Amit Presentation 18.04

8/9/2019 Amit Presentation 18.04

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Current recommendations for

the Management of Severe

Sepsis & Septic Shock

Dr. Amit Kocheta,

DNB Trainee

Anesthesiology & criticalcare

BMHRC, Bhopal


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Introduction

Severe sepsis & septic shock are major

healthcare problems

Affects millions of individuals around theworld & killing one in four

The speed and appropriateness of therapy

in initial hours, likely to influence outcome


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Definitions

Sepsis: Infection with systemic manifestations

Severe sepsis: Sepsis plus organ dysfunction or

tissue hypoperfusion

Sepsis-induced hypotension: SBP < 90 or MAP

< 70 or a SBP decrease > 40 mm Hg or < 2 sd

Septic shock: Sepsis-induced hypotension

persisting despite adequate fluid resuscitation Sepsis-induced tissue hypoperfusion: Either

septic shock, an elevated lactate, or oliguria


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Diagnostic criteria for sepsisInfection, documented or suspected, and some of the following:

General variables Fever (38.3C)

Hypothermia (core temperature 36C)

Heart rate 90 min1 or 2 SD above the normal value for age

Tachypnea

Altered mental status

Significant edema or positive fluid balance (20 mL/kg over 24 hrs) Hyperglycemia (plasma glucose 140 mg/dL or 7.7 mmol/L) in the absence of diabetes

Inflammatory variables Leukocytosis (WBC count 12,000 L1)

Leukopenia (WBC count 4000 L1)

Normal WBC count with 10% immature forms

Plasma C-reactive protein 2 SD above the normal value

Plasma procalcitonin 2 SD above the normal value

Hemodynamic variables Arterial hypotension (SBP 90 mm Hg; MAP 70 mm Hg; or an SBP decrease 40 mm

Hg in adults or 2 SD below normal for age)


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Diagnostic criteria for sepsis cont. Organ dysfunction variables

Arterial hypoxemia (PaO2/FIO2 300) Acute oliguria (urine output 0.5 mL/Kg hr or 45 mmol/L for at least 2 hrs, despite

adequate

fluid resuscitation)

Creatinine increase 0.5 mg/dL or 44.2 mol/L

Coagulation abnormalities (INR 1.5 or a PTT 60 secs)

Ileus (absent bowel sounds)

Thrombocytopenia (platelet count, 100,000 L1) Hyperbilirubinemia (plasma total bilirubin 4 mg/dL or 70 mol/L)

Tissue perfusion variables Hyperlactatemia ( upper limit of lab normal)

Decreased capillary refill or mottling

Diagnostic criteria for sepsis in the pediatric population signs and symptoms of inflammation plus infection with hyper- or hypothermia (rectal

temperature 38.5C or 35C),

tachycardia (may be absent in hypothermic patients), and

at least one of the following indications of altered organ function: altered mentalstatus, hypoxemia, increased serum lactate level, or bounding pulses.


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Recommendations

ManagementA. Initial Resuscitation

B. Diagnosis

C. Antibiotic Therapy

D. Source Control

E. Fluid Therapy

F. Vasopressors

G. Inotropic Therapy

H. Corticosteroids

I. rhAPCJ. Blood Products

Supportive therapyA. Mechanical ventilation

B. Sedation/Analgesia & NMB

C. Glucose Control

D. Renal Replacement

E. Bicarbonate Therapy

F. DVT Prophylaxis

G. Stress Ulcer Prophylaxis

H. SDD

I. Limitation of Support

Surviving sepsis campign: International guidelines for management

of severe sepsis & septic shock. Crit Care Med. 2008;36(1):296-327.


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Initial Resuscitation

1. Protocolized resuscitation: As hypoperfusion is

recognized or blood lactate conc 4 mmol/L

Goals in first 6 hrs:

CVP 8-12 mm Hg MAP 65 mm Hg

Urine output 0.5 mL/kg/hr

ScvO2

or SmvO2

70% or 65%, respectively

2. If goal not achieved: PRBCs to achieve a Hct of

30% &/orDobutamine be used, to increase

CaO2 / COP & O2 delivery


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Diagnosis

1. Obtain appropriate cultures, before antimicrobialtherapy

At least two blood cultures, percutaneously and

each vascular access device

Cultures of other sites (preferably quantitative)

such as urine, CSF, wounds, resp secretions, or

other body fluids

2. Prompt imaging studies to confirm source ofinfection, along with sampling if indicated.

Bedside USG is very useful in difficulty

www.usgain.com


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Role of biomarkers

Currently the potential role of biomarkers for

diagnosis remains undefined

The procalcitonin level, although often useful, is

problematic in patients with an ac inflammatorypattern from other causes (postoperative, shock)

In near future, rapid diagnostic methods (PCR,

micro-arrays) might prove extremely helpful for a

quicker identification of pathogens and majorantimicrobial resistance determinants


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Antibiotic Therapy

1. I/V antibiotic therapy be started ASAP, withinthe first hour

2. Initial empirical anti-infective therapy include

one or more drugs that have activity against all

likely pathogens, penetrate in adeq

concentration into presumed source of sepsis

3. Antimicrobial regimen be reassessed daily to

optimize activity, prevent resistance, reducetoxicity & costs

Continued


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Antibiotic Therapy

4. Combination therapy for known or suspectedPseudomonas infections

5. Combination empirical therapy for neutropenic

patients with severe sepsis

6. Empirical combination therapy NR for > 3-5 d.

Single therapy as soon as susceptibility known

7. Duration of therapy typically be 7-10 d; longer

courses may be appropriate in selected pts8. In noninfectious conditions, antimicrobials be

stopped promptly


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Source Control

1. Specific anatomical diagnosis of infection besought within first 6 hrs, amenable to sourcecontrol measures

2. In infected peripancreatic necrosis, definitive

intervention is best delayed until adequatedemarcation

3. Effective intervention with least physiologicinsult be employed

4. When intravascular devices are a possiblesource, remove them promptly


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Fluid Therapy

1. Fluid resuscitation with either natural/artificial,colloids or crystalloids. There is no evidence-based support for one type of fluid over another

2. SAFE study indicated that albumin was safe and

equally effective as crystalloid3. As volume of distribution is much larger for

crystalloids than for colloids, Crystalloids requiresmore fluid to achieve the same end points and

results in more edema, but less expensive4. Initially target a CVP of 8 mm Hg (12 mm Hg inventilated patients). Further fluid is often required

Continued


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Fluid Therapy

5. Fluid challenge technique be applied wherein

fluid administration is continued as long as

hemodynamic improvement continues :

In hypovolemia 1000 mL of crystalloids or300-500 mL of colloids over 30 min

More rapid & greater amounts in sepsis-

induced tissue hypoperfusion

Amount reduced when cardiac filling pressuresincrease without hemodynamic improvement


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Vasopressors1. They sustain life & maintain perfusion in life-

threatining hypotension, even in hypovolemia.Maintain MAP 65 mm Hg

2. Either norepinephrine or dopamine be first choiceto correct hypotension in septic shock

3. Following drugs NR as initial vasopressor

Epinephrine: tachycardia, reduced splanchniccirculation & hyperlactemia

P

henylephrine: decrease in stroke volume Vasopressin: lower levels in septic shock. Lowdoses may be effective in refractory pts.Terlipressin has similar effects but is long lasting

Continued


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Vasopressors

4. Epinephrine first alternative in septic shock,

poorly responsive to nor-epineph or dopamine

5. Low-dose dopamine NR for renal protection

6. All patients requiring vasopressors have IBPmonitoring.

In shock states, NIBP is commonly inaccurate;

IBP provide a more appropriate, continuous

and reproducible measurement.


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Inotropic Therapy

1. Dobutamine infusion be administered in

presence of myocardial dysfunction as

suggested by elevated cardiac filling pressures

and low cardiac output2. Guidelines recommend against the use of a

strategy to increase cardiac index to

predetermined supranormal levels


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Corticosteroids

1. I/V hydrocortisone be given onlywhen BP ispoorly responsive to fluid & vasopressors

2. ACTH stimulation test shouldt be used to identifywho should receive hydrocortisone

3. Dexamethasone NR, if hydrocort is available, canlead to suppression of HPA axis

4. Fludrocortisone is optional if hydrocort is used

5. Wean from steroid when vasopressors no longer

required6. Hydrocortisone > 300 mg/d shouldt be used

7. Corticosteroids NR for the treatment of sepsis inthe absence of shock


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Recombinant Human Activated Protein C

1. Recommended for adult patients with high riskof death, APACHE II 25 or MODS, if there

are no contraindications

2. Not recommended for adult patients withsevere sepsis and low risk of death, APACHE

II < 20 or one organ failure

Increased risk of bleeding with rhAPC, in

surgical pts & invasive procedures. Decisiondepends on assessing mortality reduction vs

increases in bleeding & cost


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Blood Product Administration

1. PRBC indicated when Hb < 7.0 g/dL, to a target

of 7.0-9.0 g/dL in adults

2. Erythropoietin shouldt be used for anemia assoc

with severe sepsis (except RF induced)3. FFP NR to correct lab clotting abnormalities in

absence of bleeding or planned invasive

procedures

4. Antithrombin NR for treatment of septic shock,

increased risk of bleeding when used with

heparinContinued


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Blood Product Administration

5. Platelets transfusion:

Indicated when counts < 5000/mm3 regardless

of apparent bleeding

May be considered when counts 5000-

30,000/mm3 when significant risk of bleeding

Counts 50,000/mm3 are typically required for

surgery or invasive procedures


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Mechanical Ventilation of Sepsis-

Induced ALI/ ARD

S1. Target a TV of 6 mL/kg PBW2. Maintain PP 30 cm H2O, Considering chest

wall compliance

3. No single mode of ventilation advantageousover others that respects same principles oflung protection

4. Permissive hypercapnia may be allowed to

minimize PP & TV. Limitations in pts with metacidosis & C/I in raised ICP. NaHCO3 or THAMmay be used in selected pts to facilitate it

Continued


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Mechanical Ventilation

5. Use PEEP (> 5 cm H20 ) to avoid extensive

lung collapse at end-expiration. It keeps lung

units open to participate in gas exchange &

increase PaO2

6. Prone positioning in pts requiring potentially

injurious levels of FiO2 or PP & who are not at

high risk for adverse consequences

7. Unless C/I, head end elevated 30-45 to limitaspiration risk and prevent VAP. Pts shouldt

be fed enterally with head of the bed at 0Continued


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Noninvasive mask ventilation

Advantages: better communication, lower

incidence of infection, reduced sedation &

improved outcome

Unfortunately, only suitable in few cases1. Mild-mod hypoxemic Resp failure, responsive to

relatively low levels of PS and PEEP

2. Stable hemodynamics

3. Comfortable and easily arousable

4. Able to protect airway & spont clear secretions

5. Anticipated to recover rapidlyContinued


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Weaning protocol

1.Regular spontaneous breathing trials to evaluateability to discontinue MV

Criteria :Arousable, hemodyn stable, no new

serious conditions, low ventilatory and PEEP req,

safely managed with a face mask or nasal cannula

Options: low level of PS, CPAP, or a T-piece

If successful, consider for extubation

2. Routine use of PA catheter NR3. Conservative fluid strategy for pts with ALI, who

dont have tissue hypoperfusion, decreases days

of ventilation and ICU stay


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Sedation & Analgesia

1. Follow sedation protocols with a sedation goal

2. Intermittent bolus or continuous infusion to

predetermined end points (sedation scales)

3. Daily interruption/lightening of cont infusion withawakening & retitration if necessary

Benefits include potentially shorter duration of

mechanical ventilation & ICU stay, better

assess of neurologic function & reduced costs


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Neuromuscular Blockade

1. Avoided if possible in septic pts, due to risk ofprolonged blockade following discontinuation

2. If required to facilitate MV, either int bolus or

cont infusion with TOF monitoring be used

3. When used appropriately:

Improve chest wall compliance

Prevent respiratory dyssynchrony

Reduce Paw pressures Reduce O2 consumption by decreasing work of

breathing & resp muscle blood flow


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Glucose Control

1. Following stabilization, pts with severe sepsisand hyperglycemia should receive I/V insulin

2. Use a validated protocol for insulin dose & targetglucose levels to < 150 mg/dL

3. Intensive insulin therapy causes a reduction inICU mortality/ morbidity

4. All patients on insulin receive a glucose caloriesource & values monitored every 1-2 hrs until

stable and then every 4 hrs A large RCT NICE-SUGAR(> 6,000 pts), planned to

compare target blood sugar 80-110 vs. 140-180 mg/dL

Normoglycemia in Intensive Care Evaluation & SurvivalUsing Glucose Algorithm Regulation


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Renal Replacement

1. Continuous RRT & intermittent hemodialysis areequivalent in pts with severe sepsis & ARF

2. Use continuous therapies to facilitate manag of

fluid balance in hemodyn unstable septic pts

Bicarbonate Therapy

NaHCO3 therapy NR for improving hemodyn or

reducing vasopressors in pts with hypoperfusion-

induced lactic acidemia with pH 7.15 It is assoc with Na+ and fluid overload, increase

in lactate and PCO2 & decrease in serum Ca++


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DVT Prophylaxis

1. Low-dose UFH, 2-3 times/d; or LMWH daily,unless C/I (thrombocytopenia, coagulopathy,active bleeding, recent ICH)

2. Patients who have C/I for heparin receive

mechanical prophylaxis ie, GCS or IPC3. In very high-risk pts, with severe sepsis and H/O

DVT, trauma, or ortho surgery, a combinationtherapy be used

In very high risk pts, LMWH is proven superiorthan UFH

UFH is preferred over LMWH in moderate tosevere renal dysfunction


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Stress Ulcer Prophylaxis

H2 blocker or PPIs be given to pts with severesepsis to prevent upper GI bleed. The benefitof prevention must be weighed against thepotential effect of an increased stomach pH ondevelop of VAP

Consideration for Limitation of Support Advance care planning, communication of

likely outcomes & realistic goals of treatment,

should be discussed with patients and families. Decisions for less aggressive or withdrawal of

support may be in the patient's best interest


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Recommendations specific to pediatric

severe sepsis

The overall mortality is much lower than adults.

In addition to age-appropriate differences in vital

signs, definition ofSIRSrequires either temp or

leukocyte abnormalities. Severe sepsis requiressepsis plus CVS dysfunction orARDS or two or

more other organ dysfunctions

1. Greater use of physical exam therap end points

2. Dopamine as first drug of choice for hypotension

3. Steroids only in adrenal insufficiency

4. rhAPC not recommended


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Conclusions

Strong agreement among a large cohort ofinternational experts regarding recommendationsfor best current care of pts with severe sepsis

EBR are the first step toward improved outcomes

for this important group of critically ill patients Significant program support & educational

materials at no cost to the userwww.survivingsepsis.org

Surviving Sepsis Campaign: InternationalGuidelines forManagement of Severe Sepsis and SepticShock.CritCare Med. 2008;36(1):296-327


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Thanks

Homage & Hope

BMHRC, Bhopal

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Amit Presentation 18.04