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Surviving Sepsis

2008 Guidelines

Early Goal Directed Therapy


MAZEN KHERALLAH, MD, FCCP
INFECTIOUS DISEASE AND CRITICAL CARE MEDICINE

Therapy Across the Sepsis Continuum


Infection SIRS Sepsis Severe Sepsis Septic Shock

Microorganism invading sterile tissue

A clinical response arising from a nonspecific insult, with 2 of the following: T >38oC or <36oC HR >90 beats/min RR >20/min WBC >12,000/mm3 or <4,000/mm3 or >10% bands

SIRS with a presumed or confirmed infectious process

Sepsis with organ failure Vascular collapse Renal Hemostasis Lung LA

Refractory hypotension

Chest 1992;101:1644

Sepsis Syndromes
1992: SCCM/ACCP

Parasite

Virus Infection
Fungus
Shock

Severe Sepsis

Sepsis

SIRS Trauma Burns

BSI

Bacteria

Surviving Sepsis Campaign


Launched in Fall 2002 as a collaborative effort of

European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine Goal: reduce sepsis mortality by 25% in the next 5 years Guidelines revealed at SCCM in Feb 2004
Critical Care Medicine March 2004 32(3):858-87. Website: survivingsepsis .org

THE SEVERE SEPSIS BUNDLES: SSC/IHI


6 Hour Bundle

24 Hour Bundle
Glucose control maintained < 150 mg/dL Drotrecogin alfa (activated) administered in accordance with hospital guidelines Steroids given for septic shock requiring continued use of vasopressors for > 6 hours Lung protective strategy with plateau pressures < 30 cm H2O for mechanically ventilated patients

Measure serum lactate Blood Cultures prior to antibiotics Broad spectrum antibiotics within 3 hours of presentation, 1 hour in hospital Initial fluid resuscitation with 20-40 mL/kg crystalloid (or equivalent colloid) if hypotensive (SBP < 90 mmHg or MAP < 70) or lactate > 4 mmol/L Vasopressors If septic shock or lactate > 4 mmol/L: CVP and ScvO2 or SvO2 measured CVP maintained 8-12 mm Hg Inotropes (and/or PRBCs if Hct < 30%) delivered for ScvO2 <70% or SvO2<65% if CVP > 8 mmHg

http://www.ihi.org

SCCM 2009: Sepsis Management "Bundles" Boost Guideline Implementation, Reduce Mortality
15,022 Patients

7% Absolute Risk Reduction 19% Relative Risk Reduction

Society of Critical Care Medicine (SCCM) 38th Critical Care Congress. Late breaker. Presented February 2, 2009

SUMMARY: SEPSIS GUIDELINES 2008


Strong Recommendation (1): Recommended
A
DVT Prophylaxis H2 Blocker PUD Prophylaxis No Routine Use of SGC No Renal Dose Dopamine No High Dose Steroids

B
Antibiotics within 1 hr for Septic Shock Glycemic Control Crystalloid = Colloid PPI PUD Prophylaxis Low VT for ALI HOB >45 Limited Transfusion No Antithrombin II No Erythropoietin Intermittent = Continuous sedation
Weaning Protocol/SBT

C
EGDT and Protocolized Resuscitation

D
Antibiotics within 1 hr in No septic Shock Patients 7-10 day Antibiotic Duration Consider Limiting Support

Fluid Challenge BC prior to Abx Source Control Dopamine or Norepinephrine Limit P plateau <30 cm H2O PEEP De-escalation Antibiotic Therapy Conservative Fluid in ALI with no Shock

Avoid NMB

SUMMARY: SEPSIS GUIDELINES 2008


Weak Recommendation (2): Suggested
A B
APC in high risk and non-surgical equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis NIV for ALI/ARDS mild/moderate hypoxemia

C
PRBCs or Dobutamine APC for high risk and surgical

D
Wean Steroids

Low dose steroids for septic shock


ACTH test not to be done

B/S < 150


Prone Position in ARDS

Therapy Across the Sepsis Continuum


Infection SIRS Sepsis Severe Sepsis Septic Shock

Steroids

Drotrecogin Alpha

Early Goal Directed Therapy


Antibiotics and Source Control Insulin and Tight Glucose Control
Chest 1992;101:1644

Therapy Across the Sepsis Continuum


Infection SIRS Sepsis Severe Sepsis Septic Shock
CVP > 8-12 mm Hg MAP > 65 mm Hg Urine Output > 0.5 ml/kg/hr ScvO2 > 70% SaO2 > 93% Hct > 30%

* Early Goal Directed Therapy


Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand: Fluids, Blood, and Inotropes
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001;345:1368.

Rivers E, Nguyen B, Havstad S, et al 2001;345:1368-1377.

Early Goal-Directed Therapy Results: 28 Day Mortality


60 50 40
Mortality %

49.2%

P = 0.01*
33.3%

Vascular Collapse 21% vs 10%


p=0.02

30
20 10 0
Standard Therapy N=133 EGDT N=130

MODS 22% vs 16%


P=0.27

*Key difference was in sudden CV collapse, not MODS

NEJM 2001;345:1368-77.

The Importance of Early Goal-Directed Therapy for Sepsis-induced Hypoperfusion


NNT to prevent 1 event (death) = 6 - 8
60 50

Standard therapy EGDT

Mortality (%)

40

30
20 10 0

In-hospital mortality (all patients)

28-day mortality

60-day mortality

Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

If venous O2 saturation target not achieved: (2C)


Consider further fluid Tansfuse packed red blood cells if required to

hematocrit of 30% and/or Dobutamine infusion max 20 g.kg1 .min1

Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

SIRS Screen
First section screens for SIRS SIRS includes objective vital signs data:
Temperature 100.4 or 96.8 F Heart Rate 90 Respiratory Rate 20 WBC count 12,000 or 4,000, or greater than 0.5K/uL bands

If the patient has 2 or more of the above, they screen positive for SIRS

Infection Screen
Second section screens for infection The patient is screened for infection if they have SIRS Does the patient have suspected or documented infection? Has the patient received antibiotics (not prophylaxis)? If one of the above is confirmed, the patient is screened for organ dysfunction

Severe Sepsis Screen


Third section screens for Organ Dysfunction Respiratory: SaO2 < 90 % Cardiovascular: SBP < 90 Renal: urine output < 0.5ml/hr; creatinine increase > 0.5mg/dl from baseline CNS: altered LOC, Glascow coma scale 5 Any one of the above, in addition to positive

results from sections 1 and 2, indicates severe sepsis.

SBAR
The RN should approache the MD, informing him using SBAR technique, that the patient has screened positive for severe sepsis.

SBAR Communication Technique


Situation: RN caring for John Smith Screened positive for severe sepsis

Background: Positive for SIRS (describe) Known or suspected infection Organ dysfunction (describe)
Assessment: Share complete VS and SaO2

SBAR Communication Technique


Recommendation:
I

need you to come and evaluate the patient to confirm if they have severe sepsis. It is recommended that I get an ABG, lactate, and CBC, Can I proceed and get these? Any other labs you would like me to obtain? If the pt is hypotensive: Can I start an IV and give a bolus of NS 20 ml/kg?

Resuscitation Goals (Grade 1C)


Central venous pressure (CVP): 812mm Hg Mean arterial pressure (MAP) 65mm Hg Urine output 0.5mL.kg1.hr 1 Central venous (superior vena cava) or

mixed Venous oxygen saturation 70% or 65%, respectively Hemoglobin >10 mg/dL

Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

Resuscitation Goals (Grade 1C)


Tekanan Vena Sentral (TVS) : 8-12 mmHg Mean arterial pressure (MAP) 65mm Hg Produksi urin 0.5mL.kg1.hr 1 Central venous (superior vena cava) atau

mixed Venous oxygen saturation 70% or 65% Hemoglobin >10 mg/dL

Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

Initiation of Resuscitation (1C)


Begin resuscitation immediately in

patients with CVP < 8, hypotension or elevated serum lactate >4mmol/l; Do not delay pending ICU admission.

Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

CVP <8 mmHg


Central line placement and CVP

monitoring 500 mL 0.9% NaCl bolus every 15 minutes to maintain a CVP goal Colloids if CVP <4 Transfuse 1 unit of PRBCs if Hg <10

A higher target CVP of 1215 mmHg is recommended in the presence of


Mechanical ventilation Pre-existing decreased ventricular

compliance Increased intra-abdominal pressure

MAP <65 mmHg


Arterial line placement Norepinephrine 2-20 mcg/min

Vasopressin 0.04 Unit/min


Phenylephrine 40-200 mcg/min

Hydrocortisone 50 mg IV every 6

hours

ScvO2 <70%
Arterial line placement

Transfuse 1 PRBCs if Hg level <10 mg/dL


Start Dobutamine 2.5-20 mcg/kg/min IV

infusion Intubation and ventilation

Critical Care is A Promise


If you are admitted to our ICU with severe sepsis we will:


Obtain blood cultures and lactic acid level Start antibiotics within one hour Target a central venous pressure target to 8

mmHg Target a mean arterial blood pressure target of 65 mmHg Target a central venous O2 saturation of 70% Target your urine output to >0.5 mL/Kg/Hour

Thank You