Surviving Sepsis THE 6 GOLDEN HOURS

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Surviving Sepsis. 1,400 people die each day from sepsis w/ over

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Surviving Sepsis THE 6 GOLDEN HOURS

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1. AUTUMN Caycedo, MD MAJ(p), MC Ft. Benning, GA Surviving Sepsis THE 6 GOLDEN HOURS

2. Surviving Sepsis 1,400 people die each day from sepsis w/ over million lives lost each year We have the technology and resources today to treat most conditions and injuries yet infection, which has been killing people since history began, still defeats us,--- Prof Graham Ramsay, ESICM President. Mortality from severe sepsis is 30-50% (50-60% if in shock)

3. Surviving Sepsis Surviving Sepsis Guidelines were initiated by the Society of Critical Care Medicine, the European Society of Intensive Care Medicine, and the International Sepsis Forum to improve the care of septic patients prior to transfer to an intensivist So do these guidelines work?

4. Surviving Sepsis Implementation of the Surviving Sepsis Campaign guidelines has been shown to: Decrease the Mortality rate by up to 50% Decrease the length of hospital stay by 30% Decrease the development of ARDS by 60% and Decrease renal failure by 22% Aggressive intervention in the 1st 6 hours of sepsis saves lives!!

5. Goals Be able to recite the targets for fluid resuscitation within the first 6 hours of sepsis Dispel the myth of LevophedLeave them dead! Have the tools to implement these guidelines at your hospital

6. Outline Initial resuscitation Vasopressors Steroids Recombinant human activated protein C Blood products Mechanical Ventilation Glucose control Prophylaxis Interactive Summary

7. Initial Resuscitation Resuscitate in ED for hypotension or Lactate >4 or Shock index >1.2 (HR/SBP) May require over 6L of NS, can also use Hespan x2 doses--- FLUIDS, FLUIDS, FLUIDS, and WARM FLUIDS Central line and A-line need to be placed ASAP Resuscitation Goals: CVP 8-12 (12-15 if on vent), MAP>65, UOP 0.5cc/kg/hr, SVO2 >70%

8. Initial Resuscitation Blood cultures and urine culture (sputum culture not necessary initially) Antibiotics w/in 1 hourstart broad, de-escalate when susceptibilities return, continue IV antibiotics for 7- 10 days Beta-lactam-aminoglycoside no advantage over beta-lactam monotherapy and increases risk of AKI on Cochrane Systemic review Imaging studies based on chief complaint

9. Vasopressors Start Norepinephrine if MAP<65 and unresponsive to fluid resuscitation Can add vasopressin 0.03 units/min to norepinephrine Epinephrine can be used as a first line alternative when BP is unresponsive to norepinephrine Dobutamine can be used in pts w/ low cardiac outputcan also help increase SVO2 (dose 20mcg/kg/min)

10. Remember No more Levophed---Leave them Dead! Instead: Norepi--- Leave them Peppy!

11. Dont Forget! Resuscitation Goals: CVP 8-12 (12-15 if on vent), MAP>65, UOP 0.5cc/kg/hr, SVO2 >70%

12. Steroids Use steroids if poorly responsive to fluid and vasopressor There is sufficient evidence to support using low dose corticosteroids in patients with septic shock based on Cochrane Database Review Hydrocortisone (50mg IV Q6h) is preferred to dexamethasone Stop steroids once vasopressors are weaned Steroids can decrease the use of Vasopressors from 7 days to 3 days ACTH stimulation test not necessary

13. Dont Forget! Resuscitation Goals: CVP 8-12 (12-15 if on vent), MAP>65, UOP 0.5cc/kg/hr, SVO2 >70%

14. Recombinant human activated protein C Consider if multisystem organ failure, high risk of death, APACHE II score >25- need to talk with an intensivist High Risk of bleeding- do not give if pt will need major surgery (can give 12hrs after surgery), do not give if plt count <30,000, do not give if pt was on coumadin w/in 7 days, do not give if PT >30 percent Can stop 2hrs before minimally invasive procedure and resume 2hrs after the procedure

15. Blood Products Transfuse for Hgb <7 w/ goal of 7-9, in the 1st 6hrs can transfuse to keep Hct >30% if SVO2 is <70 Do not use FFP unless active bleeding Administer plts if count is <5,000 regardless of bleeding Administer plts if count is <30,000 and bleeding Do not use erythropoietin or antithrombin therapy

16. Dont Forget! Resuscitation Goals: CVP 8-12 (12-15 if on vent), MAP>65, UOP 0.5cc/kg/hr, SVO2 >70% Low dose Atrial natriuretic peptide has been shown on Cochrane Database Systemic Review to increase urine production, decrease need for dialysis, and decrease LOS

17. Mechanical Ventilation in ARDS Low target tidal volumes- Start at 8cc/kg then decrease to 6cc/kg of predicted body wt Plateau pressures <30 Permissive hypercapnea Use PEEP to avoid lung collapse at end expiration Prone positioning HOB elevation 30-45 deg Conservative fluid therapy Regular spontaneous breathing trials

18. Mechanical Ventilation No significant difference was found in outcomes when comparing High-Frequency Ventilation with conventional ventilation for treatment of ALI and ARDS (Cochrane Database of Systemic Reviews)

19. Dont Forget! Resuscitation Goals: CVP 8-12 (12-15 if on vent), MAP>65, UOP 0.5cc/kg/hr, SVO2 >70%

20. Glucose Control Initiate if sugars are >180 Goal is to keep sugars in 150 range Provide glucose source and monitor q 1-2hrs on IV insulin drip FSBG can overestimate glucose levels in anemic pts Hypoglycemia is associated w/ worse prognosis (NICE-SUGAR trial)

21. Bibcarbonate Therapy Just say NO! ---if pH remains at <7.15, talk with intensivist about starting Resuscitation Goals: CVP 8-12 (12-15 if on vent), MAP>65, UOP 0.5cc/kg/hr, SVO2 >70%

22. Prophylaxis Remember DVT prophylaxis- use SQ Heparin instead of Lovenox for renal failure and age >75 Remember Stress Ulcer prophylaxis- using H2 Blocker or PPI (but PPIs are associated w/ increased risk of Ventilator-acquired pneumonia) Remember Skin prophylaxis- specialty bed, positioning of pt by nurses

23. Interactive Summary Begin resuscitation in ED or Clinic with? FLUIDS, FLUIDS, FLUIDS, and WARM FLUIDS Resuscitation Goal for CVP is? 8-12 mmHg Resuscitation Goal for MAP is? >65 mmHg Resuscitation Goal for SVO2 is? >70% If patient is not responding to fluids start ___ Norepinephrine drip/ Levophed

24. Conclusions Fluids, Fluids, Fluids, and WARM Fluids Central line and A-line Goals: CVP>8, MAP >65, UOP >0.5cc/kg/hr, SVO2 >70% Start Norepinephrine drip early! Add steroids if struggling w/ pressors Transfuse PRBCs if Hgb <7 Goal for Tidal Volume is 6cc/kg Maintain plateau pressures <30 Keep glucose <150

25. Questions? or

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