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Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012

Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

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Page 1: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs

September 12, 2012

Page 2: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Learning Objectives

• Discuss the scope of sepsis morbidity and mortality.

• Describe the role of sepsis biomarkers in screening, diagnosis, risk stratification, and monitoring of response to therapy in sepsis.

• List factors to be considered when evaluating sepsis testing and results.

• Identify situations where point-of-care analyte testing might benefit patients with a suspected or confirmed diagnosis of sepsis.

• Apply information to assist in the identification and treatment of patients with sepsis and improve patient outcomes.

Page 3: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Introduction to Sepsis

Definition, Etiology, Morbidity and Mortality

Page 4: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Definition of Sepsis

ACCP/SCCM Consensus Conference. Crit Care Med. 1992;20(6):864-74.

Sepsis – Systemic overwhelming immune response to infection. – Manifested by two or more Systemic Inflammatory

Response Syndrome (SIRS) criteria as a result of proven or suspected infection

Temperature ≥ 38°C or ≤ 36°C

HR ≥ 90 beats/min

Respirations ≥ 20/min

WBC count ≥ 12,000/mm3 or ≤

4,000/mm3

or > 10% bands

PaCO2 < 32 mmHg

Page 5: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis is Serious.

Complex chain of events: – Inflammatory and anti-inflammatory processes – Humoral and cellular reactions – Circulatory abnormalities

Results in impaired blood flow, which damages organs by depriving them of nutrients and oxygen. These conditions can also mask sepsis

http://www.nigms.nih.gov/Education/factsheet_sepsis.htm

Inflammation Procoagulants

Antifibrinolytic Events

Sepsis

Page 6: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

“Except on few occasions, the patient appears to die from the body's response to infection rather than from it.”

Sir William Osler, 1904 “The Evolution of Modern Medicine”

Page 7: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Common Locations for Sepsis Infections

http://www.nigms.nih.gov/Education/factsheet_sepsis.htm

Lungs

Urinary Tract

Abdomen

Vascular Catheters

(endovascular)

Appendix

Skin and soft tissue

Page 8: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Clinical Manifestations of Shock Delirium and Encephalopathy

Acute Lung Injury or ARDS Oliguria

Anuria ↑ Creatinine Metabolic acidosis

↓ Platelets ↑ PT/APTT ↓ Protein C ↑ D-dimer

Adrenal Dysfunction

Altered Glucose Metabolism

Jaundice ↑ Enzymes ↓ Albumin ↑ PT

Gut Dysfunction

Hyperpyrexia or Hypothermia

ARDS: Acute respiratory distress syndrome; PT: Prothrombin time; APTT: Activated partial thromboplastin time

Page 9: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Signs and Symptoms of Sepsis

Sepsis can begin in different parts of the body and can have many different symptoms.

Rapid breathing and a change in mental status, may be the first signs of sepsis.

Other symptoms include: • Fever • Chills/hypothermia • Decreased

urination • Tachycardia • Nausea and

vomiting

Page 10: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Severe Sepsis

Bone RC, Balk RA, Cerra FB et al. Chest. 1992;101:1644-55.

Trauma

Infection

Sepsis Other

Pancreatitis

Burns

SIRS

The Relationship Between SIRS, Sepsis, and Severe Sepsis

Septic Shock

Page 11: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

The Sepsis Continuum

Adapted from Bone RC, Balk RA, Cerra FB et al. Chest. 1992;101:1644-55.

Infection/Trauma SIRS Sepsis Severe Sepsis

Septic Shock

Systemic Inflammatory Response Syndrome A clinical response arising from a nonspecific insult, including ≥ 2 of the following: • Temperature > 38ºC or < 36ºC • Heart rate > 90 beats/min • Respiratory rate > 20

breaths/min or PaCO2 < 32 Torr • WBC > 12,000 cells/mm3,

< 4,000 cells/mm3, or > 10% immature

SIRS with a presumed or confirmed infection

Sepsis with ≥ 1 sign of organ failure: • Cardiovascular

(refractory hypotension) • Renal • Respiratory • Hepatic • Hematologic • CNS • Unexplained metabolic

acidosis

Local or systemic Infection or traumatic injury

Severe sepsis perfusion abnormalities such as lactic acidosis, oliguria, or an acute alteration in mental status. Immediate intervention needed to prevent death: • Fluid resuscitation • Reversal of

hypotention • Antibiotics

Page 12: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Microbes

Many different types of microbes can cause sepsis:

http://www.nigms.nih.gov/Education/factsheet_sepsis.htm

CDC/ Matthew J. Arduino CDC/ Robert Simmons

Staphylococcus sp. (Bacteria) Aspergillus sp. (Fungi) Influenza (Virus)

CDC/ Erskine. L. Palmer, PhD; M. L. Martin

• Severe cases often result from a localized infection but sepsis can also spread throughout the body.

– Bacteria (most common) – Fungi – Viruses

Page 13: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Incidence in the United States: 2000

Martin GS, Mannino DM, Eaton S et al. N Engl J Med. 2003;348:1546-54. SEER Cancer Statistics Review. National Cancer Institute. www.cancer.gov. 2007. HIV/AIDS Surveillance Report. Centers for Disease Control. 2001;11. Incidence & Prevalence: 2006 Chart Book on Cardiovascular and Lung Diseases. NHLBI, NIH. 2006. Turabelidze G. J Neurol Sci. 2008;269:158-62.

0

50

100

150

200

250

Sepsis Breast Cancer

Acute Myocardial

Infarction

Multiple Sclerosis

Lung Cancer

Colon Cancer

AIDS

Inci

denc

e pe

r 100

,000

Sepsis mortality rates are higher too

Page 14: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Incidence

Martin GS et al. N Engl J Med. 2003;348:1546-54.

1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001

300

200

100

0

Men Women

Popu

latio

n-A

djus

ted

Inci

denc

e

of S

epsi

s (N

o./1

00,0

00)

Increases in: Hospital acquired infections? Resistant bacteria? Px with compromised immune

systems? Px with indwelling devices such as

catheters or ventilators?

Page 15: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Incidence (cont’d)

Page 16: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Incidence Rises w/Age

Page 17: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Martin GS, Mannino DM, Eaton S et al. N Engl J Med. 2003;348:1546-54.

1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001

Other Black White

Popu

latio

n-A

djus

ted

Inci

denc

e

of S

epsi

s (N

o./1

00,0

00)

500

400

300

200

100

0

Sepsis Incidence by Race

Page 18: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis = Longer Hospital Stays

Page 19: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Mortality Rates

Only 2% of hospitalizations in 2008 were for septicemia or sepsis, yet they made up 17% of in-hospital deaths.

CDC/NCHS, National Hospital Discharge Survey, 2008..

In hospital mortality Population Sepsis Other Diagnosis General 17% 2% < 65 years old 13% 1% > 65 years old 20% 3%

Page 20: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

AIDS Severe Sepsis

Breast Cancer

Mortality Rates

• Sepsis remains the leading cause of death in critically ill patients in the United States.

• Each year 750,000 people will develop sepsis.

• Leading non-cardiac cause of death in ICUs

• Mortality rates between 28-50%!

Angus DC, Linde-Zwirble WT, Lidicker J et al. Crit Care Med. 2001;29(7):1303-10.

National Center for Health Statistics, 2001. American Cancer Society, 2001.

Mortality rates in floor beds is much higher than in EDs or critical

care wards.

Page 21: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

33% of SIRS patients will develop sepsis.

25% of septic non-ICU patients and 50% of septic ICU patients develop severe sepsis

This is ~11% of all in-hospital patients and ~25% of ICU patients

25% of patients with severe sepsis develop septic shock

Page 22: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Morbidity and Mortality

In severe cases, one or more organs fail. • Worst case scenario:

o Blood pressure drops o Septic shock o Multiple organ system failure o Death

• The number of sepsis cases per year has been on the rise: o Aging population, the increased longevity of people

with chronic diseases, the spread of antibiotic-resistant organisms, an upsurge in invasive procedures and broader use of immunosuppressive and chemotherapeutic agents.

http://www.nigms.nih.gov/Education/factsheet_sepsis.htm

Page 23: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

How Do I Decide Who is Really Sick With an Infection?

Page 24: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Biomarkers

Use in Diagnosis, Risk, and Response

Page 25: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Utility of Biomarkers

Diagnosis/ Differentiation

Prognostication • Value of baseline • Value of change

over time

Following success/failure of

therapy

Page 26: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Diagnosis of Sepsis

Bacteria in the blood or other body fluids Source of the infection A high or low white blood cell count

A low platelet count Low blood pressure Too much acid in the blood (acidosis) Altered kidney or liver function Biomarkers

Page 27: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Diagnosis of sepsis and evaluation of its severity is complicated by the highly variable and non-specific

nature of signs and symptoms.

Distinguishing patients with

localized infections or SIRS from those with sepsis is challenging.

SIRS is not specific to sepsis and can result from other

conditions such as acute pancreatitis

and immunodeficiencies.

Biomarkers of sepsis may improve diagnosis and

therapeutic decision making.

Time is vital. Every hour of delayed

diagnosis decreases survival by 7.6% (Kumar, et al. Crit

Care Med. 2006;34(6):1593.)

Sepsis Biomarkers: Screening

Lever A, Mackenzie I. Br Med J. 2007;335:879–83.

Page 28: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Biomarkers

More than 170 biomarkers have been assessed for sepsis prognosis and diagnosis

Pierrakos C, Vincent JL. Crit Care. 2010,14:R15.

• Some common biomarkers include:

WBC Lactate Procalcitonin

Interleukins and other cytokines

C-reactive protein (CRP)

Procoagulant factors

Page 29: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Biomarker Performance in Severe Sepsis With or Without Septic Shock

Linder A, Christensson B, Herwald H et al. Clin Infec Dis. 2009;49(7):1044-50.

HBP Procalcitonin IL-6 Lactate CRP WBC

Sens

itivi

ty

1-Specificity

0.0 0.2 0.4 0.6 0.8 1.0

1.0

0.8

0.6

0.4

0.2

0.0

Page 30: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Procalcitonin Accuracy

Harbarth S, Holeckova K, Froidevaux C et al. Am J Respir Crit Care Med. 2001;164:396-402.

1 - Specificity

1.00

0.75

0.50

0.25

0.00

Sens

itivi

ty

0.00 0.25 0.50 0.75 1.00

Clinical model with PCT AUC: 0.94

Clinical model without PCT AUC: 0.77

Page 31: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Procalcitonin Reference Range

Normal subjects < 0.5 pg/ml

Chronic inflammatory processes and autoimmune diseases < 0.5 pg/ml

Viral infections < 0.5 pg/ml

Mild to moderate localized bacterial infections < 0.5 pg/ml

SIRS, multiple trauma, burns 0.5 – 2 pg/ml

Severe bacterial infections, sepsis, multiple organ failure

> 2 pg/ml (often 10 – 100 pg/ml)

ACCP/ Society of Critical Care Medicine Consensus Conference. Crit Care Med. 1992;20:864-74. Harbarth S, Holeckova K, Froidevaux C et al. Am J Respir Crit Care Med. 2001;164:396-402. Christ-Crain M, Jaccard-Stolz D, Bingisser R et al. Lancet. 2004;363:600-7.

Page 32: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Lobo SM, Lobo FR, Bota DP et al. Chest. 2003;123:2043-9.

CRP Levels Correlate With Mortality and Organ Failure in Sepsis

30

20

10

0

30

20

10

0

*

* p < 0.05

Number of Organ Failures

0 1 2 3 > 4 (116/115) (111/110) (56/56) (20/19) (4/4)

Day 0 Day 2

CR

P m

g/dL

CR

P m

g/dL

CRP Day 0 CRP Day 2 Non-Survivors

Survivors

p = 0.002 p = 0.001

Survivors vs. Non-Survivors

Page 33: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Global Tissue Hypoxia: A More Sensitive Measure of Shock

Oxygen Balance

Global Tissue Hypoxia

Lactic Acid > 4 mM/L

Page 34: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Lactic Acidosis

Mizock BA, Falk JL. Crit Care Med. 1992;20:80-95.

Glycogen Glucose Pyruvate

Lactate

Citric Acid Cycle

CO2 H2O

(Cytoplasm) (Mitochondria)

Anaerobic Glycolysis

1 Glu + 2 ADP + 2 Pi

2 Lactate + 2 ATP

1 Glu + 6 O2 + 38 ADP + 38 Pi

6 CO2 + 6 H20 + 38 ATP

O2

Aerobic Glycolysis

Page 35: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

http://www.uic.edu/classes/bios/bios100/lecturesf04am/lect12.htm

Page 36: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

http://www.uic.edu/classes/bios/bios100/lecturesf04am/lect12.htm

Page 37: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Lactic Acidosis

Mizock BA, Falk JL. Crit Care Med. 1992;20:80-95.

Glycogen Glucose Pyruvate

Lactate

Citric Acid Cycle

CO2 H2O

(Cytoplasm) (Mitochondria)

Anaerobic Glycolysis

1 Glu + 2 ADP + 2 Pi

2 Lactate + 2 ATP

1 Glu + 6 O2 + 38 ADP + 38 Pi

6 CO2 + 6 H20 + 38 ATP

O2

Aerobic Glycolysis

X X X X

Page 38: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Lactate and Prognosis

Auden J, Bernsein WK, Khastgir T et al. J Am Med Assoc. 1994;272:1678-85.

Page 39: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Lactate

There is evidence that serum lactate levels may carry prognostic value in sepsis. Risk-stratification based on serum lactate levels.

o Patients with a lactate of > 4 mmol/L had a mortality of > 40%, compared with under 15% for patients with a lactate of < 2 mmol/L.1

Other studies have shown lactate to be predictive of critical care admission.2

1 Drumheller B, Goyal M, Pines J et al. Ann Emerg Med. 2007;50:S21-2. 2 Chan YL, Tseng CP, Tsay PK et al. Crit Care Med. 2004;8:R12-20.

Page 40: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

38-40%

28 day in-hospital mortality Death within 3 days

Lactate1

30

25

20

15

10

5

0 0-2.4 2.5-3.9 > 4.0

% o

f Mor

talit

y R

ate

% o

f Mor

talit

y R

ate

0-2.4 2.5-3.9 > 4.0 N = 827 N = 238 N = 112

Initial Lactate (mmol/L)2

50

40

30

20

10.0

0.0

Serum Lactate as a Predictor of Mortality

1 Trzeciak S, Dellinger RP, Chansky ME et al. Intensive Care Med. 2007;33:970-7. 2 Shapiro NI, Howell MD, Talmor D et al. Ann Emerg Med. 2005; 45:524-8.

28%

Page 41: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Serum Lactate and Mortality in Severe Sepsis

Initial serum lactate evaluated in 839 adults admitted with severe sepsis. High initial serum lactate

associated with ↑ mortality regardless of presence of shock or MODS.

Mikkelsen ME, Miltiades AN, Gaieski DF et al. Crit Care Med. 2009;37:1670-7.

Low Int High

Shock Non-Shock

28-D

ay M

orta

lity

(%)

50 45 40 35 30 25 20 15 10 5 0

p < 0.001

p = 0.001

p = 0.022

p = 0.024

Low Int High

MODS=Multiple Organ Dysfunction Syndrome, also MSOF; Multisystem Organ Failure.

Page 42: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Jansen TC, van Bommel J, Mulder PG et al. Crit Care. 2008,12:R160.

Prognostic Value of Serum Lactate

Page 43: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Jansen TC, van Bommel J, Mulder PG et al. Crit Care. 2008,12:R160.

Serum Lactate as a Predictor of Mortality

Mea

n La

ctat

e Le

vel (

mm

ol/L

) 7

6

5

4

3

2

1

0

Arrival Scene (T1) Emergency Department (T2)

Non-survival Survival

p = 0.001 p < 0.001

Page 44: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Adapted from Jansen TC, van Bommel J, Mulder PG et al. Crit Care. 2008,12:R160.

8/66 (12%)

Mortality

24/58 (41%)

Mortality p < 0.001

7 Missing (4 Died)

11 Missing (0 Died)

First Lactate Measurement

Second Lactate Measurement

N = 55

8/54 (15%)

Mortality

0/1 (0%)

Mortality

p = 1.00

N = 51

2/14 (14%)

Mortality

18/37 (49%)

Mortality

p = 0.025

N = 106

10/68 (15%)

Mortality

18/38 (47%)

Mortality p < 0.001

N = 124

< 3.5 mmol/l ≥ 3.5 mmol/l

< 3.5 mmol/l ≥ 3.5 mmol/l < 3.5 mmol/l ≥ 3.5 mmol/l

< 3.5 mmol/l ≥ 3.5 mmol/l

Second Lactate Cumulative

Value of Blood Lactate Levels

Page 45: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Jansen TC, van Bommel J, Mulder PG et al. Crit Care. 2008,12:R160.

Lactate, SBP, and Mortality

Mor

talit

y (%

)

SBP (mmHg) Lactate (mmol/l)

< 100 > 100

> 3.5

< 3.5

60

50

40

30

20

10

0

Page 46: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Lactate May Predict Mortality in Sepsis

Hermans MAW, Leffers P, Jansen LM et al. Emerg Med J. 2011;Epub.

Sens

itivi

ty

1-Specificity 0.0 0.2 0.4 0.6 0.8 1.0

1.0

0.8

0.6

0.4

0.2

0.0

Predictor AUC (95% CI) MEDS 0.81 (0.73-0.88)

CRP 0.68 (0.58-0.78)

Lactate 0.75 (0.60-0.90)

MEDS (n = 331) Lactate (n = 47) CRP (n = 326)

Mortality in Emergency Department Sepsis

Page 47: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Improving Lactate a Good Prognostic Sign

Bakker J, Gris P, Coffernils M et al. Am J Surg. 1996;171:221-6.

INITIAL +8h +16h +24h FINAL

8

6

4

2

0

Time

Lact

ate

(mm

ol/L

)

Survivors

Non-survivors p < 0.05 p < 0.05

p < 0.01

Page 48: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis is No Longer Just an ICU Disease

Levy MM, Dellinger RP, Townsend SR et al. Crit Care Med. 2010;38:367-74.

Page 49: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

You have to go to the disease instead of waiting for it to come to you!

Hospital Origin and Mortality

Origin Mortality

Surviving Sepsis Campaign. http://ssc.sscm.org.

ED 52.4% 27.6% ICU 12.8% 41.3% Wards 34.8% 46.8%

Page 50: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Risk Stratification of Sepsis

Surviving Sepsis Campaign. http://ssc.sscm.org.

Hypotension, vasopressors 36.7%

Lactate > 4 mmol/L only 30.0%

SBP < 90 mmHg and lactate > 4 mmol/L 46.1%

Mortality Risk

Page 51: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Biomarkers: Monitoring Response to Therapy

1 Nguyen HB, Rivers EP, Knoblich BP et al. Crit Care Med. 2004;32(8):1637-42. 2 Becker KL, Snider R, Nylen ES. Crit Care Med. 2008;36(3):941-52. 3 Nguyen HB, Loomba M, Yang JJ et al. J Inflam. 2010;7:6.

Lactate levels are particularly useful when measured serially, to guide response to resuscitation and fluid therapy.

Lactate clearance (≥ 10% decrease in lactate concentration between initial and repeat measurements) has been shown to be a better prognostic factor than a single lactate determination.1,2

Early goal-directed therapy targeting global tissue hypoxia may be more effective than standard care in decreasing lactate during the first six hours of intervention.3

Page 52: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

12-Month Survival Based on Lactate Clearance Quartile

Nguyen HB, Loomba M, Yang JJ et al. J Inflam. 2010;7:6. *During the first 6 hours in the emergency department (p < 0.01).

Mor

talit

y Pr

obab

ility

Lactate Clearance Quartiles*

0 2 4 6 8 10 12

1.0

0.8

0.6

0.4

0.2

0.0

Time (Months)

1 (-24.3 ± 42.3%) 2 (30.1 ± 7.5%) 3 (53.4 ± 6.6%) 4 (75.1 ± 7.1%)

Page 53: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Testing and Results

Guidelines, Algorithms, and Protocols

Page 54: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Blood gases Electrolytes Glucose Hematocrit Lactate

Factors to Consider When Evaluating Sepsis

Page 55: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Resuscitation Bundle

The Sepsis Resuscitation Bundle is published by the Surviving Sepsis

Campaign and is used by multiple hospitals across

the country.

The goal is to perform all indicated tasks 100% of the time within the first 6 hours of identification of

severe sepsis.

Surviving Sepsis Campaign. http://ssc.sscm.org.

Page 56: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

© Surviving Sepsis Campaign and the Institute for Healthcare Improvement 56

1

Evaluation for Severe Sepsis Screening Tool

Page 57: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

1. Is the patient’s history suggestive of a new infection?

Pneumonia, empyema Skin/soft tissue infection

Endocarditis

UTI Bone/joint infection Implantable device infection

Acute abdominal infection

Wound infection Other ____________

Meningitis Bloodstream catheter infection

57

Yes No

© Surviving Sepsis Campaign and the Institute for Healthcare Improvement

Page 58: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

58

1

2

Yes

No

© Surviving Sepsis Campaign and the Institute for Healthcare Improvement

Evaluation for Severe Sepsis Screening Tool

Page 59: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

2. Are any of the following signs and symptoms of infection both present and new to the patient?

Hyperthermia > 38.3 ºC Tachypnea > 20 bpm Leukopenia (WBC count < 4000 ul-1

Hypothermia < 36 ºC Acutely altered mental status

Hyperglycemia (plasma glucose > 120 mg/dL) in the absence of diabetes

Tachycardia > 90 bmp Leukocytosis (WBC count > 12,000 uL-1)

59

Note: Laboratory values may have been obtained for inpatients but may not be available for outpatients

© Surviving Sepsis Campaign and the Institute for Healthcare Improvement

Yes No

Page 60: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

60

1

2

3

Yes*

Yes*

No

No STOP *If the answer is yes to either 1 or 2, suspicion of infection is present. • Obtain lactate, blood cultures, CBC with

differential, basic chemistry labs, bilirubin • At the physician’s discretion obtain: UA, chest X-

ray, amylase, lipase, ABG, CRP, CT scan

© Surviving Sepsis Campaign and the Institute for Healthcare Improvement

Evaluation for Severe Sepsis Screening Tool

Page 61: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

3. Are any of the following organ dysfunction criteria present at a site remote from the site of the infection that are not considered to be chronic conditions?

SBP < 90 mm Hg or MAP < 65 mm Hg

Bilateral pulmonary infiltrates with PaO2/FiO2 ratio < 300

Platelet count < 100,000

SBP decrease > 40 mm Hg from baseline

Creatinine > 2.0 mg/dL or urine output <0.5 mL/kg/hour for >20 hours

Coagulopathy (INR >1.5 or aPTT > 60 sec)

Bilateral pulmonary infiltrates with a new (or increased) oxygen requirement to maintain SpO2 > 90%

Bilirubin > 2 mg/dL Lactate > 2 mmol/L

61

Note: The remote site stipulation is waived in the case of bilateral pulmonary infiltrates

Yes No

© Surviving Sepsis Campaign and the Institute for Healthcare Improvement

Page 62: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Evaluation for Severe Sepsis Screening Tool

62

1

2

3

STOP

Sepsis Resuscitation

Bundle

Sepsis Management

Bundle

Severe Sepsis

ASAP and scored over first 6 hours

ASAP and scored over first 24 hours

Yes*

Yes*

Yes No

No

No

*If the answer is yes to either 1 or 2, suspicion of infection is present. • Obtain lactate, blood cultures, CBC with

differential, basic chemistry labs, bilirubin • At the physician’s discretion obtain: UA, chest X-

ray, amylase, lipase, ABG, CRP, CT scan

© Surviving Sepsis Campaign and the Institute for Healthcare Improvement

Page 63: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Resuscitation Bundle To be accomplished as soon as possible and scored over the first 6 hours

© Surviving Sepsis Campaign and the Institute for Healthcare Improvement

Serum lactate measured

Blood cultures obtained prior to antibiotic administration

From the time of presentation, broad-spectrum antibiotics administered within 3 hours for ED admissions and 1 hour for non-ED ICU admissions

In the event of hypotension and/or lactate > 4 mmol/L •Deliver an initial minimum of 20 mL/kg of crystalloid (or colloid equivalent) •Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain MAP > 65 mm Hg

In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L •Achieve central venous pressure of > 8 mm Hg •Achieve central venous oxygen saturation of > 70%

Page 64: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Treatment Guidelines

Antibiotic therapy Begin intravenous antibiotics as early as possible

• Always within the first hour of recognizing severe sepsis and septic shock.

Broad-spectrum

• One or more agents active against likely bacterial/fungal pathogens and with good penetration into presumed source.

Reassess antimicrobial regimen daily to optimize efficacy, prevent resistance, avoid toxicity, & minimize costs.

Consider combination therapy in Pseudomonas infections.

Surviving Sepsis Campaign. http://ssc.sscm.org.

Page 65: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Treatment Guidelines

Antibiotic therapy Consider combination empiric therapy in

neutropenic patients. Combination therapy no more than 3-5 days and

de-escalation following susceptibilities Duration of therapy typically limited to 7-10 days

• Longer if response slow, undrainable foci of infection, or immunologic deficiencies.

Stop antimicrobial therapy if cause is found to be non-infectious

Surviving Sepsis Campaign. http://ssc.sscm.org.

Page 66: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Treatment Guidelines

Fluid therapy Fluid-resuscitate using crystalloids or colloids. Target a CVP of ≥ 8 mmHg (≥ 12 mmHg if mechanically

ventilated). Use a fluid challenge technique while associated with a

hemodynamic improvement. Give fluid challenges of 1000 mL of crystalloids or 300–500 mL

of colloids over 30 minutes. • More rapid and larger volumes may be required in sepsis-

induced tissue hypoperfusion. Rate of fluid administration should be reduced if cardiac filling

pressures increase without concurrent hemodynamic improvement.

Surviving Sepsis Campaign. http://ssc.sscm.org.

Page 67: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Treatment Guidelines

Inotropic therapy Use dobutamine in patients with myocardial

dysfunction • Supported by elevated cardiac filling

pressures and low cardiac output.

Do not increase cardiac index to redetermined supranormal levels.

Surviving Sepsis Campaign. http://ssc.sscm.org.

Page 68: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Treatment Guidelines

Vasopressors – Maintain MAP ≥ 65 mmHg. – Norepinephrine or dopamine centrally administered

are the initial vasopressors of choice. – Epinephrine, phenylephrine, or vasopressin should

not be administered as the initial vasopressor in septic shock. Vasopressin use may be considered in patients

with refractory shock despite adequate fluid resuscitation and high-dose conventional vasopressors.

Surviving Sepsis Campaign. http://ssc.sscm.org.

Page 69: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Sepsis Management Bundle

To be accomplished as soon as possible and scored over the first 24 hours

© Surviving Sepsis Campaign and the Institute for Healthcare Improvement

Low-dose steroids administered for septic shock in accordance with standardized ICU policy

Drotecogin alfa (activated) administered in accordance with standardized ICU policy

Glucose control maintained > lower limit of normal but < 150 mg/dL

Inspiratory plateau pressures maintained < 30 cm H2O for mechanically ventilated patients.

Page 70: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Is it Working?

15,775 patients at 252 participating Surviving Sepsis

sites1

Unadjusted hospital mortality

decreased from 37% to 30.8% over a 2 year

period

1. Intensive Care Med (2010) 36:222-231, 2. Crit Care Med (2011) 39:252-258, 3. Ann Pharmacother (2010) 44:1733-1738

Page 71: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Is it Working?

15,775 patients at 252 participating Surviving Sepsis

sites1

Unadjusted hospital mortality

decreased from 37% to 30.8% over a 2 year

period

33-month study period at Mayo-

MN2

Bundle compliance rose from

12.7% to 52.7%

Mortality declined from 30.3% to 22%

1. Intensive Care Med (2010) 36:222-231, 2. Crit Care Med (2011) 39:252-258, 3. Ann Pharmacother (2010) 44:1733-1738

Page 72: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Is it Working?

15,775 patients at 252 participating Surviving Sepsis

sites1

Unadjusted hospital mortality

decreased from 37% to 30.8% over a 2 year

period

33-month study period at Mayo-

MN2

Bundle compliance rose from

12.7% to 52.7%

Mortality declined from 30.3% to 22%

Medical City Plano (TX) evaluation3

Mortatility in the non-bundle

group: 61.1%

Mortality in the bundle group:

20%

1. Intensive Care Med (2010) 36:222-231, 2. Crit Care Med (2011) 39:252-258, 3. Ann Pharmacother (2010) 44:1733-1738

Page 73: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Is it Working?

15,775 patients at 252 participating Surviving Sepsis

sites1

Unadjusted hospital mortality

decreased from 37% to 30.8% over a 2 year

period

33-month study period at Mayo-

MN2

Bundle compliance rose from

12.7% to 52.7%

Mortality declined from 30.3% to 22%

Medical City Plano (TX) evaluation3

Mortatility in the non-bundle

group: 61.1%

Mortality in the bundle group:

20%

1. Intensive Care Med (2010) 36:222-231, 2. Crit Care Med (2011) 39:252-258, 3. Ann Pharmacother (2010) 44:1733-1738

Page 74: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Point-of-Care Analyte Benefits

A 2010 study published in the Journal of Emergency Medicine found that point-of-care testing provided a reliable and feasible way to measure serum lactate at the bedside.1

1 Shapiro NI, Fisher C, Donnino M et al. J Emerg Med. 2010;39:89-94. 2 Montassier E, Batard E, Segard J et al. Am J Emerg Med. 2010. Epub ahead of print. 3 Martin MJ, FitzSullivan E, Salim A et al. Am J Surg. 2006;191:625-30. 4 Moore CC, Jacob ST, Pinkerton R et al. Clin Infect Dis. 2008;46:215-22.

• Point-of-care lactate is useful in the diagnosis of sepsis at the bedside

– Recommended for institutions where clinical decisions are limited by lack of laboratory infrastructure or reliability.4

• Base excess (BE) – Some studies suggest BE is an accurate marker for the

prediction of elevated lactate in the emergency department (ED).2

– Some studies also show poor correlation due to effects of other conditions.3

Page 75: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Turnaround Time

Serum lactate must be available with rapid turnaround time (within minutes) to effectively treat severely septic patients.

An arterial blood gas analyzer located in the clinical laboratories usually accomplishes this.

Hospitals should invest in adequate equipment in to meet present standards of care for septic patients.

If a central analyzer is not efficient in a particular hospital setting, point-of-care analyzers should be evaluated for faster turnaround time.

http://www.survivingsepsis.com/bundles/individual_changes/serum_lactate. www.emcrit.org/wp-content/uploads/lactate-faq.pdf.

Page 76: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Case Study

Page 77: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Case Study: Mr. Z

• He tells you “My tooth is killing me! You can pull it if you need to. I feel like it is going to explode.”

• His tooth pain is severe and he came to the emergency department since he could not see his dentist until the morning. He has drainage from tooth #20, for which a culture has been obtained and sent to the lab.

• Mr. Z is a 47 year-old male who was admitted to the emergency department. He is complaining of a toothache that has been present for 7 days.

Page 78: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Case Study: Mr. Z

• He’s been started on antibiotics.

• Mr. Z is alert and oriented.

• He has a history of hypertension and had a hemorrhagic stroke 10 years ago but has had no major health issues since this time.

• His heart and lung sounds are normal and his skin is cool and moist. He has good capillary refill, abdomen soft and non-tender.

Page 79: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Case Study: Mr. Z

Admission Heart Rate 111

Temperature 38.7

SPO2 0.96

BP 128/88

Respiratory Rate 22

Serum Lactate

1) Does Mr. Z have signs of sepsis? Yes

2) What blood test would be useful? Lactate

Page 80: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Case Study: Mr. Z

Admission After 20 mg/kg normal saline (10 minutes)

Heart Rate 111 104

Temperature 38.7 38.6

SPO2 0.96 0.96

BP 128/88 130/88

Respiratory Rate 22 22

Serum Lactate 4.0

75 kg = 165 lbs » » Me! 20 mg/kg = 1.5 L!

Page 81: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Case Study: Mr. Z

Admission After 20 mg/kg normal saline (10 minutes)

After 4 Hours

Heart Rate 111 104 88

Temperature 38.7 38.6 38.1

SPO2 0.96 0.96 0.98

BP 128/88 130/88 133/78 (94)

Respiratory Rate 22 22 17

Serum Lactate 4.0 1.8

• A decrease in lactate shows improved perfusion. • If the lactate had remained elevated, more fluids could have been given. • The use of the lactate allowed the clinician to better evaluate the severity

of the situation. • Often, vital signs are normal when lactates are elevated

Page 82: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives
Page 83: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Applications

Identification, Treatment, and Outcomes

Page 84: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Treatment of Patients With Sepsis

Early goal-directed therapy: standard operating procedure Apply with critical care/sepsis team if patient

remains hypotensive or lactate remains high following fluid challenges

Daniels R. J Antimicrob Chemother. 2011;66(Suppl 2):ii11–ii23.

1. Site central venous catheter using ultrasound guidance where practicable, according to proper procedures for infection control

2. If central venous pressure (CVP) < 8 mmHg, give further fluid challenges to achieve a target CVP of > 8 mmHg (> 12 mmHg if ventilated) unless the patient shows signs of fluid overload

3. If patient remains hypotensive, start a norepinephrine infusion to target SBP > 90 mmHg or MBP > 65 mmHg.

Page 85: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Improve Patient Outcomes

Nguyen HB, Rivers EP, Knoblich BP et al. Crit Care Med. 2004;32(8):1637-42. Afessa B, Keegan MT, Schramm GE et al. Crit Care Med. 2011;15(Suppl 1): P286. Boldt J, Kumle B, Suttner S et al. Acta Anaesthesiol Scand. 2001;45:194–9.

Lactate clearance is associated with improved patient outcome. Lactate measurement is associated with increased risk of death

independent of other aspects of sepsis bundle guidelines. Point-of-care measurements of lactate are faster than

central laboratories.

– May be beneficial for serial measurements.

Page 86: Spotting and Surviving Sepsis - Whitehat Communications...Spotting and Surviving Sepsis Thomas Koshy, Ph.D. Sr. Director, Scientific Affairs September 12, 2012 Learning Objectives

Questions?

Thank You!

Today is the youngest you’ll be for the rest of your life. Act like it.