1 / 57

Sepsis

Sepsis. Jay Green, PGY-4 Dr. Jason Lord August 20, 2009. Thanks. Dr. Jason Lord Dr. Dan Howes Dr. Trevor Langhan Dr. Aric Storck. Outline. Case Definitions Keys to sepsis management. Epidemiology. Why is sepsis important?. Not all SIRS is Sepsis. SIRS (2 of) T<36 or >38 HR>90

fontaine
Download Presentation

Sepsis

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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Sepsis Jay Green, PGY-4 Dr. Jason Lord August 20, 2009

  2. Thanks Dr. Jason Lord Dr. Dan Howes Dr. Trevor Langhan Dr. Aric Storck

  3. Outline Case Definitions Keys to sepsis management

  4. Epidemiology Why is sepsis important?

  5. Not all SIRS is Sepsis SIRS (2 of) T<36 or >38 HR>90 RR>20, pCO2 < 32 WBC<4, >12 or >10% bands

  6. Case

  7. Definitions SIRS Sepsis Severe sepsis Septic shock

  8. SIRS T<36 or >38 HR>90 RR>20, pCO2<32 WBC<4, >12 or >10% bands

  9. The Septic Spectrum SIRS SEPSIS Mortality:10% SEVERE SEPSIS Mortality:16% SEPTIC SHOCK Mortality:46%

  10. Case You think he’s septic ?Pulmonary source?

  11. SIRS T<36 or >38 HR>90 RR>20, pCO2<32 WBC<4, >12 or >10% bands

  12. #1 priority in sepsis?

  13. Survival With Delay in ABX Kumar et al. Crit Care Med 2006;34(6):1589

  14. Source of Infection • Abx keys • Get them in fast! • Culture first • Source control • ?MRSA/pseudomonas Kumar et al. Crit Care Med 2006;34(6):1589

  15. ABX Selection • Chest • Levo + ceftriaxone • Azithro + ceftriaxone • Tazo/Cipro (nursing home, etc) • Abdo • Pip/tazo or AGF or ceftriaxone/Flagyl • GU • Gent or ceftriaxone • Skin • Ancef +/- vanco • Head • Ceftriazone + vanco + dex

  16. Guidelines • Surviving Sepsis Campaign • Crit Care Med 2008;36(1):296 • CAEP • CJEM 2008 Sept;10(5):443

  17. SIRS T<36 or >38 HR>90 RR>20, pCO2<32 WBC<4, >12 or >10% bands

  18. Case What does our patient have?

  19. Case • Investigations? • Initial management priorities?

  20. Case • Reassess our patient • Why is lactate important?

  21. The Septic Spectrum SIRS SEPSIS Mortality:10% SEVERE SEPSIS Mortality:16% SEPTIC SHOCK Mortality:46% EGDT EGDT Mortality: 30%

  22. In-hospital mortality • 46.5% vs 30.5% (NNT = 6!) • 60-day mortality • 56.9% vs 44.3% • EGDT got more early fluid, pRBC, inotropes

  23. What Are The Components of Septic Shock ✓ • Hypovolemic • Distributive • Cardiogenic • Obstructive ✓ ✓ ✗ Hinshaw & Cox. The Fundamental Mechanisms in Shock. Plenum Press, New York. 1972.

  24. Hypovolemic Distributive Cardiogenic

  25. Hypovolemic Shock • Why are patients in hypovolemic shock? • Venodilation • 3rd spacing • Losses (vomiting, diaphoresis) • Recent poor PO intake • Crystalloid vs colloid?

  26. BMJ 1998;316:961

  27. Cochrane review, 2005 VISEP. NEJM 2008;358:125-39 NS – cheap, available – USE IT NEJM 2004;350:2247

  28. Guidelines • Surviving Sepsis Campaign • Colloid or crystalloid • CAEP • Colloid or crystalloid Crit Care Med 2008;36(1):296

  29. New and interesting • Voluven • Lu et al. 2009 Mar;21(3):143-6 • ?lung-protective in rabbits • Palumbo et al. 2006;72(7-8):655 • Improved hemodynamics and APACHE-II score • Franziska et al. 2009;35(9):1539 • Similar rates of ARF as albumin in surgical ICU pts

  30. SIRS T<36 or >38 HR>90 RR>20, pCO2<32 WBC<4, >12 or >10% bands EGDT CVP 8-12 Crystalloid (1L q30min)

  31. Distributive

  32. Vasopressin? Should we use vasopressin in sepsis?

  33. NEJM 2008;358(9)

  34. SIRS T<36 or >38 HR>90 RR>20, pCO2<32 WBC<4, >12 or >10% bands EGDT CVP 8-12 Crystalloid (1L q30min) MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min

  35. Cardiogenic

  36. Blood Transfusion • EGDT • If ScvO2<70% and hct<0.30 • TRICC • If Hb > 70g/L • How does this help? • O2 content = (1.34 x Hb x SaO2) + (0.0031 x PO2)

  37. Results • No difference in 30 or 60 day mortality • Restrictive group • Lower in-hospital mortality • 22.2% vs 28.1% (p=0.005) • Less sick pts (APACHE II score <20) did better • ARR 7.4% (95%CI 1.0 – 13.6%) • No difference in mortality in sepsis sub-group NEJM 1999;340:409

  38. TRICC vs EGDT • EGDT • Hypovolemic ED patients • Actual measurement of suboptimal O2 delivery • TRICC • Euvolemic pts enrolled within 72 hours of ICU admit • 6% sepsis, 27% had any infection

  39. Reassess Case

  40. SIRS T<36 or >38 HR>90 RR>20, pCO2<32 WBC<4, >12 or >10% bands EGDT CVP 8-12 Crystalloid (1L q30min) MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min ScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/min

  41. Etomidate • Absalom 1999, Malerba 2005, Vinclair 2007 • Single dose inhibits cortisol synthesis for 24-48h • Mohammed 2006, Ray 2007, Riche 2007 • Studies designed for etomidate vs no etomidate • No increase in mortality • CORTICUS (2008) • >28d mort with one dose (OR 1.53 (1.06-2.26)) • Etomidate non-randomized, post-hoc analysis • Bottom line • Avoid in sepsis

  42. New and interesting?

  43. Post-intubation CXR

  44. NEJM 2000;342(18)

  45. SIRS T<36 or >38 HR>90 RR>20, pCO2<32 WBC<4, >12 or >10% bands EGDT CVP 8-12 Crystalloid (1L q30min) MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min ScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/min ARDSNet TV 6cc/kg PEEP Pplateau<30

  46. Steroids • Early studies - no benefit • NEJM 1987; 317: 659-65, NEJM 1987; 317: 653-58 • Increased mortality at higher doses • Crit Care Med. 1995; 23: 1430-39 • Annane – benefit in non-responders • JAMA 2002;288(7) • CORTICUS – no benefit • NEJM 2008;358(2) • Annane - benefit in subgroup • JAMA 2009 June;301(22)

More Related