slide1 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Nabil Abouchala, MD, FCCP, FACP Consultant, Pulmonary and Critical Care Medicine PowerPoint Presentation
Download Presentation
Nabil Abouchala, MD, FCCP, FACP Consultant, Pulmonary and Critical Care Medicine

Loading in 2 Seconds...

play fullscreen
1 / 54

Nabil Abouchala, MD, FCCP, FACP Consultant, Pulmonary and Critical Care Medicine - PowerPoint PPT Presentation


  • 172 Views
  • Uploaded on

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 A Guide To The Guidelines …. Nabil Abouchala, MD, FCCP, FACP Consultant, Pulmonary and Critical Care Medicine Medical Director, Med- Sug ICU-C King Faisal Hospital & Research Center

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

Nabil Abouchala, MD, FCCP, FACP Consultant, Pulmonary and Critical Care Medicine


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012A Guide To The Guidelines …

Nabil Abouchala, MD, FCCP, FACP

Consultant, Pulmonary and Critical Care Medicine

Medical Director, Med-Sug ICU-C

King Faisal Hospital & Research Center

Riyadh, Saudi Arabia

slide4
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

1. Initial Resuscitation and Infection Issues

2. Hemodynamic Support and Adjunctive Therapy​

3. Other Supportive Therapy of Severe Sepsis

4. Special Considerations in Pediatrics​​

slide5
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
sepsis bundle
Sepsis Bundle

A. Initial Resuscitation

Serum Lactate Measured

Resuscitation Bundle

Blood Culture Obtained Prior to Antibiotic Administration

Broad-Spectrum Antibiotics Administered within 1 Hour of ED Admission

Fluid Resuscitation (30 ML/Kg) for Hypotension or Lactate >4mmol/L

Vasopressors for Ongoing Hypotension

Maintain Adequate Central Venous Pressure (CVP ≥ 8)

Maintain Adequate Central Venous Oxygen Saturation (ScvO2 ≥ 70%)

Re-measure Serum Lactate

early goal directed therapy in the treatment of severe sepsis and septic shock

Early Goal-directed Therapy in the Treatment of Severe Sepsis and Septic Shock

To Examine whether Early Goal Directed Therapy (EGDT) before admission to the ICU is superior to standard hemodynamic therapy in patients with sever sepsis and septic shock

#Citing articles

2469

N Engl J Med, 2001;345:1368-77

mortality

10-20%

Sudden

Death!

MOrtality
results
Results

37 Observational studies showing improved outcomes with early quantitative resuscitation between 2001 and 2011

  • Mortality
    • EGT : 30.5 %
    • Standard: 46.5 %
  • Absolute Risk Reduction
  • NNT =

16%

7

Multicenter trial of 314 patients with severe sepsis in eight Chinese centers (2010).

This trial reported a 17.7% absolute reduction

N Engl J Med, 2001;345:1368-77

2012 ivf recommendation
2012: IVF recommendation
  • Initial fluid challenge ≥ 1000 mL of crystalloids or minimum of 30 mL/kg of crystalloids in the 1st 4-6 hours
    • (Strong recommendation; Grade 1C).
  • Crystalloids is the initial fluid for resuscitation
    • (Strong recommendation; Grade 1A).
  • Adding albumin to the initial fluid resuscitation
    • (Weak recommendation; Grade 2B).
  • Against hydroxyethyl starches (hetastarches) with MW >200 dalton
    • (Strong recommendation; Grade 1B).
septic shock timing of antibiotics

% Survival

% Total receiving antibiotics

Only 50% of patients in Septic Shock

received antibiotics w/in 6 hrs.

Septic Shock: Timing of Antibiotics

Percent

1.00

14 ICUs; n = 2,731

.80

.60

.40

.20

0.0

.5 – 1.0

1 - 2

2 - 3

3-4

4 - 5

5 - 6

6 - 9

9 - 12

12 - 24

24 - 36

> 36

0 - .5

Time, hrs

Kumar Crit Care Med 2006

slide16
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
which inotropes to use
Which Inotropes to use?

Norepinephrine as the first choice

( Grade 1B)

Adding or substituting epinephrine when an additional drug is needed

(Strong recommendation; Grade 1B).

Vasopressin 0.03 units/min may be added

(Weak recommendation; Grade 2A)

Dopamine only in highly selected patients at very low risk of arrhythmias or low heart rate

(Weak recommendation; Grade 2C).

Dobutamine infusion be started or added with low cardiac output) or ongoing signs of hypoperfusion, even after adequate intravascular volume

(Strong recommendation; Grade 1C)

sepsis induced vasodilatation
Sepsis induced vasodilatation

Lower amount of fluid required to fill the tank

NE

slide22

Crit Care Med 2007; 35:1736–1740

Early NE + Fluids

Late NE + Fluids

Fluids

NE

LPS

slide24

Early administration of norepinephrine aimed at rapidly achieving a sufficient perfusion pressure in severely hypotensive septic-shock (DBP < 40) patients is able to increase cardiac output through an increase in cardiac preload and cardiac contractility

stroke volume variation
Stroke volume variation

SVV = SV max – SV min / SV mean

pleth variability index pvi to help clinicians optimize preload cardiac output
Pleth Variability index (PVI) to Help Clinicians Optimize Preload / Cardiac Output

Stroke Volume

Lower PVI = Less likely to respond

to fluid administration

10 %

24 %

Higher PVI = More likely to respond to fluid administration

0

0

Preload

Maxime Cannesson, MD, PhD

slide32
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
slide34

K. Blood Product Administration Target Hemoglobin (7-9 g/dl) unless …

L. Immunoglobulins: Not recommended

M. Selenium: Not recommended

N. History of Recommendations Regarding Use of Recombinant Activated Protein C

R. Renal Replacement Therapy

S. Bicarbonate Therapy

slide36

K. Blood Product Administration Target Hemoglobin (7-9 g/dl) unless …

L. Immunoglobulins: Not recommended

M. Selenium: Not recommended

N. History of Recommendations Regarding Use of Recombinant Activated Protein C

O. Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)

P. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis

Q. Glucose Control

R. Renal Replacement Therapy

S. Bicarbonate Therapy

T & U. Prophylaxis: Deep Vein Thrombosis and Stress Ulcer

V. Nutrition

W. Setting Goals of Care

slide37

O. Mechanical Ventilation of Sepsis-Induced (ARDS)

1. Target a TV of 6 mL/kg predicted body weight (grade 1A vs. 12 mL/kg)

2. Plateau pressures be measured in patients with ARDS be ≤30 cm H2O (grade 1B)

3. (PEEP) be applied (grade 1B)

4. Higher rather than lower levels of PEEP for moderate or severe ARDS (grade 2C)

5. Recruitment maneuvers be used with severe refractory hypoxemia (grade 2C)

6. Prone positioning be used Pao2/Fio2 ratio ≤ 100 mm (grade 2B)

7. HOB elevated to 30-45 (grade 1B)

8. (NIV) be used in minority of patients in whom the benefits of NIV (grade 2B)

9. Weaning protocol be in place

10. Against the routine use of the pulmonary artery catheter (grade 1A)

11. A conservative rather than liberal fluid strategy (grade 1C)

12. not using beta 2-agonists for treatment of sepsis-induced ARDS (grade 1B)

arma trial
ARMA Trial

Reducing from 12 to 6 ml/kg VT saved lives

NNT 12

14000 Lives Saved/Year

wet first dry later
Wet First –Dry later

CHEST 2009; 136:102–109

Approach that combines both adequate initial fluid resuscitation followed by conservative late-fluid management was associated with improved survival

wet first dry later1
Wet First –Dry later

CHEST 2009; 136:102–109

higher peep is better in moderate to severe ards po2 fio2 200 mmhg
Higher PEEP is betterin Moderate to Severe ARDS (PO2/FiO2 ≤ 200 mmHg)

JAMA. 2010;303(9):865-873

higher peep is better in moderate to severe ards po2 fio2 200 mmhg1
Higher PEEP is betterin Moderate to Severe ARDS (PO2/FiO2 ≤ 200 mmHg)

Death in ICU  6.3 %

NNT 16

Days off the MV -5 days

JAMA. 2010;303(9):865-873

glucose control in icu
Glucose control in ICU

-10%

+1.5%

ITT- 2001

NICE-SUGAR- 2009

slide49

P. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis

  • (NMBAs) be avoided if possible without ARDS
  • Short course of NMBA (<48 hours) for early ARDS + Pao2/Fio2<150 mm Hg

Q. Glucose Control

T & U. Prophylaxis: Deep Vein Thrombosis and Stress Ulcer

  • PPIs rather than H2RA (grade 2D)

V. Nutrition

slide50

Omega/EDEN* studies

  • Objective: dietary supplementation of Omega-3 FA increase ventilator –free days in patients with ALI/ARDS
  • Intervention: BID bolus supplementation of omega-3 FA vs isocaloric control

Rice at al. for the NHLBI ARDS Clinical Trials Network

JAMA. 2011;306(14):1574-1581

daily energy intake
Daily energy intake

Rice at al. for the NHLBI ARDS Clinical Trials Network . JAMA. 2012

survival and hospital discharge
Survival and hospital Discharge

Rice at al. for the NHLBI ARDS Clinical Trials Network . JAMA. 2012

take home message
Take home message
  • BE Goal Directed:
    • More and faster fluid
    • No hetastarch
    • Earlier Inotropes
    • Use norepineprine and epinephrine over dopamine
    • Lactic acid clearance
    • Dynamic SVV is better than CVP
  • Antimicrobials:
    • Fast <1 hr, consider early antifungals, use biomarkers to deescalate or stop
  • ARDS:
    • Wet first, dry later
    • Higher PEEP
  • Glucose control
    • Not so tight (140-180 mg/dl = 8-10 mmol/l)
  • Nutrition
    • Underfeed first week
    • No supplement