shock and sepsis 2 of 2
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Shock and Sepsis 2 of 2. William Whitehead, M.D., Ph.D. Department of Anesthesiology. Management. “Surviving Sepsis Campaign”: An international group of experts published in 2004 the first guidelines for the bedside clinician to use to improve outcomes in severe sepsis and septic shock. - PowerPoint PPT PresentationTRANSCRIPT
Shock and Sepsis2 of 2
William Whitehead, M.D., Ph.D.
Department of Anesthesiology
Management
“Surviving Sepsis Campaign”:
An international group of experts published in 2004 the first guidelines for the bedside clinician to use to improve outcomes in severe sepsis and septic shock.
Therapeutic Bundles
What are “bundles”?
A group of interventions related to a disease that,when implemented together, result in betteroutcomes than when implemented individually.
The science behind the elements of the bundle is sowell-established that their implementation should beconsidered a generally accepted practice.
Bundle components can easily be measured ascompleted or not completed.
As such, the overall bundle – all the elements takentogether – can also be measured as completed or notcompleted.
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Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012.Dellinger, R; Levy, Mitchell; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; MD, PhD; Opal, Steven; Sevransky, Jonathan; Sprung, Charles; Douglas, Ivor; Jaeschke, Roman; Osborn, Tiffany; MD, MPH; Nunnally, Mark; Townsend, Sean; Reinhart, Konrad; Kleinpell, Ruth; PhD, RN-CS; Angus, Derek; MD, MPH; Deutschman, Clifford; MD, MS; Machado, Flavia; MD, PhD; Rubenfeld, Gordon; Webb, Steven; MB BS, PhD; Beale, Richard; Vincent, Jean-Louis; MD, PhD; Moreno, Rui; MD, PhD
Critical Care Medicine. 41(2):580-637, February 2013.DOI: 10.1097/CCM.0b013e31827e83af
Figure 1 . Surviving Sepsis Campaign Care Bundles.
Critical Care Medicine 36(1):296-327 (2008)
Patient randomized
N=263Early goal directed therapy
N=130
Standard therapy N=133
CVP > 8-12 mm HgMAP > 65 mm Hg
Urine Output > 0.5 ml/kg/hr
CVP > 8-12 mm HgMAP > 65 mm HgUrine Output > 0.5 ml/kg/hrScvO2 > 70%SaO2 > 93%Hct > 30%
Antibiotics given at discretion of
treating clinicians
As soon as possible Mean 6.2hrs
ICU MDs blinded to study treatment NEJM 2001;345:1368-77.
At least 6 hoursof EGDTMean 8hrs
Transfer to ICU
Therapy Across the Sepsis Continuum
Chest 1992;101:1644..
SepsisSIRS
Severe Sepsis
SepticShock
Early Goal Directed Therapy
Antibiotics and Source Control
Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand
*
CVP:
MAP:
ScvO2:
Hgb:
CVP: central venous pressure
MAP: mean arterial pressure
ScvO2: central venous oxygen saturation
Early Goal-Directed Therapy
NEJM 2001;345:1368-77.
Lactate: An Indicator of Tissue Perfusion
Serum lactate levels are used to assess the disease severity and adequacy of global tissue perfusion
By-product of anaerobic metabolism if tissue hypoxia exists
Interpretation of elevated blood lactate levels in sepsis is limited by several important factors1: Production of elimination
Increasing glycolysis
Inhibition of pyruvate metabolism
Global changes
Bakker J, Gris P, Conerfils M, et al. Serial Blood Lactate Levels Can Predict the Development of Multiple Prgan Failure Following Septic Shock, Am J Surg 1996; 171:221-226.
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Figure 2 . Algorithm for time sensitive, goal-directed stepwise management of hemodynamic support in infants and children. Reproduced from Brierley J, Carcillo J, Choong K, et al: Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666-688.