperfusion is recognized

    Elevated Serum lactate identifies tissue hypoperfusion in

    patients at risk who are not hypotensive

    Goals of therapy within first 6 hours are Grade B

    Initial Resuscitation

    -

    Protocol for Early Goal-Directed Therapy (EGDT)

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    41/55

    Protocol for Early Goal-Directed Therapy (EGDT)

    Supplement O2Endotracheal intubations

    Mechanical ventilation

    Central venous andarterial catheterization

    Sedation, Paralysis(if intubated), or both

    CVP

    MAP

    ScvO2

    Crystalloid

    Colloid

    < 8 mmHg

    Vasoactive agents< 65 mmHg

    > 90 mmHg

    812 mmHg

    6590 mmHg

    70%

    Goalachieved

    Transfusion of RCuntil Ht 30%

    70%

    < 70%

    Inotropic agents

    Hospital admissionYesNo

    < 70%

    Study design

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    42/55

    Study designSIRS criteria

    SBP < 90 mmHgLactate > 4 mmol/L

    Assessment and consent

    Randomization (n=263)Standard Therapy

    in ED (n=130)Early goal-directedtherapy (n=133)

    Vital sign, Lab data, cardiacmonitoring, pulse oximetry,

    Urinary catheterization,

    arterial and venouscatheterization

    Continuous SvO2monitoring and

    EGDT for 6 hours

    CVP 8-12 mmHg

    MAP 65 mmHg

    Urine 0.5 cc/kg/min

    ScvO2 70%

    SaO2 93%

    Hematocrit 30%

    Cardiac index

    VO2

    CVP 8-12 mmHg

    MAP 65 mmHg

    Urine 0.5cc/kg/min

    Standard care

    Hospital admission

    Vital sign, lab data,obtained every 12 hour

    for 72 hour

    Follow upDid not complete6 hour (n=13)

    Did not complete6 hour (n=14)

    Early Goal Directed Therapy

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    43/55

    49.2%

    33.3%

    0

    10

    20

    30

    40

    50

    60

    Standard Therapyn=133

    EGDTn=130

    P = 0.01*

    *Key difference was in sudden CV collapse, not MODS

    28-day Mortality

    Early Goal-Directed Therapy

    Results

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    44/55

    ALGORITM

    Mortality 60% 20-40% 10-20% 0-10%

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    45/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    46/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    47/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    48/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    49/55

    CLINICAL PATHWAY

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    50/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    51/55

    Admission Day I

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    52/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    53/55

    Day II - VII

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    54/55

  • 8/10/2019 Sepsis Guidelins and STOP SEPSIS

    55/55