Surviving sepsis campaign highlights 2016
-
Upload
sekar-loganathan -
Category
Health & Medicine
-
view
81 -
download
4
Transcript of Surviving sepsis campaign highlights 2016
![Page 1: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/1.jpg)
Dr.Sekar Loganathan ,Junior Resident ,Dept of Anaesthesia and Intensive care,PGIMER, Chandigarh, INDIA.
![Page 2: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/2.jpg)
The need for new guidelines
• Sepsis still an economic burden on public health.
• Sepsis is the leading cause of death in non-coronary care intensive care units, with a mortality rate between 30-50%.
![Page 3: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/3.jpg)
![Page 4: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/4.jpg)
Why new definition?
• Definitions of sepsis and septic shock were last revised in 2001.
• Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management and epidemiology of sepsis, suggesting the need for re-examination.
![Page 5: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/5.jpg)
Why new definition?
• To know what distinguishes sepsis from uncomplicated infection as simple infection.
• We need to differentiate a straightforward infection from one that can cause organ dysfunction or death.
• SIRS criteria doesn’t differentiate.
![Page 6: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/6.jpg)
Overlap
![Page 7: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/7.jpg)
• SIRS criteria have been used to diagnose sepsis for more than 20 years.
• The Validity of SIRS challenged.
• Poor concurrent Validity.
![Page 8: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/8.jpg)
![Page 9: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/9.jpg)
Previous definitions
![Page 10: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/10.jpg)
• The care in sepsis is focused on prompt recognition and early treatment.
• “Shift of focus from inflammation to Organ Dysfunction ”
![Page 11: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/11.jpg)
![Page 12: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/12.jpg)
![Page 13: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/13.jpg)
![Page 14: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/14.jpg)
![Page 15: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/15.jpg)
New definitions • Sepsis is defined as life-threatening organ
dysfunction caused by a dysregulated host response to infection.
• NB:– The SIRS criteria have been removed– It may present in simple, non-complicated infection, or in
response to non infectious-triggers (i.e. trauma, pancreatitis, post-cardiac arrest syndrome),
– Or may even be absent in critically ill patients with obvious evidence of a life-threatening infection.
![Page 16: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/16.jpg)
New definitions • Septic shock is a subset of sepsis in which
underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.
– Clinical criteria identifying such condition include the need for vasopressors to obtain a MAP≥ 65mmHg and an increase in lactate concentration > 2 mmol/L, despite adequate fluid resuscitation.
Terms like Severe Sepsis/Septicemia has been removed
![Page 17: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/17.jpg)
• Finally, all these new definitions are recommended for coding and research purposes.
![Page 18: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/18.jpg)
DEFINITON
2012 2016
SEPSIS-presence of infection + systemic manifestation of infection.
Severe sepsis- sepsis+ sepsis induced organ dysfunction or tissue hypoperfusion
Sepsis - life-threatening organ dysfunction caused by a dysregulated host response to infection.
Septic shock- subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality.
No severe sepsis category.
![Page 19: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/19.jpg)
INITIAL RESUSCITATION2012 2016
ATLEAST 30 ml/kg in first 3 hrsCrystalloid fluid (no recommendation on 0.9% NS or balanced salt solutions).
Albumin if patients require substantial fluids
same
Proctocolised care including•CVP•Scvo2•Normalise lactate
Use dynamic resuscitation markers•Target MAP of 65mmhg•Reassess hemodynamic status to guide resuscitation•Normalise lactate
![Page 20: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/20.jpg)
DIAGNOSIS 2012 2016
Use of the 1,3 beta D-glucan assay mannan and anti-mannan antibody assays if available and invasive candidiasis is in DD of cause of infection.
Imaging stiduies for cause of infection.
No specific recommendation for fungal etiological diagnosis and imaging studies.
![Page 21: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/21.jpg)
ANTIBIOCTICS 2012
2016
One or more antibiotics active against persumed pathogen.
Combination theraphy (double coverage) for neutropenbic patients and for pseudomonas.
Initial broad spectrum antibiotics.
Against combination therapy.
May use procalcitonin to de-escalation of antibiotic
![Page 22: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/22.jpg)
SOURCE CONTROL
2012 2016
Achieve within 12 hrs if feasible.
Achieve as soon as possible medically and logically feasible.
![Page 23: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/23.jpg)
VASOACTIVE MEDICATIONS2012 2016
Choice of vasopressors:
Norepinephrine > epinephrine > Vasopressin
Norepinephrine > Vasopressin > Epinephrine
![Page 24: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/24.jpg)
BLOOD PURIFICATION
• No recommendation regarding the use of blood purification techniques.
• Limitations of the available studies .• Evidence very low either in favour or against
this techniques.• Needs further research studies.
![Page 25: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/25.jpg)
ANTICOAGULANTS
• Against the use of antithrombin for the treatment of sepsis and septic shock.
• Antithrombin- abundant anticoagulant in the blood, decreased plasma activity at onset of sepsis correlates with the DIC and lethal outcome.
• No beneficial effect on overall mortality.• Associated with the increased risk of bleeding.
![Page 26: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/26.jpg)
• No recommendation regarding the use of thrombomodulin or heparin for the treatment of sepsis or septic shock.
• Shows beneficial effect on survival- systematic reviews.
• RCT ongoing on DIC- pending results.
![Page 27: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/27.jpg)
VENTILATOR STRATEGIES 2012 2016No recommendation.
Weak recommendations for noninvasive ventilation in selected patients with sepsis induced ARDS.
Prone position ventilation in sepsis- induced ARDS with P/F < 100 mm hg.
Against high frequency oscillatory ventilation.
Unable to make recommendation on noninvasive ventilation.
Prone position ventilation in sepsis-iduced ARDS, P/F < 150mm hg
NMBA for < 48 hrs in adults with P/F < 150 mmhg
![Page 28: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/28.jpg)
VENTILATION STRATEGIES
• Spontaneous breathing trials
• Weaning protocol in mechanically ventilated patients with sepsis induced respiratory failure.
![Page 29: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/29.jpg)
SEDATION AND ANALGESIA
• Neuromuscular blocking agents – intermittent bolus or continuous infusion with TOF monitoring- 2012.
• 2016- no specific recommendation.
![Page 30: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/30.jpg)
GLUCOSE CONTROL
• Arterial blood rather than capillary blood for POC testing if patient have arterial catheters.
• Recommends central labarotory testing of blood glucose over POC glucometers.
• Glucometers- erroneous higher values.
![Page 31: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/31.jpg)
RENAL REPALCEMENT THERAPY
• Against the use of RRT in patients with sepsis and acute kidney injury for increase in creatinine or oliguria without other definitive indications for dialysis.
![Page 32: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/32.jpg)
STESS ULCER PROPHYLAXIS 2012 2016PPI preferred rather than H2RB
Either PPI or histamine-2 receptor antagonists.
Small increase in risk of C.diificile infection with PPIs.
![Page 33: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/33.jpg)
NUTRITION
• Against early parenteral nutrion.• Early enteral nutrition.• Against omega-3 fattyacids as an immuno
supplementation.• Against routine monitoring of gastric residual
volume .• Post-pyloric feeding tubes.
![Page 34: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/34.jpg)
![Page 35: Surviving sepsis campaign highlights 2016](https://reader035.fdocuments.net/reader035/viewer/2022070517/58d110bc1a28ab823e8b6625/html5/thumbnails/35.jpg)
THANK YOU