Sepsisandseveresepsis
-
Upload
davidjmock -
Category
Health & Medicine
-
view
603 -
download
0
Transcript of Sepsisandseveresepsis
SEPSIS ,SEVERE SEPSIS AND SEPTIC SHOCK
2008 UPDATE
J.TAVARES,MD,FCCP,FAASM
Rivers E et al. N Engl J Med 2001;345:1368-1377
Protocol for Early Goal-Directed Therapy
• SEPSIS RESUSCITATION BUNDLE:• 1-Serum Lactate• 2-Blood Cultures• 3-Antibiotics within 3 hours/1 hr• 4-IVF • 5-CVP 8-12 or 12-15mmHg• 6-Scv02>70%
LACTIC ACID
• High Lactate levels due to liver failure.
• Cutoff value still 4mmol/L .• Rapid turnaround time (ABG
analyzer).
• SEPSIS RESUSCITATION BUNDLE:• 1-Serum Lactate• 2-Blood Cultures• 3-Antibiotics within 3 hours/1 hr• 4-IVF • 5-CVP 8-12 or 12-15mmHg• 6-Scv02>70%
FLUID MANAGEMENT
• 1-Crystalloids comparable to Colloids(SAFE Trial:NEJM,2004)
• 2-May use Albumin in individuals with Albumin less than 4.
• 3- ?Hydroxyethyl starch(HES )
PENTASTARCH
• NEJM(358;2; jan 10/08)• Ringer’s Lactate vs Pentastarch• Mortality: no diference at 28
days(24.1% vs 26.7%) ; higher in the Pentastarch group at 90 days(33.9% vs 41.0%; P=0.09)
PENTASTARCH
• MORBIDITY:
• Higher rate of acute renal failure(22.8% vs 34.9%)
• Lower platelets count• More PRBC transfusions
Brunkhorst F et al. N Engl J Med 2008;358:125-139
Kaplan-Meier Curves for Overall Survival
• SEPSIS RESUSCITATION BUNDLE:• 1-Serum Lactate• 2-Blood Cultures• 3-Antibiotics within 3 hours/1 hr• 4-IVF • 5-CVP 8-12 or 12-15mmHg• 6-Scv02>70%
CVP 8-12:?for how long
• Comparison of 2 fluid mngt strategies in ALI(nejm;354,2006
• 1000 Pts(500 conservative fluid mangt;497 liberal)
• No difference in 60 day mortality,but less lung injury, faster weaning and fewer days in ICU for conservative.
Rivers E et al. N Engl J Med 2001;345:1368-1377
Protocol for Early Goal-Directed Therapy
RBC Transfusion
• Controversies in RBC transfusion in the critically ill(chest/131/5/may,2007)
• TRICC trial(NEJM 1999;340)• Lack of benefit of RBC
transfusions:1-immune suppression(leukocytes);2-prolonged RBC storage
RBC TransfusionClinical Recommendations)• 1-general critically ill:Hb=7g/dl• 2-critically ill with septic shock(<6h):8-
10• 3-critically ill with septic
shock(>6h):7g/dl• 4-critically ill with chronic cardiac
disease:7g/dl• 5-critically ill with acute cardiac
disease:8-10g/dl
Sepsis management bundle• 1-Tight blood sugar control
• 2-Low dose steroids
• 3-Drotrecogin alfa
• 4-Plateau pressures<30cm H2O
• 5-Extubation readiness.
Intensive insulin therapy in the ICU• Leuven study(nejm;nov2001)• 1-BG<110 2-mortality reduced from 8% to
4.6%• 3-Severe hypoglycemia(<40): 0.8%
in the conventional group and 5.1% in the intensive treatment group.
• 4-Surgical ICU patients.
Van den Berghe G et al. N Engl J Med 2001;345:1359-1367
Kaplan-Meier Curves Showing Cumulative Survival of Patients Who Received Intensive Insulin Treatment or Conventional Treatment in the Intensive Care Unit (ICU)
IIT in the ICU
• Leuven 2(nejm 2006;354)• 1-Blood glucose 80-110• 2- patients staying in ICU for 3 or
more days: mortality decreased from 52.3% to 43%
• 3-Severe hypoglycemia(<40): 3.1% in the conventional group and 18.7% in the treatment group.
• 4-medical IICU patients.
IIT in the ICU
• VISEP studies and Glucocontrol studies both in Europe(stopped because of increased risk of hypoglycemia).
• Both criticized for not having enough number of patients.
• Ongoing clinical trial by NIH(NICE-SUGAR) trial may have sufficient statistical power to address the above issues.
Brunkhorst F et al. N Engl J Med 2008;358:125-139
Kaplan-Meier Curves for Overall Survival
ITT in the ICU
• Glycemic control needs to be done safely.
• Use of computerized systems:
• Glucommander(can be loaded in a bedside computer,hanheld computer or nursing station computer
Glucommander
• 5 parameters: • 1-low end of target range for blood
glucose• 2-high end of target range for glucose• 3-the initial multiplier(adjusted for
insulin sensitivity)• 4-the maximum time interval between
measurements• 5-the insulin concentration
Sepsis management bundle• 1-Tight blood sugar control
• 2-Low dose steroids
• 3-Drotrecogin alfa
• 4-Plateau pressures<30cm H2O
• 5-Extubation readiness.
Adrenal Insufficiency
• 2002:Annane et al(JAMA;288):299 patients-76% of nonresponders to cosyntropin stimulation test,on ventilator were randomized to hydrocortisone plus fludrocortisone for 7 days:13% reduction in mortality for those treated
Adrenal Insufficiency
• The CORTICUS trial(double-blinded,randomized,placebo-controlled multicenter European trial)( Goal:800 patients):
• Comparing hydrocortisone(50mg IV q6h for 5 days,taper to 50mg IV q12h for 3 days,then 50mg daily for 3 days)with placebo in septic shock.
Adrenal Insufficiency
• The retrospective Corticus cohort study(Critical Care Medicine:Volume 35(4) April 2007pp 1012-1018)
• Total of 562 patients(after exclusion:477pts were left)
Sprung C et al. N Engl J Med 2008;358:111-124
Enrollment and Outcomes
CORTICUS
• 1-Hydrocortisone did not improve survival or reversal of shock even in patients who did not respond to Cosyntropin test
• 2- Hydrocortisone hastened reversal of shock.
Sepsis management bundle• 1-Tight blood sugar control
• 2-Low dose steroids
• 3-Drotrecogin alpha
• 4-Plateau pressures<30cm H2O
• 5-Extubation readiness.
Bernard G et al. N Engl J Med 2001;344:699-709
Proposed Actions of Activated Protein C in Modulating the Systemic Inflammatory, Procoagulant, and Fibrinolytic Host Responses to Infection
Drotrecogin Alfa
• 1-PROWESS trial:NEJM 2001;344:699-709.
• 2-ADDRESS trial:(APACHE<25 or only one organ dysfunction at baseline)-NEJM 2005;353:1332-1341.:no significant reduction in 28-day mortality.
• 3-ADDRESS one year follow-up(critical care medicine 2007;35:1457-1463):no increased risk of death or evidence of harm at 1 year.
Bernard G et al. N Engl J Med 2001;344:699-709
Kaplan-Meier Estimates of Survival among 850 Patients with Severe Sepsis in the Drotrecogin Alfa Activated Group and 840 Patients with Severe Sepsis in the Placebo Group
Bernard G et al. N Engl J Med 2001;344:699-709
Incidence of Serious Adverse Events
How do I do it(Resuscitation Phase)• Septic shock:• 1-IVF (up to 20cc/kg bolus to keep
MAP>=65• 2-if unable to achieve above,place
central line for CVP monitoring:keep CVP 8-12mmHg(12-15 if PPV).
• 3-If CVP goal achieved but MAP<65,start vasopressors
How do I do it(Resuscitation Phase)
• 4-NE,DA,PE,Vasopressin• 5-follow serial lactate levels 6-If MAP>65,check ScVo2(goal is
ScVo2>70%). 7-If ScVo2<70% and
Ht<30%,transfuse PRBC
How do I do it(Resuscitation Phase)
• 9-If Ht>30% and ScVo2 still <70%,start Dobutamine.
If ScVo2>70%,goal achieved
FLUIDS
• Normal Saline:500 cc boluses
• Albumin:25g iv x 3 doses
• Avoid Hespan
Vasopressin
• 0.01-0.04 units/mn IV
• Do not titrate.
How do I do it(Management Phase)
• STEROIDS• 1-No need for baseline cortisol
level or Cosyntropin test: If BP is not responding to IVF and Vasopressors after 1 to 2 hours,start HYDROCORTISONE at 50mg IV every 6 hours for 5 days(do not taper)
How do I do it(Management)• ACTIVATED PROTEIN C
• 2-APACHE>25 or at least two organs failure,start drotrecogin alpha.
• 3-If APACHE<25 or only one organ failure,may consider drotrecogin.
How do I do it(management)
• BLOOD GLUCOSE• 4-Tight Blood Sugar control: use
hospital protocol). Acceptable to keep blood sugar less than 150.
How do I do it(Management)
• Mechanical ventilation
• 5-keep plateau pressure below 30 cmH20
• 6-Spontaneous Awakening Trials• 7-Spontaneous Breathing Trials
Antibiotics
• USE HOSPITAL PROTOCOL
Goal for 2009
• DECREASE SEPSIS MORTALITY BY 25%
Material for Research
• 1-Procalcitonin
• 2-C Reactive Protein
• 3-Statins