Transcript webcast slides - Dellinger

R. Phillip Dellinger, MD, MCCM, FCCP
Acting Chair & Chief of Department of Medicine
Head, Division of Critical Care Medicine
Cooper University Hospital
Camden, New Jersey
Professor of Medicine Cooper Medical School of
Rowan University
What’s new with the 2012
guidelines and
associated changes in the database
R. Phillip Dellinger MD, MCCM
Christa A. Schorr RN, MSN, FCCM
Cooper Medical School Rowan University
Cooper University Hospital
Camden, NJ
Potential Conflicts of Interest
• Neither has direct or indirect potential financial conflict of
interest as to any material presented in this presentation
• As to potential intellectual conflict of interest both hold
leadership positions in Surviving Sepsis Campaign
Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock: 2012
R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane,
Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung,
Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally,
Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus,
Clifford S. Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A.
Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving
Sepsis Campaign Guidelines Committee including the Pediatric Subgroup.
Crit Care Med 2013; 41:580-637
Intensive Care Medicine 2013; ..
Currently Funded with a Gordon and
Betty Moore Foundation Grant
No direct or indirect industry support for
guidelines revision
Grading Quality of Evidence
GRADE System
• A- high quality
• B- intermediate
• C- low
• D- very low
– Case series or expert opinion
• Upgrade capability
• Ungraded (UG) recommendation
Grading Strength of Recommendation
GRADE System
• 1- strong recommendation
– We recommend
• 2- weak recommendation
– We suggest
Early Screening and a Performance Improvement Program
Antibiotic Therapy
• We recommend that intravenous antibiotic
therapy be started as early as possible and within
the first hour of recognition of septic shock (1B)
and severe sepsis without septic shock (1C).
(Best Practice versus Stand of Care)
Resuscitation of Sepsis Induced
Tissue Hypoperfusion
• Recommend MAP 65 mm Hg
FLUID THERAPY
Fluid therapy
1. We recommend crystalloids be used in the
initial fluid resuscitation of severe sepsis
(Grade 1B).
Fluid therapy
1. We suggest the use of albumin in the fluid
resuscitation of severe sepsis and septic
shock when patients require substantial
amounts of crystalloids (Grade 2C).
Fluid challenge
Initial fluid challenge in sepsis-induced tissue
hypoperfusion (hypotension or elevated
lactate)
A minimum of 30ml/kg of crystalloids
(a portion of this may be albumin equivalent).
(1B)
Vasopressors
Vasopressors
1. We recommend norepinephrine as the first
choice vasopressor (Grade 1 B).
Vasopressors
2. We suggest epinephrine (added to and
potentially substituted for norepinephrine)
when an additional agent is needed to
maintain blood pressure (Grade 2B).
Vasopressors
3. Vasopressin .03 units/min can be added to
norepinephrine with the intent of raising
MAP to target or decreasing or decreasing
norepinephrine dosage.
(UG)
Phenylephrine
Pure vasopressor and in general not recommended
Sepsis Induced Tissue Hypoperfusion
(Recommend Quantitative
Resuscitation)
 Requirement for vasopressors after fluid
challenge
or
Lactate ≥ 4 mg/dL
Initial Resuscitation of Sepsis Induced Tissue
Hypoperfusion
Recommend
Insertion central venous catheter
• Central venous pressure: 8–12 mm Hg
• Higher with altered ventricular compliance or
increased intrathoracic pressure
Grade 1C
Arterial Systolic Pressure Variation
Parry-Jones, et al. Int J Respir Crit Care Med 2003;2:67
Effect on Stroke Volume
Part
A
t
Effect on Stroke Volume
Effect on Cardiac Filling
Initial Resuscitation of Sepsis Induced Tissue
Hypoperfusion
Recommend
Insertion central venous catheter
• ScvO2 saturation (SVC)  70%
Grade 1C
Lactate Clearance
In patients with elevated lactate levels as a
marker of tissue hypoperfusion we suggest
targeting resuscitation to normalize lactate as
rapidly as possible (grade 2C).