septic shock
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Topic ReviewTopic ReviewSeptic Shock ManagementSeptic Shock Management
Piti Niyomsirivanich, MD.
10 Jan 2013
Take home message
• Adequate preload• Appropriate Antibiotic within 1 hr• Proper dose of vasopressors
• Consult
Outline• Definition• Pathophysiology• Early Goal Directed Therapy• Fluid Resuscitation• Vasopressors• Steroids• Antibiotics
• Glucose control• Blood product administration• Bicarbonate therapy• Stress ulcer prophylaxis
Definition• Bacteremia : Bacteria in blood• Septicemia : Bacteria + toxin in blood• SIRS : 2/4 of following conditions
– 1)Temp > 38 C or < 36 C– 2) Pulse rate > 90 /min– 3) RR > 20 /min or PaCO2 < 32 mmHg– 4) WBC > 12,000/ul or < 4000 /ul and/or Band form > 10%
• Sepsis = SIRS from infection• Severe sepsis = Sepsis+ end organ damage
– CVS , Renal , pulmonary , Hematologic ,Metabolic acidosis • Septic Shock = Sepsis + hypotension
Pathophysiology
Guideline
Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008
Since 2001 10+ years ago!!!
Result of EGDT
N Engl J Med 2001; 345:1368-1377 November 8, 2001
Early goal directed therapySIRS
+SBP < 90 mmHg or MAP < 65 mmHg
-Or-Lactate > 4 mmol/L
After 20-30 ml/kg crystalloid IVF
CultureAntibiotic within 1 hourVolume accessment
Supplement oxygen or ET tube (if necessary)
Critical care consultation
CVP ?
MAP ?
ScvO2 ?
Goals achieved
Resuscitation complete
IVF
Vasopressor (NE/dopamine)
Blood transfusion to Hct > 30%
Inotropic agent
ONEHour
Five Hours
< 8-12 mmHg
8-12 mmHg
>/= 65 mmHg
> 70%
< 65 mmHg
< 70%
N Engl J Med 2001; 345:1368-1377November 8, 2001
Sedatives & muscle relaxants
Fluid Resusitation• Fluid therapy
– crystalloids or colloids (1B)
– Target a CVP of 8-12 mmHg (1C)
– Give fluid challenges of 1000 mL of crystalloids • or 300–500 mL of colloids over 30 mins.
Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008
Frank-Starling Law
Shock
• BP = CO X TVR• CO = HR X SV• SV = EDV – ESV • BP = ( EDV- ESV ) X HR X TVR
• BP = EF X HR X TVR X EDV
EDV
X EDV
Volume
N Engl J Med 2001; 345:1368-1377November 8, 2001
Fluid
• Crystalloids– NSS– Ringer Lactate Solution
• Colloids– albumin– Dextrans– Gelatins e.g. Haemaccel– Hydroxyethylstarch e.g. Voluven
Fluid
• Crystalloids– NSS– Ringer Lactate Solution
• Colloids– albumin– Dextrans– Gelatins e.g. Haemaccel– Hydroxyethylstarch e.g. Voluven
Low cost
edemaHemodilution
Hyperchloremic metabolic acidosis
Fluid
• Crystalloids– NSS– Ringer Lactate Solution
• Colloids– albumin– Dextrans– Gelatins e.g. Haemaccel– Hydroxyethylstarch e.g. Voluven
Low cost
Lactate liverAcetate peripheral tissue
Potassium
edema
Fluid
• Crystalloids– NSS– Ringer Lactate Solution
• Colloids– albumin– Dextrans– Gelatins e.g. Haemaccel– Hydroxyethylstarch e.g. Voluven
SAFE Study * not differrent VS NSS
hypocalcemia expensive
*A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit
N ENGL J MED 2004; 350:2247-2256 May 27, 2004
Fluid
• Crystalloids– NSS– Ringer Lactate Solution
• Colloids– albumin– Dextrans– Gelatins e.g. Haemaccel– Hydroxyethylstarch e.g. Voluven
Coagulopathy (inh. F VIII/ vWF)
Renal damage
Cross matching problem
Osmotic diuresis
Anaphylaxis 0.27%
Fluid
• Crystalloids– NSS– Ringer Lactate Solution
• Colloids– albumin– Dextrans– Gelatins e.g. Haemaccel– Hydroxyethylstarch e.g. Voluven
GelofundolHaemaccel
30,000-35,000 kDa
Renal Excretion
Short half life
Anaphylaxis 0.34%
Fluid
• Crystalloids– NSS– Ringer Lactate Solution
• Colloids– albumin– Dextrans– Gelatins e.g. Haemaccel– Hydroxyethylstarch e.g. Voluven
• MW 450-480 kDa Hetastarch Hespan
•MW 200 kDa •HAES-Steril 6%,10%
•MW 70 kDa •HES 70/0.5
•Voluven
Anaphylaxis 0.058%
Cochrane Database Syst. Rev. CD 001319,2003
Volume Assessment• Static VS dynamic
• Non-invasive– U/S IVC– Passive leg raising test– Pulse oximetry plethysmographic waveform amplitude variation
• Invasive– CVP– Fluid challenge test– CVP variation– Pulse pressure variation
Volume Assessment
• Require Endotracheal tube
• No Endotracheal tube • W/WO Endotracheal tube
CVP measurement
a= Atrial contractionc= Ventricular Contractionx= Atrial relaXationv= Venous fillingy = Tr”Y”cuspids opening
CVP
• CVP : poor predictor of fluid volume
CHEST. July 2008;134(1):172-178.
Fluid Challenge Test for CVP
Load IV fluid 200-250 ml in 10 min
CVP + </=2
CVP + >/=5
CVP + 2-5
Continue fluid therapy
Decrease rate of fluid therapy
Wait
Ultrasound IVC
Caval Index = 100 x (diam expiration - diam inspiration)/diam expiration
Caval Index > 50% suggest low CVP
Ann Emerg Med 2010; 55:290-295.
Passive leg raising test
Esophageal doppler : in cardiac output > 8% predict fluid responsiveness
Critical Care 2006, 10:170
Pulse oximetry plethysmographic waveform amplitude variation
CASE BCVP =5 cmH2O
CASE ACVP =15 cmH2O
Pulse oximetry plethysmographic waveform amplitude variation
POP max – POP min X 100
POP mean
%POP variation > 13%
Arterial Line
Pulse Pressure Variation
Vasopressor therapy
• Dopamine VS Norepinephrine
Kaplan–Meier Curves for 28-Day Survival in the Intention-to-Treat Population.
N Engl J Med 2010; 362:779-789
Vasopressure therapyDopamine
Low doseModerate dose (beta adrenergic receptor ) 5-10 ug/kg/minHigh dose (alpha adrenergic receptor)
>10 ug/kg/min Maximum dose 50 ug/kg/min
Norepinephrinestart 0.5 mcg/min
Harrison Int. Med edition 18 th
Vasopressor therapyExample
ผู้��หญิ�ง 64 ปี หนั�ก 70 kg มาด้�วย ไข้� หนัาวสั่��นั ปี�สั่สั่าวะแสั่บข้�ด้CBC : WBC 25000/ul N% 85 Band 2% Hb 12 g/dl Plt 200,000/ul UA WBC 50-100
BP 80/40 mmHg PR 95/min Temp 37.8 C RR 18/min
จงคำ�านัวณ dose ข้อง Dopamine ให� start 5 ug/kg/min
Vasopressor therapyExample
ผู้��หญิ�ง 64 ปี หนั�ก 70 kg มาด้�วย ไข้� หนัาวสั่��นั ปี�สั่สั่าวะแสั่บข้�ด้CBC : WBC 25000/ul N% 85 Band 2% Hb 12 g/dl Plt 200,000/ul UA WBC 50-100
BP 80/40 mmHg PR 65/min Temp 37.8 C RR 18/min
จงคำ�านัวณ dose ข้อง Dopamine ให� start 5 ug/kg/min
Rate (ml/min)60 X W (kg) X D (ug/kg/min)
C
C = Volume
Solute1,000
Vasopressor therapyExample
ผู้��หญิ�ง 64 ปี หนั�ก 70 kg มาด้�วย ไข้� หนัาวสั่��นั ปี�สั่สั่าวะแสั่บข้�ด้CBC : WBC 25000/ul N% 85 Band 2% Hb 12 g/dl Plt 200,000/ul UA WBC 50-100
BP 80/40 mmHg PR 65/min Temp 37.8 C RR 18/min
จงคำ�านัวณ dose ข้อง Dopamine ให� start 5 ug/kg/min
Rate (ml/min)60 X 70 X 5
2000
C = 500
10001,000 = 2000
(Dopamine 1000 mg ผู้สั่ม 5%D/W 500 ml)
= 10.5 ml/hr
Early goal directed therapySIRS
+SBP < 90 mmHg or MAP < 65 mmHg
-Or-Lactate > 4 mmol/L
After 20-30 ml/kg crystalloid IVF
CultureAntibiotic within 1 hourVolume accessment
Supplement oxygen or ET tube (if necessary)
Critical care consultation
CVP ?
MAP
ScvO2
Goals achieved
Resuscitation complete
IVF
Vasopressor (NE/dopamine)
Blood transfusion to Hct > 30%
Inotropic agent
ONEHour
Five Hours
< 8-12 mmHg
8-12 mmHg
>/= 65 mmHg
> 70%
< 65 mmHg
< 70%
N Engl J Med 2001; 345:1368-1377November 8, 2001
Sedatives & muscle relaxants
ScvO2ให�เง�นัไปีโรงเร$ยนั
ข้ากลั�บเหลั&อ 50 บาท
แปีลัว(าให�เง�นัไปีโรงเร$ยนัพอใช้�
ScvO2O2 content
O2 content เหลั&อ 70%
แปีลัว(าให�ออกซิ�เจนัไปีเนั&,อเย&�อพอใช้�
ScvO2
O2 delivery
• DO2 = [1.39 x Hb x SaO2 + (0.003 x PaO2)] x CO
• Depend on – Hemoglobin– O2 saturation– Cardiac output
– ScvO2 < 70%• target Hct > 30• Inotropic drug increase cardiac output
ScvO2
Goals achieved
Blood transfusion to Hct > 30
Inotropic agent> 70%
< 70%
Contin Educ Anaesth Crit Care Pain (2004) 4 (4) 123-126
Alternative for ScvO2
• Lactate clearance– lactate clearance >10% or higher
• 6% lower in-hospital mortality than those resuscitated to an ScvO2 of at least 70%
– (95% CI, −3% to 15%)– noninferiority trial.
JAMA. 2010 Feb 24;303(8):739-46.
Antimicrobial Therapy• administration of broad-spectrum antibiotic therapy within 1
hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D);
• reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C);
• a usual 7–10 days of antibiotic therapy guided by clinical response (1D);
• source control with attention to the balance of risks and benefits of the chosen method (1C);
Survival Sepsis Guideline .Crit Care Med 2008
Empirical Antibiotic• Host
– Immunocompetent– Neutropenia– IVDU– Post Splenectomy– AIDS
• Risk factors & exposures• Site of infection
• Antibiotics of choice ??
Antibiotic therapy in patients with septic shock European Journal of Anaesthesiology (EJA). 28(5):318-324, May 2011
Tips
• every 10 min, survival is decreased by 1%.*
• First dose Full dose– Then renal adjustment
* Antibiotic therapy in patients with septic shock European Journal of Anaesthesiology (EJA). 28(5):318-324, May 2011
De-escalate Therapy
• De-escalate Empirical antimicrobial therapy in life-threatening situations– Start with Broad Spectrum
• ‘Broad-spectrum antibiotics’ refers to antibiotics with activity against Pseudomonas aeruginosa, including imipenem-cilastatin, piperacillin-tazobactam, ceftazidime or ciprofloxacin.
• Limited-spectrum antibiotics will only refer to β-lactam antibiotics without activity against P. aeruginosa (essentially, ceftriaxone and amoxicillin-clavulanate).
Antibiotic therapy in patients with septic shock European Journal of Anaesthesiology (EJA). 28(5):318-324, May 2011
De-escalate Therapy : Life Threatening
• "สั่�,นัๆ แต่( aggressive" แลั�วปีร�บลังมา– Recurrent infections were more common in Group No
De-escalate (19% versus 5%, P = 0.01)– An inadequate empiric antibiotic therapy was more
frequent in Group No De-escalate (27.5% versus 7.7% P = 0.02)
– Mortality between the two groups 18.3% (D) vs 24.6% (ND)
Critical Care 2010, 14:R225
Antibiotic therapy in patients with septic shock European Journal of Anaesthesiology (EJA). 28(5):318-324, May 2011
Steroids in CIRCI(critical illness related corticosteroid insufficiency)
•stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C)
•Survival Sepsis Guideline 2008
Serum cortisol•< 15 ug/dl definite adrenal insufficiency•13-35 ug/dl Suspected•>35 ug/dl no benefit
•สั่มาคำมเวช้บ�าบ�ด้ว�กฤต่�แห(งปีระเทศไทย
Steroids in CIRCI
Surge in cortisol (> 9 ug/dl) response to ACTH 250 ug stimulation
Benefit from steroids
JAMA. 2002 Aug 21;288(7):862-71
CIRCI
Baseline cortisol level < or = 35 microg/dl is a useful diagnostic threshold for diagnosis of steroid responsiveness in Thai patients with septic shock
ACTH stimulation test should not be used
sensitivity was 85%, the specificity was 62%
J Med Assoc Thai 2010 Jan;93 Suppl 1:S187-95
CIRCI
• Hydrocortisone 100 mg bolus then 200 mg V drip in 24 hr
• OR
• Hydrocortisone bolus q 4-6 hr NOT q 8 hr– e.g. Hydrocortisone 50 mg V q 6 hr
• Then taper off
Blood Sugar control
Blood Sugar control
• NICE-SUGAR study– 3050 patients– Medicine & Surgery Ward– Multicenter randomized open label study– ICU & non ICU
– Intensive control 81-108 mg%– Conventional control 144-180 mg%
The NICE-SUGAR Study InvestigatorsN Engl J Med 2009; 360:1283-1297March 26, 2009
NICE-SUGAR Study
The NICE-SUGAR Study InvestigatorsN Engl J Med 2009; 360:1283-1297March 26, 2009
Sliding Scale Insulin
Basal Insulin with Scheduled Insulin (prandial insulin) with Correctional dose
• CBG (ก(อนัอาหาร) เช้�า กลัางว�นั เย1นั ก(อนันัอนั
Somchai Pathanaangkul ,Royal Thai Army Medical Journal Vol 57 No.4 Oct.-Dec. 2004
Blood Transfusion● Give red blood cells when hemoglobin decreases to 7.0 g/dL (70 g/L) to targe
t a hemoglobin of 7.0–9.0 g/dL in adults (1B). A higher hemoglobin level may be required in special circumstances (e.g., myocardial ischaemia, severe hypoxemia, acute hemorrhage, cyanotic heart disease, or lactic acidosis)
● Do not use erythropoietin to treat sepsis-related anemia. Erythropoietin may be used for other accepted reasons (1B) Do not use fresh frozen plasma to correct laboratory clotting abnormalities unless there is bleeding or planned invasive procedures (2D)
● Do not use antithrombin therapy (1B)Administer platelets when (2D) Counts are 5000/mm3 (5 109/L) regardless of bleeding
Counts are 5000–30,000/mm3 (5–30 109/L) and there is significant bleeding risk
Higher platelet counts (50,000/mm3 [50 109/L]) are required for surgery or invasive procedures
Blood Transfusion• TRICC Study
– Study design: Multicenter RCT– Setting: 25 ICUs across Canada– Hb
• 7-9 g/dl (Restrictive Strategy) • 10-12 g/dl (Liberal Strategy)
– Primary Outcome : mortality rate 30 days– Results
• Hb 7-9 g/dl group mortality rate 22.2%• Hb 10-12 g/dl mortality rate 28.1% • (P=0.05)
TRICC Study
Hb 7-9 g/dl
Hb 10-12 g/dl
Bicarbonate Therapy
• We recommend against the use of sodium bicarbonate therapy for the purpost of improving hemodynamics or reducing vasopressure requirement with hypoperfusion-induced lactic acidemia with pH > 7.15 (1B)
Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008
Hb O2 Dissociation curve
Stress Ulcer Prophylaxis
• We recommend that stress ulcer prophylaxis using H2 blocker (1A)
• Or PPI (1B) be given to patients with severe sepsis to prevent upper GI bleed.
• Weighted aginst the potential effect of an increased stomach pH on development of VAP
Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008
Other
• Sucralfate*– Not associated with an increase in stress
ulceration.– Less impact gastric colonization Less VAP– Increase aspiration
• Enteral Feeding
*EAST Practice Management Guidelines Committee
Take home message
• Adequate preload• Antibiotic within 1 hr• Proper dose of vasopressors.
• Consult
Thank you
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