eight strategies for managing severe sepsis (rev ssc 2012)

7/26/2019 Eight Strategies for Managing Severe Sepsis (Rev SSC 2012)

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Eight Strategies for Managing Severe Sepsis+Update Surviving Sepsis Campaign 2012

Emerg Med40(9):1! 200

Dr. Catenacciis assistant professor of emergen"# medi"ineand medi"a$ dire"tor of the department of "riti"a$ "are transportat the Universit# of %$a&ama at 'irminghamDr. Kingis an attending ph#si"ian of emergen"# medi"ine atrinit# Medi"a$ Center in 'irmingham


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US%: he in"iden"e of severe sepsis*0!000 "ases,#ear

%nnua$ in"rease of 1-he rising in"iden"e ma# &e due to the aging of the US popu$ation

pro$iferating antimi"ro&ia$ resistan"emore invasive pro"edures &eing performed

more preva$ent immuno"ompromised states


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Estimates of morta$it# range from 20- to0-! depending on the stage of thedisease studied

he "osts are astounding:%n estimated .22!000 is spent on ever#

"ase

.1/* &i$$ion is spent annua$$#


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Emergen"# department visits have a$soin"reased over the past to de"ades popu$ations at ris for sepsise$der$#

%ngus noted a 100fo$d in"reased in"iden"e ofsepsis in the e$der$# "ompared ith other agegroups

3igher patient vo$ume has &een asso"iatedith an in"rease in the severit# of i$$ness

am&e reported a 9- in"rease in "riti"a$$# i$$patients presenting to emergen"# departments&eteen 1990 and 1999


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5n addition to higher patient vo$umes anda"uit# $eve$s! the emergen"# departmentph#si"ian is "ha$$enged over"roding from

the 6&oarding7 of patients aaiting admission8ationa$ data from 2001 to 2004! ang

re"orded a mean emergen"# department $ength of sta# of 4*

hours for severe$# septi" patients ith 204- of patients sta#ing $onger than si

hours


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WHAT IS SEPSIS?

=ree ord sepeinto putref# or maerotten

1992! the %meri"an Co$$ege of Chest;h#si"ians and the So"iet# of Criti"a$Care Medi"ine esta&$ished some"ommon ground


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Consensus statementdefining the s#stemi"inf$ammator# response s#ndrome (S5>S) as: he &od#?s ph#sio$ogi" response to a variet# of

"$ini"a$ insu$ts or mu$tip$e stressors: 5nfe"tious

oi"o$ogi"

raumati"

5s"hemi"

5mmuno$ogi"


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he s#ndrome is manifested :a temperature a&ove 100@A

3eart rate greater than 90

>espirator# rate of more than 20 or a;aCB2 &e$o


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Sepsis

S5>S resu$ting from a do"umented orpresumed infe"tion


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5nfe"tion

patho$ogi" pro"ess "aused theinvasion of norma$$# steri$e tissues pathogeni" organisms


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Severe sepsis

Sepsis "omp$i"ated either:h#potension &efore a f$uid "ha$$enge

organ d#sfun"tion

a $a"tate $eve$ eua$ to or a&ove 4 mmo$,


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Septi" sho"

Sepsis ith persistent h#potension

he definition of persistent h#potensionas:a s#sto$i" &$ood pressure &e$o 90 mm 3g

or more than 40 mm 3g &e$o &ase$ine

% mean arteria$ pressure &e$o *0 mm 3g

despite adeuate f$uid resus"itation


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Eight strategies to he$p improve theout"omes of patients ith sepsis

1 5n"reased provider aareness

2 Ear$# anti&ioti" administration


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NO. 1: INCREASED PROVIDER

AWARENESS

Surviving sepsis "ampaignSo"iet# of Criti"a$ Care Medi"ine

European So"iet# of 5ntensive CareMedi"ine

5nternationa$ Sepsis Aorum

eight more organiDations have oined the

effort! in"$uding the American Collegeo Emergenc! P"!#ician#


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;hase 1: 2002

;hase 2: 200


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NO. $: EAR%& ANTI'IOTIC

AD(INISTRATION

5f targeted anti&ioti"s are given ear$#

pathogeni" organisms i$$ &e destro#edfaster

toin produ"tion i$$ &e $imited

the detrimenta$ effe"ts of a ro&ust

inf$ammator# response ma# &e "ur&ed


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=iving anti&ioti"s ithin the first hour of theonset of h#potension resu$ted in an overa$$surviva$ rate of *99-

Aor ea"h hour that anti&ioti"s ere de$a#ed!morta$it# in"reased an average of */-

ar"he noted a *fo$d in"rease in morta$it# inpatients ho re"eived anti&ioti"s more thanto hours after admission


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inappropriate empiri" anti&ioti" therap# asasso"iated ith in"reased morta$it# (odds ratio1)

5&rahim "ondu"ted a prospe"tive stud# of 492patients ith &a"teremia ho ere admitted tothe 5CU! morta$it# rates for those treated ith inappropriate anti&ioti"s as /19-

"ompared to 24- for appropriate$# treatedpatients


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%du$t $ifethreatening sepsis ith anun"$ear sour"e


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NO. ): SO*RCE CONTRO%

5nfe"ted prostheti" devi"es ma# need to&e removed in the emergen"#department

5mmediate surgi"a$ "onsu$tation foroperative de&ridement is indi"ated ifsuspi"ion of a ne"rotiDing sin infe"tion

eists


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NO. +: EAR%& ,OA%-DIRECTED

THERAP&

his stud#"ommen"ed &efore5CU admission!

ithin si hours ofthe patients? arriva$at a &us# ur&anemergen"#

department


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NO. : *SE O/

CORTICOSTEROIDS

Aurther studies ith $arger num&ers ofpatients are reuired to tru$# define thero$e of steroid rep$a"ement therap# in

septi" patients


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Aor no! the 200 SSC guide$ines emphasiDethe use of intravenous h#dro"ortisone in adu$tsepti" sho" patients on$# if their &$oodpressure is poor$# responsive to f$uidresus"itation and vasopressor therap#

he guide$ines a$so re"ommend againstroutine$# using steroids in septi" patientsithout sho"! un$ess arranted thepatient?s histor# of endo"rine or "orti"osteroiduse


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NO. 0: %*N,-PROTECTIVE

VENTI%ATION


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oer tida$ vo$umes (/ m$,g of idea$&od# eight)to$erate a degree ofh#poventi$ation and permissive

h#per"apnea (p3 *< to *4)Use positive endepirator# pressure to

improve o#genation and maintain

p$ateau pressures $ess than


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NO. : INTENSIVE ,%&CE(IC

CONTRO%

h# septi" patients seem to &enefitmore from intensive g$#"emi" "ontro$ith pro$onged 5CU sta#s is not "$ear at

this time%dditiona$ $arge! mu$ti"enter studies are

needed to revea$ the &est strateg# for

g$#"emi" "ontro$ in sepsis


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he 200 SSC guide$ines:

redu"tion in mor&idit# and morta$it# ofintensive g$#"emi" "ontro$ ith $onger5CU sta#s

re"ommend that patients ith severesepsis and h#perg$#"emia re"eiveintravenous insu$in therap# to a targetedg$u"ose $eve$ of $ess than 10 mg,d$


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NO. 2: RECO('INANT H*(AN

ACTIVATED PROTEIN C

5ndi"ations for r3%;C use in theemergen"# department are $imited

%s demonstrated the E83%8CEdata! there ma# &e a ro$e for ear$#therap#


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3oever! &ased on the riss of &$eedingand "ost! r3%;C shou$d pro&a&$# &e"onsidered on$#:after hemod#nami" optimiDation is a"hieved

appropriate anti&ioti"s are given

if there is signifi"ant de$a# in admission to

the 5CU


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eight strategies for managing severe sepsis (rev ssc 2012)

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