sepsis care in 2015
TRANSCRIPT
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Sepsis Care in 2015
Salim R. Rezaie, MDUTHSCSA, San Antonio, TX
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No
Financial
Disclosures
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Objectives
BP
Target
Hb
Transfusion
Threshold
SIRS
Screening
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CVP
MAP
ScvO2
<8 mmHg
<65mmHg
<70%
IVF
Pressors
PRBCs
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Surviving Sepsis Campaign
MAP ≥65 mmHg
Level 1C Rec
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LeDoux D et al.
Crit Care Med 2000
Bourgoin A et al.
Crit Care Med 2005
10 Patients
28 Patients
MAP
65mmHg
75mmHg
85mmHg
Lactate
Renal Fxn
UOP
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Dunser MW et al.
Crit Care Med 2009274 Patients
MAP
<75mmHg
Increased
Renal
Replacement
Therapy
MAP
<60mmHg
Increased
Mortality 3x
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Does a Higher MAP Decrease
Renal Failure in Sepsis?
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29 Centers in France
with 776 Patients
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Low Target
Group
MAP
65 – 70 mmHg
High Target
Group
MAP
80 – 85 mmHg
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Difference
NO
Difference
28 or 90 Day
Mortality
28 Day Survival
w/o Organ Support
More
Atrial
Fibrillation
Longer
Pressor
Duration &
Dose
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3L IVF in 24h
then
Pressors
Mortality = 34 – 36.6%
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Don’t Chase
MAP ≥65mmHg
Bottom Line
Give Fluids
Early
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CVP
MAP
ScvO2
<8 mmHg
<65mmHg
<70%
IVF
Pressors
PRBCs
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Surviving Sepsis Campaign
Maintain Hct ≥30%
Hb ≤7g/dL
Level 1B Rec
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Liberal Transfusion Harms
Hebert PC et al.
NEJM 1999838 Patients
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Liberal Transfusion Benefits
Vincent JL et al.
Anesthesiology 20081,040 Patients
Park DW et al.
Crit Care Med 2012407 Patients
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Does a Liberal Transfusion Strategy
Improve Mortality in Sepsis?
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32 Centers in Europe
with 998 Patients
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Transfusion
Requirements
In
Septic Shock
(TRISS)
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Liberal
Transfusion
Hb ≤9g/dL
Restrictive
Transfusion
Hb ≤7g/dL
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50% Less
Transfusions
36% No
Transfusions
No 90 Day Mortality Difference
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Acute
Myocardial
Infarction
Excluded
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Chatterjee S et al.
JAMA Intern Med 2013
+
Increased All-Cause Mortality
18.2% vs 10.2%
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Bottom Line
Use A
Restrictive
Transfusion
Strategy
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Infection SIRS
Sepsis
Severe
Sepsis
Septic
Shock
Pancreatitis
Burns
Trauma
Other
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Severe Sepsis
Infection Organ
Dysfunction>2 SIRS
Criteria
1992
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How Good is SIRS at Screening for
Severe Sepsis?
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172 ICUs in Australia
& New Zealand
With 109,663 Patients
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SIRS + SIRS -
87.9% 12.1%
Will Miss
1 in 8
Severe Sepsis
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SIRS Criteria Screening
13% Incremental
Increase
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Bottom Line
≥2 SIRS Criteria
Lacks Sensitivity
& Specificity for
Sepsis
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ProCESS
ARISE
ProMISe
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ProCESS ARISE ProMISe
Country
Patients
Primary
Outcome
1351 12601600
60d
Mortality
90d
Mortality
90d
Mortality
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Before Randomization…
A B CThen Followed for 1st 6 Hours
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The ProCESS Trial
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Trust the ProCESS
21% 18.2% 18.9%
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EGDT Usual
IVF
Pressors
CVC
PRBC
4.9L 3.5L
27.4% 30.3%
Mandatory Mandatory
64.1% 18.5%
Rivers Study 1999
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ProCESS
EGDT Protocol Usual
IVF
Pressors
CVC
PRBC
5.0L 5.5L 4.4L
54% 52% 44%
93% 56% 57%
14.4% 8.3% 7.5%
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Flexibility in Management
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Feasibility in the Community
Mostly
University EDs
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The ARISE Trial
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18.6% 18.8%
ARISE
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EGDT Pragmatic
IVF
Pressors
CVC
PRBC
1.96L 1.71L
66.6% 57.8%
90% 61.9%
13.6% 7.0%
ARISE
A-Lines 91% 76%
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Community/Rural
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Intravenous Fluids
3 – 4.5 L
in
1st 6 Hours
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2001 Rivers Study Mortality
47 31% (NNT = 6)
Sepsis Trilogy Mortality
18.2 – 29.5%
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The ProMISe Trial
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29.5% 29.2%
ProMISe
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EGDT Usual
IVF
Pressors
CVC
PRBC
2.23L 2.02L
53.3% 46.6%
92.1% 50.9%
8.8% 3.8%
ProMISE
A-Lines 74.2% 62.2%
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Nail in the Coffin for EGDT?
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>10 Years
Later…
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EGDT Usual Care
The Gap
Sepsis Care 2015
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CVP
ScvO2
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Surviving Sepsis Campaign
Updates 6 Hour Bundle
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Surviving Sepsis Campaign
1. Check Lactic Acid
2. Send Blood Cultures
3. Give Antibiotics
4. 30mL/kg IVF (if low BP/High Lactate)
Within 3 Hours…..
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Surviving Sepsis Campaign
1. Vasopressors if MAP <65mmHg
2. Re-assess Volume Status & Tissue Perfusion
3. Re-Check Lactic Acid (Unless Initially Normal)
Within 6 Hours…..
CVP ScvO2 Cardiac US Passive Leg Raise
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MAP ≥65 mmHg
Give Fluids
Early
Restrictive
Transfusion
Hb ≤7g/dL
SIRS Criteria
Poor SensitivityAnd
Finally…
Miss 1 in 8
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EARLY
Recognition IVF Antibiotics