update in management of septic shock day/session 1/last.pdf · sepsis the systemic inflammatory...
TRANSCRIPT
Update in Management of
Septic Shock
Prepared by :
Dr. Ibraheem Doom
Terminology Systemic Inflammatory Response Syndrome (SIRS)
Presence of at least two of : Temp > 38 or < 36
HR > 90
RR > 20 or PaCO2 < 32
WBC > 12 or < 4 or Bands > 10%
Sepsis The systemic inflammatory response to infection.
Severe Sepsis Organ dysfunction secondary to Sepsis.
e.g. hypoperfusion, hypotension, acute lung injury,
encephalopathy, acute kidney injury, coagulopathy.
Septic Shock Hypotension secondary to Sepsis that is resistant to adequate
fluid administration and associated with hypoperfusion.
Infection
Parasite
Virus
Fungus
Bacteria Trauma
Burns
Sepsis SIRS Severe
Sepsis
Severe
SIRS
Adapted from SCCM ACCP Consensus Guidelines
shock
BSI
Surviving Sepsis Campaign
Guidelines for Management of
Severe Sepsis/Septic Shock
Surviving Sepsis Campaign
A global program to:
Reduce mortality rates
Improve standards of care
Secure adequate funding
evidence-based guidelines
Grading System
Initial Resuscitation
A: Airway
B: Breathing
C: Circulation
D:DIAGNOSIS/Disability
AIRWAY
Ensure and maintain
patency of Airway
BREATHING
All patients in shock need Oxygen
supplementation
And some need Mechanical
Ventilation Support
CIRCULATION
sepsis-induced hypoperfusion : Lactic acidosis
Confusion ,Delirium
Oligouria
Decrease capillary refilling time
Hypotension
CIRCULATION
So early restoration of perfusion is
necessary to prevent or limit multiple organ
dysfunction, as well as reduce mortality .
Tissue perfusion should be promptly
restored using:
intravenous fluids
Vasopressors & inotropes
possibly red blood cell transfusions
Early Goal-Directed Therapy
Goals during first 6 hours:
Central venous pressure: 8–12 mm Hg
Mean arterial pressure 65 mm Hg
Urine output 0.5 mL kg-1/hr-1
Central venous (CvO2) or mixed venous oxygen [SvO2] saturation 70%
Grade: B
In-hospital mortality
(all patients)
0
10
20
30
40
50
60 Standard therapy
EGDT
28-day mortality
60-day mortality
NNT to prevent 1 event (death) = 6-8
Mo
rta
lity
(%
)
if Central venous or mixed venous O2
sat persist < 70% after CVP of 8–12 mm Hg • Packed RBCs if Hct < 30%
• Dobutamine to max 20 g/kg/min
Grade: B
Serum Lactate Level
Recent evidence show that serum Lactate
levels are used as diagnostic and
prognostic factor in sepsis .
Serum Lactate marker is beneficial as well
as other markers of early goal -target .
Serum Lactate Level
Recent evidence show that measurement
of serum Lactate levels at presentation
Repeat lactate within 6 hours if initial
lactate > 2.0
.
Serum Lactate Level
The target of serum Lactate in
management of sepsis < 2 mg/dL
If serum lactate > 4 indicate sever sepsis
If serum lactate > 6 or persist high despite
of therapy indicate poor prognosis
Serum Lactate Level
Clearance of lactate is associated with
improved survival
NEW Algorithms of care based on lactate
clearance appear to work as well or better
than other approaches.
Fluid Therapy
Fluid therapy may consist of :
Crystalloids
Colloids (Natural or artificial )
Grade: C
Fluid Therapy
Fluid challenge over 30 min
• 500–1000 ml crystalloid
• 300–500 ml colloid
Repeat based on response and tolerance
Grade: E
Fluid Therapy
Liberal replacement :
Can use 6 Liters .
Better in first 6 hour .
Adjust by fluid and CVS status .
RL > N/S
Conservative replacement :
Use maintenance fluid replacement .
Better in the next 48-72 hours .
Fluid Replacement Strategy in the Critically ill
Vasopressors
Either norepinephrine or dopamine administered through a central catheter is the initial vasopressor of choice.
• Failure of fluid resuscitation
• During fluid resuscitation
Grade: D
Vasopressors
Do not use low-dose dopamine for
renal protection.
Grade: B
Vasopressors
In patients requiring vasopressors,
place an arterial catheter as soon as
possible.
Grade: E
Circulating Vasopressin Levels in Septic Shock
Vasopressors Vasopressin
Not a replacement for norepinephrine or dopamine as a first-line agent
Consider in refractory shock despite high-dose conventional vasopressors
If used, administer at 0.01-0.04 units/minute in adults
Grade: E
Vasopressors Vasopressin
Not a replacement for norepinephrine or dopamine as a first-line agent
Consider in refractory shock despite high-dose conventional vasopressors
If used, administer at 0.01-0.04 units/minute in adults
Grade: E
During Septic Shock
10 Days Post Shock
Diastole Systole
Diastole Systole
Inotropic Therapy
Consider dobutamine in patients with measured low cardiac output despite fluid resuscitation.
Continue to titrate vasopressor to mean arterial pressure of 65 mm Hg or greater.
Grade: E
Therapeutic End-points
Capillary refill < 2 sec
Warm extremities
Urine output > 0.5 ml/kg/hr
Normal mental status
Central venous O2 saturation > 70%
Serum Lactate < 2 mg/dL
DIAGNOSIS
Early diagnosis of Sepsis and Septic
shock based on high clinical suspicion and
clinical parameters .
Sepsis mortality can be reduced with early
detection & rapid initiation of treatment&
support of organ failure or dysfunction:
Diagnosis
Appropriate cultures
Minimum 2 blood cultures
• 1 percutaneous
• 1 from each vascular access 48 hrs
Cutures from other possible sites of infection
Grade: D
Antibiotic Therapy
Begin intravenous antibiotics within
first hour of recognition of severe
sepsis.
Grade: E
Antibiotic Therapy
Recommended empirical broad spectrum
antibiotics
Choose one or more Antibiotics active
against likely bacterial or fungal
pathogens.
Consider microorganism susceptibility
patterns in the community and hospital.
(LOCAL POLICY)
Grade: D
Antibiotic Therapy
Reassess antimicrobial regimen at 48-72 hrs • Microbiologic and clinical data
• Narrow-spectrum antibiotics
• Non-infectious cause identified
• Prevent resistance, reduce toxicity, reduce costs
Grade: E
SOURCE OF INFECTION
Identification and treatment of the site
of infection are essential
Control of sites of infection by
appropriate methods as: removal of
vascular line ,drainage of abscess
,debridement and So on …
Grade: E
Culture Negative
20%
Lung 47%
Abdomen 15%
Urine 10%
Other 8%
Steroids
Indications of Steroids is controversial .
It is indicated to patients who still require vasopressors despite fluid replacement .
Low dose Hydrocortisone 200-300 mg/day, for 7 days in three or four divided doses or by continuous infusion.
Grade: C
Steroids
Optional:
Decrease steroid dose if septic
shock resolves.
Grade: E
Steroids
Optional:
Taper corticosteroid dose at
end of therapy.
Grade: E
Steroids
Optional:
Add fludrocortisone (50 µg orally
once a day) to this regimen.
Grade: E
Steroids
Do not use corticosteroids >300
mg/day of hydrocortisone to treat
septic shock.
Grade: A
Thrombin
Thrombomodulin
Protein
C (Inactive) Protein C Activity
Blood Vessel Blood Flow
Protein C
Receptor
Protein
S
Recently NOT recommended based on
new trial, the (PROWESS-SHOCK TRIAL ) :
rhAPC did not improve 28-day
mortality
So this drug is withdrawal from the market
Blood Product Administration
packed RBCs
Transfuse < 7.0 g/dl to maintain Hb 7.0-9.0 g/dL
In some circumstances :( )
Coronary artery disease
Acute hemorrhage
refractory Lactic acidosis
Grade: B
Blood Product Administration
Do not use Erythropoietin to treat sepsis-
related anemia. Erythropoietin may be
used for other accepted reasons.
Grade: B
Blood Product Administration
Fresh frozen plasma
• Bleeding
• DIC
Grade: E
Blood Product Administration
• Do not use antithrombin therapy.
Grade: B
Blood Product Administration
Platelet administration
Transfuse for < 5000/mm3 -
Transfuse for 5000/mm3 – 30,000/mm3 with significant bleeding risk
Transfuse < 50,000/mm3 for invasive procedures or bleeding
Grade: E
Mechanical Ventilation in
Septic Shock
LUNG PROTECTIVE VENTILATION
Reduce tidal volume over 1–2 hrs to 6 ml/kg predicted body weight
Maintain inspiratory plateau pressure < 30 cm H20
Grade: B
Peak Airway
Pressure
Inspiratory Plateau
Pressure
PEEP (5 cm
H2O 5
0
Mechanical Ventilation of Severe Sepsis
Semirecumbent position unless contraindicated with head of the bed raised to 45o
Grade: C
Mechanical Ventilation of Septic Patients
Use weaning protocol and a spontaneous breathing trial (SBT), at least daily
Grade: A
Prior to SBT
a) Arousable
b) Hemodynamically stable (without vasopressor agents)
c) No new potentially serious conditions
d) Low ventilatory and end-expiratory pressure requirements
e) Requiring levels of FIO2 that could be safely delivered with a face mask or nasal cannula
Consider extubation if SBT is successful
Sedation and Analgesia in Sepsis
AVOID EXESSIVE SEDATION
SEDATION SHOULD BE TITARED USING
OBEJECTIVE ASSESSMENT or
INTERMITTENT BOLUS .
Light sedation is better than heavy sedation
DAILY INTERRUPTION of sedation.
Grade: B
Neuromuscular Blockers
Should be avoided if possible
Grade: E
Glycaemic Control
Target Blood Glucose in Septic Patient Glucose < 150 mg/dL
Continuous infusion insulin and glucose
Monitoring of blood glucose : • Initially every hour
• After stabilization q4h
Grade: D
Intensive insulin therapy in critically
ill patients
Tight glycaemic control= 80-110 mg/dl (4.4-6.1 mmol/l)
Renal Replacement
Hemodynamic instability: CVVH preferred
Hemodynamic stability: Intermittent hemodialysis and
continuous venovenous filtration equal (CVVH)
Grade B
Bicarbonate therapy not recommended to improve hemodynamics in patients with lactate induced pH >7.15
Grade: C
Bicarbonate Therapy
Deep Vein Thrombosis Prophylaxis
Heparin (UH or LMWH)
Contraindication for heparin
Mechanical device
High risk patients
Combination Heparin and mechanical
Grade: A
Stress Ulcer Prophylaxis
H2 receptor blockers
Role of proton pump inhibitors
Grade: C
NUTRITION
Enteral nutrition is generally safer and
more effective than total parenteral
nutrition, but total parenteral nutrition is
sometimes required in patients with
abdominal sepsis, surgery, or trauma.
PREVENTION
Handwashing
Elevation of head of the bed
Sterile techniques for the insertion of catheters, and
possibly the use of antibiotic-impregnated catheters. New
catheter insertion sites for catheter changes
Isolation of patients who have resistant organisms
Isolation of significantly immunocompromised patients
Preventing the progression from sepsis to septic shock
requires early diagnosisand aggressive resuscitation. Early
goal-directed therapy, lung-protectiveventilation,
antibiotics, are critical therapies in early septic shock
Sepsis Resuscitation Bundle
Identify Sepsis as early as possible
Serum lactate measured
Blood cultures obtained prior to
antibiotic administration
Quickly administer appropriate
antibiotics and source control
Hemodynamic Support
Hemodynamic profile may be variable
Establish institutional goals for physiologic
resuscitation
Early goal target therapy should be achieved
Monitor for signs and symptoms of
hypoperfusion and achieve end-targets
points .
Target Hb is 7-9 mg/dL
Sepsis Management Bundle
Low-dose steroids* administered for septic shock in accordance with a standardized ICU policy
(activated pc) RECENTLY NOT RECOMMENDED
Sepsis Management Bundle
Glucose control maintained lower limit
of normal, but < 150 mg/dl (8.3 mmol/L)
Lung Protective Ventilator Strategies
Inspiratory plateau pressures
maintained < 30 cm H2O for
mechanically ventilated patients.
Sedation, Daily Awakenings &
Spontaneous breathing Trials
Sepsis Management Bundle
Monitor for and prevent recurrence of sepsis
Infection Control Practices.
Nutritional Support
Early Mobilization
Success with these measures is most likely with a multi-
disciplinary approach.
Sepsis Management Bundle
A clinician, armed with the sepsis bundles, attacks the three heads
of severe sepsis: Hypotension, Hypoperfusion and Organ
Dysfunction.
Sponsoring Organizations
American Association of Critical Care Nurses
American College of Chest Physicians
American College of Emergency Physicians
American Thoracic Society
Australian and New Zealand Intensive Care Society
European Society of Clinical Microbiology and Infectious Diseases
European Society of Intensive Care Medicine
European Respiratory Society
International Sepsis Forum
Society of Critical Care Medicine
Surgical Infection Society