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Scott Weingart simplifies emergent data on our approaches to early, goal-directed therapy in sepsis. How a little goes a long way.
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F*Ckin’ Process
trial
Our first 15,000
Severe Sepsis Patients
The old days…
60
Hospitals
Recognition
Treatment
0%
10%
20%
30%
40%
50%
Jan-‐11 Feb-‐11 Mar-‐11 Apr-‐11 May-‐11 Jun-‐11 Jul-‐11 Aug-‐11 Sep-‐11 Oct-‐11 Nov-‐11 Dec-‐11 Jan-‐12 Feb-‐12 Mar-‐12 Apr-‐12 May-‐12 Jun-‐12 Jul-‐12 Aug-‐12 Sep-‐12
* N = 9,133
January 2011 41%
September2012 19%
January 2012 27%
22% ARR of In-Patient Mortality
How’d We Do It?
We really didn’t do
Ok there was some of
stuff…
Administrative Buy-In
Recognition
Treatment
Recognition
Treatment
They’re Not Looking!
Occult or Cryptogenic
Severe Sepsis
Triage Screen
Lactate
Lactate or
Persistent Hypotension
Turnaround <
30 Minutes
Panic Value if
≥ 4
Why are more lactates a good
thing?
How do Severe Sepsis Patients Die?
Time
Stability
Denominator Shift
Crit Care 2010;14:R77
Pneumonia 14% Severe Sepsis 40%
Pre-Lactate Screen
Pneumonia 8% Severe Sepsis 30%
Post-Lactate Screen
What did they do after they found them?
Recognition
Treatment
Treat the Source Perfuse the Tissues
Early Abx Source Control
Don’t box ‘em with the tube A Wee bit of Fluid
Pressors
Early Antibiotics
Kumar et al. & Gaieski et al.
Individual Hospital Empiric
Guidelines
Immediate Availability
Source Control
“He’s too sick to intervene”
Arterial Oxygen Saturation
How not to kill septic patients
while intubating
Responsiveness
Volume?
Empirically Gave 2-3
Liters
SWEAR ON YOUR
PATIENT’S LIFE
2nd Lactate?
Recognition
Treatment
0%
10%
20%
30%
40%
50%
Jan-‐11 Feb-‐11 Mar-‐11 Apr-‐11 May-‐11 Jun-‐11 Jul-‐11 Aug-‐11 Sep-‐11 Oct-‐11 Nov-‐11 Dec-‐11 Jan-‐12 Feb-‐12 Mar-‐12 Apr-‐12 May-‐12 Jun-‐12 Jul-‐12 Aug-‐12 Sep-‐12
* N = 9,133
January 2011 41%
September2012 19%
January 2012 27%
22% ARR of In-Patient Mortality
ARISE ProCESS ProMISe
Gain from Sepsis Interventions
Easy Crap
Mental Masturbation
95%
5%
5%
FOAMcc
Fluids Vasopressors
Endpoints
Hemodynamics
Plumber’s
Approach
Hemodynamic Resuscitation
EGDT
Fluids
Debate
Give everyone two liters of…
Balanced Crystalloid
Ann Surg. 2012 May;255(5):821-9 JAMA. 2012 Oct 17;308(15):1566-72)
HIP
Give 1 (or max 2)
liter(s) more
Tense the Tank
Critical Care 2007, 11(Suppl 2):P37 Crit Care Med 2011;39(4):689-94 Critical Care 2010, 14:R142 Crit Care Med. 2012;40(12):3146-3153 Crit Care Med. 2013 Jan;41(1):143-50
Peripheral Pressor
Administration Crit Care Med. 2013 Sep;41(9):2108-15
First 24 hrs: Think you Need
Additional Fluid?
Volume Loading by SV
After First 24 hrs:
Better have a think about it
Microcirculatory Resuscitation?
Glycocalyx
?
Goals
MAP > 65 CI > 2.2 (2.5)
Microcirc Goals?
ScvO2
2nd Lactate?
Lack of Prognostic Value of Lactate Clearance in a Center with a Severe
Sepsis Protocol
199 patients received aggressive monitored severe sepsis care.
39 patients expired during their hospital course
(18% mortality)
The mean arrival lactate was 4.8 (± 3.0) in the survivors compared to 7.3 (± 4.4) in those patients
who died (p<0.0001).
Lactates ≥4 were significantly associated with increased mortality (p<0.05).
However, the patients who achieved lactate
clearance did not have significantly improved survival when compared to those patients in
whom clearance was not achieved (p=.60).
In addition, patients with rebound in lactate ≥4, after initial clearance, showed a 10-fold increase
in mortality (p<.05).
If you are already doing the good stuff, clearance doesn’t
matter--unless they rebound…
May not be applicable to places without a team that wants to care about these
patients
emcrit.org/smacc
The old days…
Gain from Sepsis Interventions
Easy Crap
Mental Masturbation
95%
5%
5%
Stop Sepsis Deaths
You don’t need to do a whole lot of
You just need to give a
