Transcript Surviving Sepsis Early Goal Directed Therapy 2008 Guidelines

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
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
Sepsis
Severe Sepsis Septic Shock
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
Severe
Sepsis
Infection
Sepsis
SIRS
Fungus
Shock
Trauma
BSI
Bacteria
Burns
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
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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
 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
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
B
DVT Prophylaxis
Antibiotics within 1 hr
for Septic Shock
EGDT and Protocolized
Resuscitation
Glycemic Control
Fluid Challenge
Crystalloid = Colloid
BC prior to Abx
PPI PUD Prophylaxis
Source Control
Low VT for ALI
Dopamine or
Norepinephrine
H2 Blocker PUD
Prophylaxis
No Routine Use
of SGC
No Renal Dose
Dopamine
No High Dose
Steroids
HOB >45
Limited Transfusion
No Antithrombin II
No Erythropoietin
Intermittent =
Continuous sedation
Weaning Protocol/SBT
Avoid NMB
C
Limit P plateau <30
cm H2O
PEEP
De-escalation
Antibiotic Therapy
Conservative Fluid in
ALI with no Shock
D
Antibiotics within 1
hr in No septic
Shock Patients
7-10 day Antibiotic
Duration
Consider Limiting
Support
SUMMARY: SEPSIS GUIDELINES 2008
Weak Recommendation (2): Suggested
A
B
C
D
APC in high risk
and non-surgical
PRBCs or
Dobutamine
Wean Steroids
equivalency
of continuous
veno-veno
hemofiltration
or intermittent
hemodialysis
APC for high risk
and surgical
NIV for ALI/ARDS
mild/moderate
hypoxemia
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
49.2%
Vascular
Collapse
P = 0.01*
40
Mortality %
33.3%
21% vs 10%
p=0.02
30
MODS
20
22% vs 16%
10
P=0.27
0
Standard Therapy
N=133
EGDT
N=130
*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
Mortality (%)
50
Standard therapy
EGDT
40
30
20
10
0
In-hospital
mortality
(all patients)
28-day
mortality
Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.
60-day
mortality
◦ 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 µg.kg−1 .min−1
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): 8–12mm Hg
 Mean arterial pressure (MAP) ≥ 65mm Hg
 Urine output ≥ 0.5mL.kg–1.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.
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 PRBC’s if Hg <10
A higher target CVP of 12–15 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 PRBC’s if Hg level <10 mg/dL
 Start Dobutamine 2.5-20 mcg/kg/min IV
infusion
 Intubation and ventilation
‫‪Critical Care is A Promise‬‬
‫ان هللا يحب العبد اذا عمل عمال أن يتقنه‬
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