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Jacob Scott

Spectrum Health Medical Group

Sepsis Updates

Disclosures

• No financial disclosures

Objectives

• Understand the new definitions of sepsis

• Understand current best practice for initial care of patients

with *severe* sepsis/septic shock

• Brief review of novel therapy with promise

Clinical Definition

New Definition-Why?

• Last definition update was in 2001-prior to landmark

research and extensive education efforts at standardizing

treatment

• Previous definitions were based on expert opinion—

professional societies felt it important to use more concrete

research to confirm best definition

• Cohorts were obtained from 5 large data sets encompassing

177 hospitals--~5,000,000 patient records were assess

New definition

• Infections were defined in a patient when cultures were

obtained and antibiotics were initiated in a 24 hours time

interval

• 4 separate candidate criteria for determining sepsis where

applied in cases of infection

• SIRS

• Sequential organ failure assessment (SOFA)

• Logistic organ dysfunction system (LODS)

• Quick sequential organ failure assessment (qSOFA)

New Definition

• Sepsis should be defined as life-threatening

organ dysfunction caused by a dysregulated host

response to infection

• Organ dysfunction defined by an increase in

SOFA score of 2 • These patient’s have a 10% increased risk of mortality

• Septic shock-sepsis requiring a vasopressor to

maintain MAP > 65, or sepsis with serum lactate

of 2 after adequate volume resuscitation• These patient have a 40% increased risk of mortality

New Rapid assessment for Sepsis in non-ICU Patients

• Non-ICU patients with a qSOFA score of

at least 2 much better discriminating

those with infections who at risk of

decompensation

• Criteria include RR > 22, SBP < 100,

and altered mental status

• Severe sepsis no longer exists—all

sepsis should be considered SEVERE

Treatment of Sepsis

Rivers Trial 2001

Questions About EGDT

• The Good-Sepsis mortality has fallen

nation wide since standardization efforts

have taken place (20-30%)

• Questions about what elements most

important

Rivers Trial 2001

What We Think We are Measuring

Is CVP a Good Measure of Volume Status?

What Else Did We Think in 1984?

How Bad is CVP?

What Is a Useful tool for Volume Status?

Am J Respir Crit

Care Med Vol 162.

pp 134–138, 2000

Rivers Trial 2001

Testing Rivers and EGDT

ProMISe Trial

ProMISe Trial

ProCESS Trial

ProCESS Trial

ARISE

ARISE

What Do I Make of These Studies?

• Understand “usual care” has been informed for

the last 20 years by EGDT and the surviving

sepsis guidelines

• Not all septic patients need lines

• Can probably get away from so much IVF, but

need to monitor something

• No longer strong evidence to follow SvO2 in

severe sepsis/septic shock, although it is not

wrong to do so

Take Home Points

• Early and appropriate antibiotics are super important

Effect of Abx Timing on Survival

Crit Care Med 2006;34:1589-96

Time from hypotension onset (hours)

Fra

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Take Home Points

• Early and appropriate antibiotics are super important

• The new definitions for sepsis are helpful for identifying

sicker patient that likely need our help in the ICU, but I don’t

know when they will be adopted

• Remember, it took 20 years for CMS guidelines to be

implemented based largely on EGDT

• Septic patients still need fluids, and dynamic measurements

of hemodynamic parameters are better than static

measurements (interpreting doc needs to know what they

are doing with dynamic measurements)

Surviving Sepsis 2017

Vitamin C

Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J, Hydrocortisone,

Vitamin C and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective

BeforeAfter

Study, CHEST (2017), doi: 10.1016/j.chest.2016.11.036.

• Patients with severe sepsis and septic shock and

with a procalcitonin > 2 admitted between January

2016-July 2016 were treated with study protocol

• Medications included 1.5 grams of vitamin C Q6H,

Thiamine 200 mg IV Q12H, and hydrocortisone 50

mg IV Q6H

• Control group was same patient population from

June 2015-December 2015

Questions???