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 Microorganism invading sterile tissue § A clinical response arising from a nonspecific insult, with 2 of the following: § T >38 o. C or <36 o. C § HR >90 beats/min § RR >20/min § WBC >12, 000/mm 3 or <4, 000/mm 3 or >10% bands Sepsis Severe Sepsis Septic Shock SIRS with a presumed or confirmed infectious process Sepsis with organ failure q. Vascular collapse q. Renal q. Hemostasis q. Lung q. LA Refractory hypotension Chest 1992; 101: 1644

Sepsis Syndromes 1992: SCCM/ACCP Parasite Virus Severe Sepsis Infection Fungus Shock BSI Bacteria Sepsis SIRS Sev e SIR re S Trauma Burns

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

THE SEVERE SEPSIS BUNDLES: SSC/IHI 6 Hour Bundle ü ü ü ü 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 m. L/kg crystalloid (or equivalent colloid) if hypotensive (SBP < 90 mm. Hg or MAP < 70) or lactate > 4 mmol/L Vasopressors If septic shock or lactate > 4 mmol/L: ü CVP and Scv. O 2 or Sv. O 2 measured ü CVP maintained 8 -12 mm Hg Inotropes (and/or PRBCs if Hct < 30%) delivered for Scv. O 2 <70% or Sv. O 2<65% if CVP > 8 mm. Hg 24 Hour Bundle ü Glucose control maintained < 150 mg/d. L ü Drotrecogin alfa (activated) administered in accordance with hospital guidelines ü Steroids given for septic shock requiring continued use of vasopressors for > 6 hours ü Lung protective strategy with plateau pressures < 30 cm H 2 O for mechanically ventilated patients http: //www. ihi. org

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) 38 th Critical Care Congress. Late breaker. Presented February 2, 2009

SUMMARY: SEPSIS GUIDELINES 2008 Strong Recommendation (1): Recommended A B DVT Prophylaxis Antibiotics within 1 hr for Septic Shock EGDT and Protocolized Resuscitation Glycemic Control Fluid Challenge Crystalloid = Colloid BC prior to Abx PPI PUD Prophylaxis Source Control Low VT for ALI Dopamine or Norepinephrine H 2 Blocker PUD Prophylaxis No Routine Use of SGC No Renal Dose Dopamine No High Dose Steroids HOB >45 Limited Transfusion No Antithrombin II No Erythropoietin Intermittent = Continuous sedation Weaning Protocol/SBT Avoid NMB C Limit P plateau <30 cm H 2 O PEEP De-escalation Antibiotic Therapy Conservative Fluid in ALI with no Shock D Antibiotics within 1 hr in No septic Shock Patients 7 -10 day Antibiotic Duration Consider Limiting Support

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

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

Therapy Across the Sepsis Continuum Infection SIRS Sepsis Severe Sepsis Septic Shock q CVP > 8 -12 mm Hg q MAP > 65 mm Hg q Urine Output > 0. 5 ml/kg/hr q Scv. O 2 > 70% q Sa. O 2 > 93% q Hct > 30% * Early Goal Directed Therapy Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O 2 delivery with O 2 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.

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

Early Goal-Directed Therapy Results: 28 Day Mortality 60 50 49. 2% P = 0. 01* 40 Mortality % Vascular Collapse 33. 3% p=0. 02 30 MODS 20 22% vs 16% 10 0 21% vs 10% P=0. 27 Standard Therapy N=133 EGDT N=130 *Key difference was in sudden CV collapse, not MODS NEJM 2001; 345: 1368 -77.

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

◦ If venous O 2 saturation target not achieved: (2 C) 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.

SIRS Screen First section screens for 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. 5 K/u. L bands If the patient has 2 or more of the above, they screen positive for SIRS

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

Severe Sepsis Screen Third section screens for Organ Dysfunction Respiratory: Sa. O 2 < 90 % Cardiovascular: SBP < 90 Renal: urine output < 0. 5 ml/hr; creatinine increase > 0. 5 mg/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.

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

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 Sa. O 2

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?

Resuscitation Goals (Grade 1 C) Central venous pressure (CVP): 8– 12 mm Hg Mean arterial pressure (MAP) ≥ 65 mm Hg Urine output ≥ 0. 5 m. L. kg– 1. hr – 1 Central venous (superior vena cava) or mixed Venous oxygen saturation ≥ 70% or ≥ 65%, respectively Hemoglobin >10 mg/d. L Rivers E, Nguyen B, Havstad S, et al. 2001; 345: 1368 -1377.

Initiation of Resuscitation (1 C) Begin resuscitation immediately in patients with CVP < 8, hypotension or elevated serum lactate >4 mmol/l; Do not delay pending ICU admission. Rivers E, Nguyen B, Havstad S, et al. 2001; 345: 1368 -1377.

CVP <8 mm. Hg Central line placement and CVP monitoring 500 m. L 0. 9% Na. Cl bolus every 15 minutes to maintain a CVP goal Colloids if CVP <4 Transfuse 1 unit of PRBC’s if Hg <10

A higher target CVP of 12– 15 mm. Hg is recommended in the presence of Mechanical ventilation Pre-existing decreased ventricular compliance Increased intra-abdominal pressure

MAP <65 mm. Hg 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

Scv. O 2 <70% Arterial line placement Transfuse 1 PRBC’s if Hg level <10 mg/d. L Start Dobutamine 2. 5 -20 mcg/kg/min IV infusion Intubation and ventilation

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

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 mm. Hg Target a mean arterial blood pressure target of ≥ 65 mm. Hg Target a central venous O 2 saturation of ≥ 70% Target your urine output to >0. 5 m. L/Kg/Hour

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