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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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