Transcript Document

SIRS
Dr. Jonathan R. Goodall
M62 Coloproctology Course
31st March 2006
SIRS
SIRS
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Definitions
Recognising the patient with SIRS
Management of the patient with
SIRS
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Activated Protein C
Use of Steroids
Glucose Control
S pring
Is
R eluctantly
tarting
S
to happen
S omething
I ntrinsically
R elated to
epsis
S
S omething
I ntensivists
R eliably
mug about
S
are
Syndrome
I nstictively
ecognised by
R
urgeons
S
S omething
I nfrequently
ecognised by
R
HOs
S
Definitions
 Systemic
Inflammatory
Response Syndrome (SIRS)
 Severe Sepsis
 Septic Shock
 Refractory Shock
Definitions
 SIRS:
2 or more of:
Temperature > 38°C or < 36°C
 Heart rate > 90 bpm
 Resp rate > 20 breaths.min -1 or
PaCO2 < 4.3kPa (32mmg)
 WBCs > 12 or < 4 (or >10%
immature forms)
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Definitions
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Sepsis
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Severe Sepsis
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= SIRS with documented infection site
Sepsis + organ dysfunction,
hypoperfusion or hypotension
Septic Shock
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Severe sepsis (SBP < 90mmHg)
despite adequate fluid resuscitation
Crit Care Med 2004 Vol. 32 No 3
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Experts from 11 international
organisations (2003)
Management guidelines that would
be of practical use for the bedside
clinician
International effort to increase
awareness & improve outcome…
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
Key Recommendations
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Recommendations on groups of
treatments
Total consensus reached on all but
two of recommendations
Most of recommendations are not
supported by ‘high-level’ evidence
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
A. Initial Resuscitation
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Resuscitation should begin as soon as
condition is recognised
In first 6 hours should include all of the
following:
CVP 8-12mmHg
 MAP > 65mmHg
 UO > 0.5ml.kg-1.hr-1
 CvO2 > 70%
Grade B: Early Goal Directed Therapy in the
Treatment of Severe Sepsis. Rivers et al NEJM
2001; 345:1368-77
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Dellinger et al, Crit Care Med 2004 Vol 32, No 3
B. Diagnosis
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Appropriate cultures should always
be obtained before antimicrobial
therapy
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At least 2 blood cultures
One from each IV device >48 hours old
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Other cultures as appropriate
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Grade D/E
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
C. Antibiotic Therapy
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Appropriate antimicrobial therapy
should be started within 1 hour of
onset Grade E
Initial empirical therapy Grade D
Focussed after 48-72 hours
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? Monotherapy
7-10 day course Grade E
Stop if non-infective cause found
Grade E
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
D. Source control
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Evaluate all patients for the presence of a
focus of infection amenable to ‘source
control measures’ (SCM) (Grade E)
Method of SCM must weigh benefits &
risks (Grade E)
Once a source of infection identified, SCM
should be instituted as soon as possible
(Grade E)
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IV access devices should be removed
promptly (Grade E)
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
E. Fluid Therapy
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Fluid resuscitation may consist of
natural or artificial colloids or
crystalloids. There is no evidencebased support for one type of fluid
over another.
Rates:
500-1000ml crystalloids over 30 mins
 300-500ml colloids over 30 mins
Grade C
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Dellinger et al, Crit Care Med 2004 Vol 32, No 3
F & G Vasopressors & Inotropes
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Use when appropriate fluid
resuscitation fails to restore
adequate MAP
Noradrenaline or dopamine ±
dobutamine (Grade D)
Low-dose (renal) dopamine should
not be used. (Grade B) Bellomo et al
Lancet 2000: 356:2139-2143
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
H. Steroids
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IV hydrocortisone (200-300mg/day)
should be used for 7 days in
patients requiring vasopressor
therapy (Grade C)
> 300mg/day should not be used
Steroids should not be for the
treatment of sepsis in the absence
of shock (Grade E)
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
I. Activated Protein C
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Recommended in patients at high
risk of death without
contraindications (Grade B) Bernard
GR et al, N Engl J Med 2001;344:699709
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
Activated Protein C - properties
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Anticoagulant
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Pro-fibrinolytic
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Degrades factor Va & VIIIa thereby
inhibiting generation of thrombin
Promoted fibrinolysis by inhibiting
plasminogen activator inhibitor
Anti-inflammatory
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Direct effects on endothelium and
neutrophils
PROWESS Study Group
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1690 patients with sepsis enrolled
Mortality rate 30.8% in placebo
group vs 24.7% in APC group
Relative risk of death reduction
19%; absolute risk reduction 6%
(P=0.005)
Increased incidence serious
bleeding (3.5 vs 2 %)
Bernard GR et al, N Engl J Med 2001;344:699-709
M. Glucose Control
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Following initial stablisation
maintain blood glucose < 8.3
mmol/l
(Grade B) Intensive Insulin Therapy in
Critically Ill Patients. van den Berghe et al
N Engl J Med 2001;345:1359
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
Intensive Insulin Therapy
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1548 patients admitted to ICU
Intensive Treatment Group
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Insulin started if glucose > 6.1 mmol.l-1
Glucose controlled 4.4 - 6.1 mmol.l-1
Conventional Treatment Group
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Insulin started if glucose > 12 mmol.l-1
Glucose controlled 10.0 – 11.1mmol.l-1
van den Berghe NEJM 2001;345:1359
Intensive Insulin Therapy
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Mortality Rates
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Treatment Group
Conventional Group
4.6%
8.0%
Unbiased risk reduction 32%
Also reduced incidence of
complications (eg septicaemia,
acute renal failure)
van den Berghe NEJM 2001;345:1359
M. Glucose Control
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…There is no reason to think these
data are not generalisable to all
severely septic patients…
Intensive Insulin Therapy in the
Medical ICU. van den Berghe et al N Eng J
Med 2006; 354: 449-461
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
P. DVT Prophylaxis
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Use unfractionated or LMW heparin
For patients with contraindication to
heparin, use of a mechanical
prophylactic device is recommended
In very high risk patients, use both
pharmacological and mechanical
prophylaxis
Grade A
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
Q. Stress Ulcer Prophylaxis
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H2 receptor antagonsists are more
efficacious than sucralfate and are
the preferred agents
Proton pump inhibitors have not
been assessed in a direct
comparison to H2 receptor
antagonsists, and their relative
efficacy is not known.
Grade A
Dellinger et al, Crit Care Med 2004 Vol 32, No 3
Summary
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SIRS is very common
SIRS is a difficult problem
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It is a complex disease
It is not easy to recognise
Steroids probably useful
APC is useful
Tight glucose control is useful (in
surgical patients)
www.survivingsepsis.org