le sepsis: des urgences aux soins intensifssiz-afiu-lecongres.be/wp-content/uploads/2018/11/... ·...
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Le sepsis:
Des urgences aux soins intensifs
Daniel De Backer
Head Dept Intensive Care, CHIREC hospitals, Belgium
Professor of Intensive Care, Université Libre de Bruxelles
Past-President European Society of Intensive Care Medicine
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Rhodes et al
ICM 2017
CCM 2017
Inspired from….
➢ 55 experts
➢ 5 sections ➢ Hemodynamics
➢ Infection
➢ Adjunctive therapies
➢ Metabolic
➢ Ventilation
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JAMA 2017
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Le sepsis aux urgences
1. Comment reconnaître ?
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Sepsis is a life-thretening organ
dysfunction caused by a dysregulated
host response to infection
JAMA 315:801; 2016
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Le sepsis: comment reconnaître?
➢ Suspecter une infection…
➢Détecter une dysfonction d’organe…
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Organ dysfunction is
characterized clinically by a
change in SOFA score ≥2 related
to the episode of new infection
JAMA 315:801; 2016
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Seymour C et al
JAMA 315:762; 2016
Sepsis = infection + 2 qSOFA points
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Seymour C et al
JAMA 315:762; 2016
SOFA in the ICU qSOFA outside the ICU
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Le sepsis: comment reconnaître?
➢ Suspecter une infection…
➢Détecter une dysfonction d’organe…
➢ qSOFA 2
➢ 2 pts dysfonction d’organe
➢ Signes biologiques
➢ Signes cliniques habituels…T°/GB/CRP…
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Evaluation of skin perfusion
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The Mottling Score Ait Oufella et al
ICM 37:801;2011
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The Mottling Score Ait Oufella et al
ICM 37:801;2011
N=60 / H6
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Le sepsis aux urgences
1. Comment reconnaître ?
2. Prise en charge
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Le sepsis aux urgences:
Prise en charge
➢ Identifier / Contrôler la source
➢Antibiotiques
➢Traitement supportif
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Rhodes et al
ICM 2017
CCM 2017
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NY state
49331 pts
149 hosp
NEJM 2017
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HEMODYNAMIC
RESUSCITATION
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Vincent JL and De Backer D
NEJM 369:1726; 2013
Fluids at the different stages of shock
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New bundlesLevy-M et al
ICM 2018
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9190 pts with sepsis
Liu V et al
Annals ATS 2013
Not too much but also not limited….
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Andrews-B et al
JAMA 2017
212 patients in Zambia
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Jama 2017
=> Patients were reassessed for tolerance, but not for indication!
~70 ml/kg
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NY state
49331 pts
149 hosp
NEJM 2017
Caution: the delay in fluid
administration may be related
to lower initial severity
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NY state
49331 pts
149 hosp
NEJM 2017
OR hospital
mortality for each
hour delay
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Le sepsis aux soins intensifs:
Prise en charge
➢ Identifier / Contrôler la source
➢Antibiotiques
➢Traitement supportif
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➢Are we happy with the
prescribed antibiotics ?
➢Are we happy with
source control?
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CID 2014
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Rhodes et al
ICM 2017
CCM 2017
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Rhodes et al
ICM 2017
CCM 2017
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Rhodes et al
ICM 2017
CCM 2017
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Vincent JL and De Backer D
NEJM 369:1726; 2013
Resuscitation targets at the different
stages of shock
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ICM 2015
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➢The concept remains valid
➢Patient identification is crucial
➢The classical EGDT may be applied when
better hemodynamic strategies cannot be used
➢Whenever possible use advance hemodynamic
monitoring tools to optimize tissue perfusion
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What is the right amount of fluids
after the salvage phase?
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Fluids and cardiac output Muller L et al
Anesthesiology
115:541; 2011
39 critically ill patients
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CVP as a target ?
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CVP
Strokevolume
DDB USI
Extreme CVP values provide some information even if all indices of preload poorly predict fluid responsiveness !
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Eskesen et al
ICM 2016
1148 pts
CVP: Never an optimal prediction but still
some reasonable guidance if nothing better
can be used….
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CVP
Stroke
volumeDDB USI
The increase in CVP does not indicate the
response to fluids
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We should individualize fluid therapy !
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The best way to administer fluids
Perfusion issue that may respond to fluids
Prediction of the response to fluids
Fluid challenge to assess response
(incl.and tolerance) to fluids
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Pay attention to the response of the patient
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ICM 2015
N = 2213
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DDB USI
Do fluids correct hypotension
in septic shock ?
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The increase in arterial pressure depends on vascular tone and
the impact on cardiac output
Preload
Arterial pressureCardiac output
Cardiac output
In sepsis, the low vascular tone limits the increase in arterial pressure in response to
fluids.
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DDB USI
Does correction of hypotension with
vasopressors affect tissue perfusion ?
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DDB USI
Albanese et al
Chest 126:534;2004
Correction of hypotension improves urine output and renal
function in septic patients
MAP 50 => 78 mmHg
Patients with septic shock (n=14)
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DDB USI
Early introduction of vasopressors may
decrease later need for fluids
When to introduce
vasopressors?
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0
5
10
15
20
25
30
Category 1
Fluids
Late NE
Early NE
++
Sennoun N et al
CCM 35:1736;2007
Rats / LPS
Early introduction of norepi
decreased fluids requirements
ml
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Duration of hypotension before initiation of
vasopressor agents is associated with poor outcomeBai X et al
Crit Care 2014
213 pts with septic shock
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DDB USI
Which blood pressure target ?
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Asfar P et al
NEJM 2014
High vs Low MAP ?
798 pts septic shock
65-70 VS 80-85 mmHg
73-75
Target
65-70
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Asfar P et al
NEJM 2014
High vs Low MAP ?
798 pts septic shock
65-70 VS 80-85 mmHg
➢ But lower incidence of AKI with high MAP in
previously hypertensive patients
➢ Higher rate of arrhythmias and AMI in high MAP
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Deruddre et al
ICM 33:1557;2007
High variablity in response to increase in MAP
11 pts septic shock
Renal Doppler
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MAP target ?
➢ 65 mmHg as a starting point
➢ Higher levels can be considered in some
patients but the response to a higher target
level shoud be evaluated
=> « MAP challenge »
➢However, the « MAP challenge » should
take place only after having optimized
other aspects of perfusion.
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Select the right vasopressor agent !
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N = 1679 * p<0.05
Norepinephrine vs Dopamine in shock (SOAP investigators)
De Backer et al
NEJM 362: 779; 2010
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* p<0.05
De Backer et al
NEJM 362: 779; 2010
Norepinephrine vs Dopamine in shock (SOAP investigators)
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0
50
100
150
200
DOPA
NOREPI
Arrhythmias
N=
P < 0.001
Atr fib Ventr fibVentr tachyc
De Backer et al
NEJM 362: 779; 2010
Norepinephrine vs Dopamine in shock (SOAP investigators)
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Norepinephrine vs Dopamine in shock (SOAP investigators)De Backer et al
NEJM 362: 779; 2010
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De Backer et al
CCM 40:725:2012Dopamine vs norepinephrine in septic shock
A meta-analysis
Norepi
better
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Vail E et al
JAMA 2017
Shifting from norepi to
phenylephrine + dopamine was
associated with increased mortality
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Rhodes et al
ICM 2017
CCM 2017
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Adding another alpha adrenergic
agent (i.e. epinephrine) would not
increase blood pressure more than
increasing the dose of
norepinephrine…
a = a
What to do if the patient is not responding
to norepinephrine ?
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Myburgh et al
ICM 34:2226;2008
280 pts
Norepinephrine vs Epinephrine
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Levy B et al
CCM 2011
30 pts cardiogenic
shock
Norepi + dobu
VS
Epi
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Annane et al
Lancet 370:676;2007
330 pts septic shock
EPI vs NOREPI (+-DOBU)
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Levy B et al
JACC 2018
Death rate: 52 % vs 37% p=0.25
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Vasoconstriction
↑ intracellular calcium
in vascular smooth muscle cells
G protein
Ca++
Voltage gated
Ca++ channel
Depolarization
of membraneCa++
Vascular smooth
muscle cell
Outer membrane
Differences arise due to receptor sensitivity and
disposition in the vascular system, as well as
stimulation of other receptors (beta/V2…)
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VASST
802 septic shock pts
Russell et al
NEJM 358:877;2008
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VASST Russell et al
NEJM 358:877;2008
0
10
20
30
40
50
60
28 day 90 day
NOREPI
VP
Mortality (%) according to severity at baseline
0
5
10
15
20
25
30
35
40
45
50
28 day 90 day
More severe n= 400
(NE > 15 mcg/min)
Less severe n= 378
(NE < 15 mcg/min)
p<0.05p<0.05
(15 mcg/min ~0.19 - 0.21 mcg/kg.min for 80-70kg pts)
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Gordon et al
JAMA 2016
A double-blind randomised controlled trial of vasopressin (up to
0.06 u/min) vs noradrenaline within 6h of onset of septic shock.
Norepi dose at randomization: 0.16 [0.10-0.31] mcg/kg.min
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Terlipressin
Bolus 0.5 – 1 mg /8-6h
Half-Life 6h
Infusion 20 – 160 µg/hMorelli A Crit Care 2009
Liu Z et al ICM 2018
O’Brien A Singer M Lancet 2002
Lange M et al ICM 2009
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Liu Z et al
ICM 2018
N=617
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Liu Z et al
ICM 2018
N=617
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DDB USI
A role for angiotensin II in septic shock ?
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Chawla L et al
Crit Care 2014
Administration of AGII decreases the need
for norepinephrine
20 pts distributive shock
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NEJM 2017
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Nitric oxide inhibition ?
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Lopez et al
CCM 32:21;2004
LNNMA IN PATIENTS WITH SEPTIC SHOCK
DDB USI
Placebo
LNNMA
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DDB USI
➢ Norepinephrine as the 1st choice agent
➢ Vasopressin as an alternative.
➢ Angiotensin appears to be promising in septic shock
but more data are needed.
➢ If one drug seems of limited efficacy, add a second
agent of another class rather than another agent of
same class.
VASOPRESSOR SUPPORT IN SHOCK
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And steroids….
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CORTICUS
Sprung et al
NEJM 358:111;2008
500 pts septic shock
Shock reversal
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300 Patients in septic shock
Annane et al
JAMA 288:862; 2001
EFFECT ON OUTCOME
Placebo
HC
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CORTICUS Sprung et al
NEJM 358:111;2008
500 pts septic shock
Outcome
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ADRENALVenkatesh et al
NEJM 378:798;2018
3800 pts septic shock
Outcome
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Annane et al
NEJM 378:809;2018
1241 pts septic shock
OutcomeAPPROCCHSS
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VANISH 2016: 0.16 [0.10-0.31] mcg/kg.min
Norepi (epi) dose at randomization
CORTICUS 2008: ~0.5 mcg/kg.min
Annane JAMA 2002: 1.1 (0.9) mcg/kg.min
ADRENAL 2018: 50% <0.2 mcg/kg.min
APPROACHS 2018: 1.2 mcg/kg.min
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Inotropic agents:
Why ?
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Parillo J et al
JCI 76:1539;1985
In vitro myocardial muscle
Reversible alteration in contractility
Myocardial depression in patients with septic shock
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Reversible myocardial depression in patients with septic shock
Parker et al. Ann Intern Med 1984: 100; 483-490
DDB USI
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Vieillard-Baron et al
AJRCCM 168:1270;2003
=> Inotropic agents should not be used to correct a low EF
Echographic evaluation of LVEF in patients with septic shock
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Inotropic agents:
Which?
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Dobutamine
5 mcg/kg.min
Vincent et al
CCM 18:689;1990
EFFECT OF DOBUTAMINE
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
BASE DOBU
Cardiac index
P<0.01
L/min.M²
DDB USI
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An increase in cardiac output is not always achieved by an
increased contractility
19 patients with septic shock
Jellena et al
CCM 34:2392;2006
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Morelli et al
ICM 31:638;2006
EFFECT OF LEVOSIMENDAN
DDB USI
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Morelli et al
ICM 31:638;2006
EFFECT OF LEVOSIMENDAN
DDB USI
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Levosimendan in sepsisGordon A et al
NEJM 2016
➢ No evaluation of cardiac output
➢ No evaluation of contractility
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Select the right hemodynamic tool
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CIRCULATORY FAILURE
Central
line
Arterial
line
CVP
ScvO2
PvaCO2
AP
PPV
Lactate
ECHO
Rapid improvement No improvement
Complex cases
Expect and reevaluatePAC
TPTD
PAP
PAOPEVLW
GEDVICM 2016
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De Backer-DHajjar L
Pinsly MRICM 2018
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Vincent JL and De Backer D
NEJM 369:1726; 2013
What is the resuscitation goal ?
Early phase
Later stages
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