Surviving sepsis
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Crit Care Med 2004; 32: 858-73. Intensive Care Med 2004 ; 30 : 536. “Surviving Sepsis” . Barcelona declaration (ESICM congress, 2002) Surviving Sepsis Campaign Guidelines (CCM & ICM, 2004) SSC guidelines Version 2 . Potential conflicts of interest.

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Surviving sepsis

Crit Care Med 2004; 32: 858-73.

Intensive Care Med 2004 ; 30 : 536.

“Surviving Sepsis”

  • Barcelona declaration (ESICM congress, 2002)

  • Surviving Sepsis Campaign Guidelines (CCM & ICM, 2004)

  • SSC guidelines Version 2

C. Brun-Buisson


Potential conflicts of interest

Potential conflicts of interest

« The challenges involved in producing first-rate guidelines and performance standards are only exacerbated by the intrusion of marketing strategies masquerading as evidence-based medicine. »

C. Brun-Buisson


Population adjusted incidence of sepsis usa 1979 2000

240

83

Population-adjusted Incidence of Sepsis, USA, 1979-2000

Severe Sepsis: 34%

France: Choc septique 9%

Severe Sepsis: 34%

G.Martin et al, NEJM 2003; 348: 1546-54.

C. Brun-Buisson


Surviving sepsis1

Recommandations SFAR – SRLF 2006

“Surviving Sepsis”?

1. Identification & initial assessment


Sirs and organ dysfunction criteria

SIRS: Conventional criteria

Fever / hypothermia

Tachypnea

Tachycardia

Leukocytosis / leukopenia

Others

Biomarkers:

Elevated PCT, ..

SIRS and Organ Dysfunction Criteria

  • Organ dysfunctions

  • lactates > 4 mmol/l

  • - SBP < 90 mm Hg

  • - PaO2/FiO2 < 300

  • - Oliguria, creatinine > 176 mmol/L

  • - INR > 1,5 / PT > 60 sec

  • - thrombocytopenia < 100 000/mm3

  • bilirubin > 34 µmol/l

  • Glasgow coma score ≤ 13

But < 50% of patients with SIRS have documented infection

C. Brun-Buisson


Infection sepsis initial assessment

Tachycardia

Tachypnea

Arterial pressure

Urine output

Fever or

hypothermia

Skin perfusion

Lactate

Neurologic status

Sev Sepsis?

Hematology

And coagulation

Biochemistry

Initial assessment (H0-H3)

Infection/Sepsis: Initial assessment

Evaluation

of

sepsis

Recommandations SFAR – SRLF 2006

C. Brun-Buisson


Algorithm for disposition of patients in ed

Clinical

Hypoperfusion

?

Acute care area

Maintain non-invasive

monitoring + urine output

mAP <65 ?

No

No

YESI

Lactate >4 ?

mAP < 65 ?

Urine < 0,5

ml/kg/h ?

YES

No

YES

YES

Comorbidity ?

YES

No

Etiology at risk ?

YES

No

YES

YES

Suspected

Severe Sepsis

Algorithm for disposition of patients in ED

  • Monitoring HR, RR, AP, Urine

  • Oxygen to SpO2>95%

  • Biochemistry (lactate) & microbiology

  • Cristalloids (500 ml/15 min) to mAP >65

  • Call referent intensivist

Organ failure?

No

YES

ICU Admission

Recommandations SFAR – SRLF 2006

C. Brun-Buisson


Infection severe sepsis initial steps

Re-assessment of

organ dysfunctions

Antibiotics

Blood cultures

+ site samples

Fluid Challenge

Source Control:

Drainage?

Surgery?

Imaging?

Infection/Severe Sepsis: initial steps

Sev Sepsis ?

0 – 3 hrs

Recommandations SFAR – SRLF 2006

C. Brun-Buisson


Surviving sepsis campaign

“Surviving Sepsis Campaign”

2. Recommendations and Guideline Revision (2006-07)

Sponsored exclusively by supporting societies


Impact on survival of early antibiotic administration

Impact on survival of early antibiotic administration

Kumar et al, Crit Care Med 2006; 34: 1589-96

C. Brun-Buisson


Surviving sepsis

C. Brun-Buisson


E rivers 2001 egt

E. Rivers, 2001 - EGT

C. Brun-Buisson


Egt mortality rates

*

*

*

EGT – Mortality rates

RR = 0.58 0.58 0.67

P = 0.01 0.01 0.03

E. Rivers et al, NEJM 2001

C. Brun-Buisson


Egt volume of fluid infused

EGT - Volume of fluid infused

* P<0.01

*

*

E. Rivers et al, NEJM 2001

C. Brun-Buisson


Surviving sepsis

Fluid Therapy

  • We recommend fluid resuscitation with either natural/artificial colloids or crystalloids.

  • There is no evidence-based support for one type of fluid over another.1B

Supportive Care: Glucose Control

  • Recommend glucose control with intravenous insulin after initial stabilization 1B

  • Suggested glucose target:

    • Normal and < 150 mg/dL 2C

C. Brun-Buisson


Surviving sepsis

C. Brun-Buisson


Potential conflicts of interest1

Potential conflicts of interest

Pour un moratoire sur l’utilisation des hydroxyéthylamidons

L. Brochard1, F. Schortgen1, C. Brun-Buisson1, D. Dreyfuss2, J.-J. Rouby3, J. Chastre4, D. Robert5, G. Hilbert6, D. Payen7, E. L’Her8, C. Richard9, M. Gainnier10, J. Pugin11,

J.-C. M. Richard12.

Conclusion

Les données dont nous disposons actuellement suggèrent fortement que la balance entre les bénéfices attendus et les risques observés avec l’administration des hydroxyéthylamidons est défavorable. Dans ces conditions, il ne parait pas justifié de continuer à utiliser ces produits pour le remplissage vasculaire en réanimation, alors que des alternatives moins toxiques (et moins coûteuses) sont disponibles. Il ne s’agit pas à notre sens d’une querelle d’experts, et nous suggérons à titre protecteur qu’un moratoire soit mis en place sur l’utilisation des hydroxyéthylamidons dans le remplissage vasculaire chez les patients de réanimation, dans l’attente de nouveaux essais démontrant de manière convaincante leur avantage et leur innocuité.

C. Brun-Buisson


Vasopressors

Vasopressors

  • We recommend either norepinephrine or dopamine as the first choice vasopressor agent to correct hypotension in septic shock (administered through a central catheter as soon as one is available) (1C)

  • We suggest that epinephrine, phenylephrine, or vasopressin should not be administered as the initial vasopressor in septic shock (2C).

C. Brun-Buisson


Ssc objectives for the first 6 hours

SSC: Objectives for the first 6 hours

  • Mesure arterial lactate level

  • Obtain blood cultures before administering antibiotics

  • Prescribe within 3 (1) hrs broad-spectrum empiric antibiotic therapy

  • If hypotension (PAS < 90 mmHg or mAP < 70mmHg) or hyperlactatemia (lactate > 4 mmol/l) :

    • Start fluid loading with cristalloïds (or equivalent colloïd) 20-40 ml /kg estimated ideal body weight.

    • Administer vasopressors to maintain mAP ≥ 65 mmHg, if persisting hypotension despite adequate fluid loading.

C. Brun-Buisson


Ssc objectives for the first 6 hours1

SSC: Objectives for the first 6 hours

  • If persisting hypotension or hyperlactatemia (> 4 mmol/l) despite initial fluid loading, measure PVC and ScvO2 (or SvO2), and:

    • Maintain CVP at 8 - 12 mmHg.

    • Consider inotropic therapy and/or RBC transfusion if hematocrit is ≤ 30 % when ScvO2 is < 70 %, or SvO2 < 65 % and CVP ≥ 8 mmHg. (2B)

Recommandations SFAR – SRLF 2006

C. Brun-Buisson


Low dose steroids 28 d survival

Responders

Low-dose Steroids: 28 d survival

Non-Responders

HR = 0.67

p=0.023

D. Annane & al, JAMA 2002;288: 862-871.

C. Brun-Buisson


Surviving sepsis

Low-dose Steroids

  • We suggest intravenous hydrocortisone be given only to adult septic shock patients after blood pressure is identified to be poorly responsive to fluid resuscitation and vasopressor therapy

    2C

  • We recommend corticosteroids notbe administered for the treatment of sepsis in the absence of shock.

    1D

C. Brun-Buisson


Low dose steroids

Low-dose Steroids

ACTH stimulation test (250-g) not recommended (2B)

Variability in assay

Variability in response on same day

Free versus protein bound measurement

Fludrocortisone optional (2C)

Dexamethasone only if hydrocortisone not available (2B)


Surviving sepsis

C. Brun-Buisson


Recombinant human activated protein c rhapc

Recombinant HumanActivated Protein C (rhAPC)

  • Suggest usein patients withclinical assessment of high risk of death due to sepsis induced organ dysfunction, typically with APACHE II ≥25 or multiple organ failure (2B)

    • And no absolute contraindications

    • Weighing the risk/benefit of relative contraindications

  • We recommend that adult patients with severe sepsis and low risk of death, most of whom will have APACHE II <20 or one organ failure, do not receive rhAPC (1A )

C. Brun-Buisson


Surviving sepsis2

Surviving Sepsis

3. Experience with implementation of the guidelines


Surviving sepsis

Probability of survival of patients with septic shock managed before or after (open circles) the implementation of standardized hospital order set

Micek S. Crit Care Med 2006; 34: 2707.

C. Brun-Buisson


Many leaks from research to practice

Aware Accept Target Doable Recall Agree Done

Valid

Research

Many “Leaks” from research to practice

If 80% achieved at each stage then0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21

C. Brun-Buisson


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