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Surviving Sepsis 2008 Guidelines Early Goal Directed Therapy

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. Severe Sepsis. Septic Shock. Sepsis. Microorganism invading sterile tissue.

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Surviving Sepsis 2008 Guidelines Early Goal Directed Therapy

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  1. Surviving Sepsis 2008 GuidelinesEarly Goal Directed Therapy Mazen Kherallah, MD, FCCP Infectious Disease and Critical Care Medicine

  2. Therapy Across the Sepsis Continuum Infection SIRS Severe Sepsis Septic Shock Sepsis 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/mm3or <4,000/mm3 or >10% bands SIRS with a presumed or confirmed • infectious • process Sepsis with organ failure • Vascular collapse • Renal • Hemostasis • Lung • LA Refractory hypotension Chest 1992;101:1644

  3. Sepsis Syndromes1992: SCCM/ACCP Parasite Severe Sepsis Virus SIRS Infection Severe SIRS Sepsis Fungus Trauma Shock Bacteria BSI Burns

  4. 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

  5. 6 Hour Bundle 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 THE SEVERE SEPSIS BUNDLES: SSC/IHI 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

  6. 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

  7. SUMMARY: SEPSIS GUIDELINES 2008 Strong Recommendation (1): Recommended A B C D DVT Prophylaxis Antibiotics within 1 hr for Septic Shock EGDT and Protocolized Resuscitation Antibiotics within 1 hr in No septic Shock Patients H2 Blocker PUD Prophylaxis Glycemic Control Fluid Challenge 7-10 day Antibiotic Duration Crystalloid = Colloid BC prior to Abx No Routine Use of SGC PPI PUD Prophylaxis Source Control Consider Limiting Support Low VT for ALI Dopamine or Norepinephrine No Renal Dose Dopamine HOB >45 Limit P plateau <30 cm H2O Limited Transfusion No High Dose Steroids No Antithrombin II PEEP No Erythropoietin De-escalation Antibiotic Therapy Intermittent = Continuous sedation Conservative Fluid in ALI with no Shock Weaning Protocol/SBT Avoid NMB

  8. 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 Low dose steroids for septic shock ACTH test not to be done NIV for ALI/ARDS mild/moderate hypoxemia B/S < 150 Prone Position in ARDS

  9. Therapy Across the Sepsis Continuum Infection SIRS Severe Sepsis Septic Shock Sepsis Steroids * Drotrecogin Alpha Early Goal Directed Therapy Antibiotics and Source Control Insulin and Tight Glucose Control Chest 1992;101:1644

  10. Therapy Across the Sepsis Continuum Infection SIRS Severe Sepsis Septic Shock Sepsis • 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.

  11. Rivers E, Nguyen B, Havstad S, et al 2001;345:1368-1377.

  12. Early Goal-Directed Therapy Results:28 Day Mortality 60 49.2% 50 Vascular Collapse 21% vs 10% p=0.02 P = 0.01* 40 33.3% 30 Mortality % MODS 22% vs 16% P=0.27 20 10 0 EGDT N=130 Standard Therapy N=133 *Key difference was in sudden CV collapse, not MODS NEJM 2001;345:1368-77.

  13. NNT to prevent 1 event (death) = 6 - 8 Standard therapy 60 EGDT 50 40 Mortality (%) 30 20 10 0 In-hospital mortality (all patients) 28-day mortality 60-day mortality The Importance of Early Goal-DirectedTherapy for Sepsis-induced Hypoperfusion Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

  14. ◦ 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.

  15. 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

  16. 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

  17. 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.

  18. SBAR The RN should approache the MD, informing him using SBAR technique, that the patient has screened positive for severe sepsis.

  19. 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

  20. 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?

  21. 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.

  22. 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.

  23. 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

  24. 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

  25. 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

  26. 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

  27. Critical Care is A Promise ان الله يحب العبد اذا عمل عملا أن يتقنه

  28. 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

  29. Thank You

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