1 early goal therapy in severe sepsis & septic shock nabil abouchala, md, fccp, facp consultant,...
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Early Goal Therapy in Severe Sepsis & Septic Shock
Nabil Abouchala, MD, FCCP, FACPConsultant, Pulmonary and Critical Care Medicine
King Faisal Hospital & Research CenterRiyadh, Saudi Arabia
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Sepsis: Defining a Disease Continuum
A clinical response arising from a nonspecific insult, including 2 of the following:• Temperature 38oC or 36oC• HR 90 beats/min• Respirations 20/min• WBC count 12,000/mm3 or
4,000/mm3 or >10% immature neutrophils
SIRS = Systemic Inflammatory Response Syndrome
SIRS with a presumed or confirmed infectious process
SepsisSIRSInfection/Trauma Severe Sepsis
Adapted from: Bone RC, et al. Chest 1992;101:1644Opal SM, et al. Crit Care Med 2000;28:S81
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Sepsis: Defining a Disease Continuum
Bone et al. Chest 1992;101:1644; Wheeler and Bernard. N Engl J Med 1999;340:207
SepsisSIRSInfection/Trauma Severe Sepsis
Sepsis with 1 sign of organ failure
Cardiovascular (refractory hypotension)
RenalRespiratoryHepaticHematologicCNSMetabolic acidosis
Shock
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Mortality
Septic Shock
53-63%
20-53%Severe Sepsis300,000
7-17%Sepsis
400,000
Incidence
Balk, R.A. Crit Care Clin 2000;337:52
Mortality Increases in Septic Shock Patients
Serum Lactate Measured
Blood Culture Obtained Prior to Antibiotic Administration
Broad-Spectrum Antibiotics Administered within 1 Hour of ED Admission
Fluid Resuscitation (30 ML/Kg) for Hypotension or Lactate >4mmol/L
Vasopressors for Ongoing Hypotension
Maintain Adequate Central Venous Pressure (CVP ≥ 8)Maintain Adequate Central Venous Oxygen Saturation (ScvO2 ≥
70%)
Resu
scit
ati
on
Bu
nd
le
SEPSIS BUNDLE
Re-measure Serum Lactate
A. Initial Resuscitation
EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC SHOCKTo Examine whether Early Goal Directed Therapy (EGDT) before admission to the ICU is superior to standard hemodynamic therapy in patients with sever sepsis and septic shock
N Engl J Med, 2001;345:1368-77
#Citing
articles
2469
Central venous andarterial catheterization
CVP8 -12 mm Hg
MAP³65 and £90 mm Hg
ScvO2
³70%
Goals achieved
Hospital admission
PROTOCOL FOR EARLY GOAL-DIRECTED THERAPY
CrystalloidColloid
Vasoactive agents
Transf. of RBCuntil Hct ³30%
Inotropic agents
N Engl J Med, 2001;345:1368-77
Alternative of using mixed venous oxyhemoglobin saturation from pulmonary artery catheter instead of central venous O2 saturation from CVP catheter
Venous Oxygen Saturation
◦ If venous O2 saturation target not achieved: (2C)· Consider further fluid· Tansfuse packed red blood cells if required
to hematocrit of ≥30% and/or· Dobutamine infusion max 20 µg.kg−1 .min−1
Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.
TREATMENT ADMINISTERED
5
3.5
8.62
10.6
13.44 13.35
0
5
10
15
0-6 h 7-72 h Total
Early GoalStandard
N Engl J Med, 2001;345:1368-77
MORTALITY
10-20%
Sudden
Death!
Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.
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 - 8M
ort
alit
y (%
)
The Importance of Early Goal-DirectedTherapy for Sepsis-induced Hypoperfusion
RESULTS
MortalityEGT : 30.5 %Standard: 46.5 %
Absolute Risk Reduction
NNT =
N Engl J Med, 2001;345:1368-77
37 Observational studies showing improved
outcomes with early quantitative resuscitation
between 2001 and 2011
Multicenter trial of 314 patients with severe sepsis in eight Chinese centers (2010). This trial reported a 17.7% absolute reduction
16%
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SEPSIS INDUCED VASODILATATION
Lower amount of fluid required to fill the tank
NE
VA
SO
CO
NS
TR
ICT
ION
Crit Care Med 2007; 35:1736–1740
Early NE + Fluids
Late NE + Fluids
Fluids
NE
LPS
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