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The golden hour(s) for severe sepsis and septic shock treatment. D. Matamis M.D, Papageorgiou Hospital Thessaloniki - Greece. DO 2 – VO 2 - SvO 2. VO 2 -VCO 2 production during shivering. VO 2 -VCO 2 production during agitation. VO 2 -DO 2 dependence. ScvO 2 jugular SvO 2

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the golden hour s for severe sepsis and septic shock treatment

The golden hour(s) for severe sepsis and septic shock treatment

D. Matamis M.D, Papageorgiou Hospital

Thessaloniki - Greece

regional svo 2
ScvO2

jugular SvO2

hepatic SvO2

renal SvO2

coronary sinus SvO2

mesenteric SvO2

Regional SvO2
tissue hypoxia
DO2/VO2 imbalance

Decrease in O2 delivery

Increase in O2 Consumption

O2 reserves

25% of the Ο2 delivered in the

periphery is used

Is it reasonable?

- CaO2 =20 ml/dl

- (a-v)DO2 = 5 ml/dl

-SvO2 75%,

Marathon Runners

Deep Divers (mammals, Birds)

Tissue Hypoxia
tissue hypoxia the concept of supra normal values
ICU patients

Trauma

Severe Sepsis

Extensive Surgery

If we increase DO2

Mortality

Goals of the hemodynamic optimization

DO2 ?

SvO2 ?, ScvO2 ?

C.I ?

Tissue Hypoxia -The Concept of Supra-normal Values
the first randomized controlled trial shoemaker et al chest 1988 94 1176
The first randomized controlled trialShoemaker et al. Chest 1988;94:1176

General surgery high risk patients.

trauma, vascular, acute abdominal catastrophe, extensive ablative surgery

Three groups 1. CVP control group

2. PAC control group

3. PAC protocol group.

Goals of therapy C.I > 4,5 lit/min/m2, DO2>600ml/min/m2,

Reduction in mechanical ventilation (9,4vs2.3) and ICU days (15,8vs10,2)

146 patients, 55 non randomized, 45 not ill enough, non consecutive enrolled,

severity illness score not employed for baseline comparability, Co-interventions,

hemodynamic and oxygen transport values for each group not reported.

slide10

The beneficial effect of supranormalization of oxygen deliverywith dopexamine hydrochloride on perioperative mortality Boyd et al. JAMA 1993;270:2699-2707

  • Dopexamine as the pharmacologic agent to increase DO2
  • The intervention was initiated preoperative
  • Patients comparable at baseline
  • Pre and post op DO2 values were higher in the treatment group
  • 28 days mortality was lower in the treatment group
        • 6% vs 22% p< 0,015
  • But
  • The median duration of ICU stay were 40 and 46 hours
  • In other studies ICU stay ranged from 5 to 24 days
  • The population in the study of Boyd at al was less critically ill.
slide11
Elevation of systemic oxygen delivery in the treatment of critically ill patientsHayes et al. N Engl J Med 1994;330:1717-1722
  • 100 patients
  • Dobutamine as the pharmacologic agent to increase DO2
  • Randomization after standard fluid resuscitation
  • Mortality was higher in the treatment group 48% vs 30%
  • But
  • Delay to start the protocol
  • More seriously ill patients, higher APACHE score in the protocol group
  • Patients in the protocol group received more aggressive treatment
  • 50 mcg/kg/min Dobutamine and more than 68% Norepinephrine
  • 70% of the patients did not reach the supranormal value
slide13
Large (762 patients) multi-center randomized trial

Three groups

Control group

Supranormal C.I group

Normal SvO2 group (>70%)

Standard clinical care in all three groups

MAP > 60 mmHg

CVP=8-12

PAOP≤18mmHg

Urine output≥0.5ml/kg

pH ≥ 7,3-7,5

- 55% of the CI group failed to achieve a supranormal value

slide15

The negative results of these study may be due to failure to achieve treatment goals rather than failure of treatment to influence outcome

slide16
7 randomized trials 1016 patients included

Major problem:

crossover of the patients

Time of intervention

Pre or postoperative in the ICU

Timing of inotropic support

Maximizing Oxygen delivery in critically ill patients: A methodologic appraisal of the evidence. Heyland et al. Crit Care Med 1996;24:517-24

treatment of sepsis
Treatment of Sepsis

Hemodynamic Optimization

Appropriate ATB treatment

slide29
21 randomized controlled trials

Mortality reduction with

hemodynamic optimization

when treated early before MSOF

when group mortality is >20%

Crit. Care Med 2002;30:1686-92

conclusion
Conclusion
  • Sepsis related mortality and ICU-hospital LOS depends of:
  • Early detection or screening for high-risk patients
  • Early detection and treatment of tissue hypoxia
  • Early administration of appropriate antibiotic treatment
  • Providing education of all involved personnel