Transcript Sepsis Goal Directed Therapy

The New Paradigm:
Goal-Directed Therapy for
Severe Sepsis and Septic Shock
Jamie Cowan
April 25, 2006
Emergency Medicine Clerkship
Patient Scenario
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45 yo male
CC “Not feeling well”
Known alcoholic w/cirrhosis
Temp 96.2
BP 100/65
HR 100
RR 18
SIRS – System Inflammatory
Response Syndrome
• Criteria: 2 or more of the following
– Temp > 38C or < 36 C
– HR > 90
– RR > 20
– PaCO2 < 32
– WBC > 12,000 or < 4,000
– Bands > 10%
Patient History and Exam
• Patient looks ill
• Known alcoholic with acute/chronic pancreatitis
• Says he had an operation to remove dead
pancreas 7 days ago
• Started feeling bad 2 days ago, felt much worse
last night, developed N/V/D
• Complains of severe abdominal and back pain
Labs
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Na – 141
K – 4.2
Cl – 100
Cr – 1.8
Glucose – 191
WBC – 13 with 15% bands
Lactate 4.1
Definition Sepsis
• Sepsis
– SIRS + probable site of infection
• Severe Sepsis
– Organ Dysfunction (Oliguria, INR, Cr)
– Hypotension
– Hypoperfusion
• Delta MS
• Lactate
• Septic Shock
– Sepsis induced Hypotension with perfusion abnormalities despite fluid
resuscitation
• Multiple Organ System Failure (MOSF or MODS)
– Shock, ARDS, ARF, DIC, Liver Failure, Hyperglycemia
Sepsis Epidemiology
• Estimated 750,000 severe sepsis cases in USA per year
– 387,000 initially present to ED
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Mortality rate ranges from 23-46%
500 deaths per day
Estimated annual cost is $16.7 billion
Global estimates range from 51-206 cases per 100,000
Early Goal-Directed Therapy in the
Treatment of Severe Sepsis and
Septic Shock
NEJM, Nov 2001
Rivers EP et al.
• Please see the following tables and figures
from this article:
– Figure 2
– Table 2
– Table 3
– Table 4
• Pubmed link:
Rivers et al. Early goal-directed therapy in the treatment of severe
sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):136877. PMID: 11794169
Key points from article
• Goal-oriented therapy for sepsis
– Balancing oxygen therapy and demand by managing
preload, afterload, and contractility
– Primary focus of ICU management
– Study examined role of goal-oriented therapy in ED
setting and effects on mortality and organ dysfunction
• Goal directed therapy in the ED setting was
associated with:
– Decreased in-hospital mortality than standard therapy
(72 hour comparison)
– Less severe organ dysfunction (APACHE II scores)
Key points
• Fluid resuscitation
– Monitor MAP, CVP
– Tx = Crystalloid/colloid, vasopressors,
ionotropes
• Estimate total body ischemia
– Monitor lactate and SvO2
– Tx = PRBC transfusions