Transcript lecture in ppsx

All of
them died
secondary
to sepsis
Pope John-Paul II
Mariana Bridi Costa,
Brazilian model
Etta James, singer
Curtis J. Merritt D.O.
Chief Internal Medicine Resident
Danville Regional Medical Center
Danville Virginia
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With that in mind the
single goal of this
presentation is to
demonstrate a stepwise
approach to make sepsis
practical
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Primary Care Providers
Hospitalists
Medical Students
Residents
Hospital Administrators
Specialists
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No pertinent financial disclosures
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A brief review of the last 12 years…
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Annual cost = $16.7 billion in the US in 2000
1,400 people die each day from sepsis
Roughly 2 million cases per year
30% dying within one month of diagnosis
80% of patients who die from major injuries are
actually killed by sepsis
Survivingsepsis.org
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12 years ago Dr. Emanuel Rivers published in
the NEJM an article that would change our
approach to sepsis
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In that study, Dr. Rivers and colleagues proved
that early recognition and aggressive treatment
of severe sepsis and septic shock resulted in a
16% reduction in absolute mortality.
That translates to NNT = 6 - 8
N Engl J Med 2001; 345:1368-1377: November 8, 2001
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We have to be willing to evolve with the
evidence based medicine and be able to look at
it critically
We have to be open to the idea of aggressive
management
We have to put away our old notions of the
“look” of sepsis
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2.
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We have to be willing to evolve with the
evidence based medicine and be able to look at
it critically
We have to be open to the idea of aggressive
management
We have to put away our old notions of the
“look” of sepsis
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Many physicians do not use the current definition
of sepsis despite attempts to standardize
terminology and diagnostic criteria. Indeed, only
17% of clinicians agree on a definition of sepsis
(12), and this disparity results in missed diagnosis
and delayed treatment. The challenges include:
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Lack of awareness of frequency and mortality rate of
sepsis
No universally accepted definition of sepsis
No single or combination of tests or markers for a reliable
diagnosis of sepsis
Need for earlier diagnosis and treatment of septic patients
Lack of adequate healthcare professional training in the
diagnosis and treatment of sepsis
*http://www.survivingsepsis.org/Background/Pages/barcelona_declaration.aspx
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To understand the definition we have to
understand the process
The River…
What do you notice about the
river?
-fast
-churning
-high rate of aeration
-large volume in a confined
space
-faces of horror
This river is very similar to normal
physiology
-fast turn over
-adequate O2
-adequate volume
Now picture that same volume in that river
after the rock walls have been removed and
the width of the channel is much larger
Much like a
stagnant swamp
Now that same volume is moving through a
much larger area
So…
What happens to flow?
What happens to O2 content?
What happens to the fish?
In sepsis, toxins and cytokines produce a
profound vasodialation and the venous side
of the circulator system experiences a lowflow, low O2 state
But that’s not the whole story…
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Used to visualize sublingual microcirculation
Normal
No embolisms
Flow speed is
adequate that
individual
RBCs can’t be
seen
Normal vessel
caliber
Rev. bras. ter. intensiva vol.23 no.3 São Paulo July/Sept. 2011
Septic Shock
Rev. bras. ter. intensiva vol.23 no.3 São Paulo July/Sept. 2011
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Microthrombi
Stagnant flow
Small caliber
Rev. bras. ter. intensiva vol.23 no.3 São Paulo July/Sept. 2011
This is why
peripheral
hypoxia (i.e. SvO2)
can continue
despite normal
vitals, CVP etc.
Rev. bras. ter. intensiva vol.23 no.3 São Paulo July/Sept. 2011
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We have to put our old definitions of sepsis
away
We have to realize that sepsis is often difficult
to diagnose without a stepwise approach
Systemic Inflammatory Response Syndrome (SIRS) with 2 of the following:
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Temp:
>38 C (100.4 F)
<36 C (96.8 F)
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Heart Rate:
>90 beats/min
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Resp Rate:
>20 breaths/min
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PCO2:
<32 mmHg
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WBC:
>12,000
<4,000
>10% Bands
N Engl J Med 2001; 345:1368-1377 November 8, 2001
SIRS
T: >100.4 F
< 96.8 F
RR: >20
HR: >90
WBC: >12,000
<4,000
>10% bands
PCO2 < 32 mmHg
2 SIRS
CRITERIA
+
An infection
or
suspected
infection
SEPSIS
SIRS
T: >100.4 F
< 96.8 F
RR: >20
HR: >90
WBC: >12,000
<4,000
>10% bands
PCO2 < 32 mmHg
2 SIRS
+
Confirmed
or suspected
infection
Hypotension
(Systolic BP <90)
Sepsis
Syndrome
+
Lactate >4
End Organ Damage
Hypotension
(Systolic BP <90)
Sepsis
Syndrome
+
Lactate >4
End Organ Damage
SEPSIS
SIRS
T: >100.4 F
< 96.8 F
RR: >20
HR: >90
WBC: >12,000
<4,000
>10% bands
PCO2 < 32 mmHg
2 SIRS
+
Confirmed
or suspected
infection
SEVERE
SEPSIS
Sepsis +
Signs of End
Organ Damage
Hypotension
(SBP <90)
Lactate >4 mmol
Persistent
Hypotension
(Systolic BP <90)
SEVERE
SEPSIS
+
Lactate >4
End Organ Damage
Refractory to IVF
Challenge
SEPSIS
SIRS
T: >100.4 F
< 96.8 F
RR: >20
HR: >90
WBC: >12,000
<4,000
>10% bands
PCO2 < 32 mmHg
2 SIRS
+
Confirmed
or suspected
infection
SEVERE
SEPSIS
Sepsis +
Signs of End
Organ Damage
Hypotension
(SBP <90)
Lactate >4 mmol
SEPTIC
SHOCK
Severe Sepsis
with persistent:
Hypotension
Signs of End
Organ Damage
Lactate >4 mmol
Jimmy is a 45 year old gentleman who presents to
the local urgent care with a complaint of cough
It began 4 days ago, steadily has worsened,
producing thick green/yellow sputum
He complains of subjective fevers and chills and a
general feeling of un-wellness
PMHx
Jimmy is a smoker of 10 years ½ ppd
Denies alcohol or drug use
No past medical history
No surgeries
He takes no medications
He is evaluated by a moonlighting resident
Vital Signs
BP: 109/89
HR: 101
Temp: 102.1
RR: 16
SpO2 98%
Physical exam of the right lung base reveals rhonchi
but is otherwise unremarkable
Chest X-ray demonstrates:
His lab work at the urgent care is:
Na
K
Cl
CO2
BUN
Cr
Glucose
140
4.0
107
11
27
2.1
152
(135-148 mEq/L)
(3.5-5.3 mEq/L)
(95-108 mEq/L)
(25-35 mEq/L)
(6-19 mEq/L)
(0.7-1.5 mg/dL)
(70-105 mg/dL)
He is sent home with a diagnosis of:
Right Lower Lobe Pneumonia
Dehydration
Cough
He is prescribed moxifloxacin 400 mg daily x 7
days and told to drink plenty of fluids
He arrives at the hospital 8 hours later
unresponsive
Vital Signs
BP: 80/61
HR: 115
Temp: 102.0
RR: 30
SpO2 81% on 15L NRB
Within 30 mins of arriving:
He has been intubated
He has a central line
He has an arterial line
He has been cultured (U/B/S) and labs drawn
He has started to receive:
3.375 gm of pipercillian/tazobactam
1.25 gm of vancomycin
Within 2 hours:
3 liters of normal saline
1 liter in the ambulance
2 liters (500 cc every 30 mins)
Vital Signs
BP: 105/72
HR: 101
Temp: 99.9
RR: 16 (on vent)
SpO2 97% FIO2 of 80%
He is stabilized in the ED and transferred to the
ICU for further care
Throughout his 6 day stay in the hospital, Jimmy
suffers from acute renal failure, persistent
hypoxemia, and an NSTEMI
He is discharged home with home health services
and eventually makes a full recovery
Question:
When was Jimmy Septic?
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Remembering our steps…
SEPSIS
SIRS
T: >100.4 F
< 96.8 F
RR: >20
HR: >90
WBC: >12,000
<4,000
>10% bands
PCO2 < 32 mmHg
2 SIRS
+
Confirmed
or suspected
infection
SEVERE
SEPSIS
Sepsis +
Signs of End
Organ Damage
Hypotension
(SBP <90)
Lactate >4 mmol
SEPTIC
SHOCK
Severe Sepsis
with persistent:
Hypotension
Signs of End
Organ Damage
Lactate >4 mmol
Question:
When was Jimmy septic?
Answer:
At urgent care.
Barcelona, Spain
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6 Hour Bundle
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
24 Hour Bundle
 Glucose control maintained < 150
mg/dL
 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
http://www.ihi.org
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But what does that mean for us practically
when we see a patient presumed to be sick
from an infection?
VITAL
SIGNS
THROUGH
THE LENS
OF SIRS
CRITERIA
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Sepsis with end organ damage, hypotension or
lactate > 4
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Central Line
Arterial Line
Early Intubation
Labs (ACC CLUE)
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ABG
 CMP/CBC/Coags
 CXR/Cardiac Enzymes
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Cultures (B/U/S)
 Lactate
 UA
 EKG
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Remembering that…
Are all physical
exam signs of end
organ damage
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6 Hour Bundle
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
24 Hour Bundle
 Glucose control maintained < 150
mg/dL
 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
http://www.ihi.org
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Broad spectrum antibiotics covering the
organisms that affect the infected area
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But how much do you give?
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Here is where the central venous catheter
comes into play
Recommendation
is 500 cc bolus of
normal saline
every 30 mins
until you reach a
CVP of 8-12
Vasopressors
Norepinephrine vs Dopamine
Neither has shown replicable
superiority
Either may be first line agent of
choice
When to use?
Then check
SVO2
And if < 70%
transfuse to a
HCT 30%
And if still <70%
add dobutamine
to increase
cardiac output
Steroids intially showed a 10%
decrease in mortality
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CORTICUS had patients whose mortality
was 30-40% vs the JAMA article which
had mortality 56%
In addition, a subset analysis showed that
patient with a similar severity level to the
original trial in JAMA had a similar 10%
outcome benefit.
Conclusion: If a patient is adequately volume
resuscitated and isn’t on pressors, they don’t need
steroids
Steroids should be withheld for 6-8 hours until
you can gauge adequately whether the patient is
volume replete or not
What do these all
have in common?
CHEST September 2010 vol. 138 no. 3 476-480
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In a recent multicenter preimplementation
(n = 1,554) and postimplementation (n = 4,801)
study, hospital length of stay was reduced by
5.02 days, and hospital charges were $47,923
less between groups (P < .0001).
A hospital seeing 250 patients per year can
realize a cost savings of > $11.98 million per
year and an average decrease in hospital length
of stay of 5 days or 1,250 bed days saved per
year by implementing EGDT.
CHEST September 2010 vol. 138 no. 3 476-480
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Should we adhere to EGDT, and does it
matter? Yes. The real question is why we are
continuing to accept the old paradigm because
by doing so, we not only are depriving our
patients of the best and most cost-efficient care
but also are accepting death as an alternative.
CHEST September 2010 vol. 138 no. 3 476-480
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