Surviving Sepsis 2008 Guidelines

Early Goal Directed Therapy

MAZEN KHERALLAH, MD, FCCPINFECTIOUS DISEASE AND CRITICAL CARE MEDICINE

SepsisSIRS Severe Sepsis Septic ShockInfection

Chest 1992;101:1644

Therapy Across the Sepsis Continuum

A clinical response arising from a nonspecific insult, with 2 of the following: T >38oC or

<36oC HR >90

beats/min RR >20/min WBC

>12,000/mm3 or <4,000/mm3 or >10% bands

Microorganism invading

sterile tissue

SIRS with a presumed

or confirmed infectious process

Sepsis with organ failure

Vascular collapseRenalHemostasisLungLA

Refractoryhypotension

Burns

Trauma

Sepsis Syndromes1992: SCCM/ACCP

Parasite

Virus

Fungus

BacteriaBSI

SevereSepsis

ShockSevereSIRS

Infection SIRSSepsis

Surviving Sepsis Campaign

Launched in Fall 2002 as a collaborative effort of European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine

Goal: reduce sepsis mortality by 25% in the next 5 years

Guidelines revealed at SCCM in Feb 2004 Critical Care Medicine March 2004 32(3):858-87. Website: survivingsepsis . org

THE SEVERE SEPSIS BUNDLES: SSC/IHI

6 Hour Bundle Measure serum lactate Blood Cultures prior to antibiotics Broad spectrum antibiotics within 3

hours of presentation, 1 hour in hospital

Initial fluid resuscitation with 20-40 mL/kg crystalloid (or equivalent colloid) if hypotensive (SBP < 90 mmHg or MAP < 70) or lactate > 4 mmol/L

Vasopressors If septic shock or lactate > 4

mmol/L: CVP and ScvO2 or SvO2

measured CVP maintained 8-12 mm Hg

Inotropes (and/or PRBCs if Hct < 30%) delivered for ScvO2 <70% or SvO2<65% if CVP > 8 mmHg

24 Hour Bundle Glucose control maintained <

150 mg/dL Drotrecogin alfa (activated)

administered in accordance with hospital guidelines

Steroids given for septic shock requiring continued use of vasopressors for > 6 hours

Lung protective strategy with plateau pressures < 30 cm H2O for mechanically ventilated patients

http://www.ihi.org

SCCM 2009: Sepsis Management "Bundles" Boost Guideline Implementation, Reduce

Mortality

15,022 Patients

7% Absolute Risk Reduction19% Relative Risk Reduction

Society of Critical Care Medicine (SCCM) 38th Critical Care Congress. Late breaker. Presented February 2, 2009

SUMMARY: SEPSIS GUIDELINES 2008

Strong Recommendation (1): Recommended

DVT Prophylaxis

H2 Blocker PUD Prophylaxis

No Routine Use of SGC

A DCB

Glycemic Control

Consider Limiting Support

BC prior to Abx

Antibiotics within 1 hr for Septic Shock

EGDT and Protocolized Resuscitation

Antibiotics within 1 hr in No septic Shock Patients

De-escalation Antibiotic Therapy

7-10 day Antibiotic Duration

Source Control

Fluid Challenge

Dopamine or Norepinephrine

Limit P plateau <30 cm H2O

PEEP

Conservative Fluid in ALI with no Shock

No Renal Dose Dopamine

No High Dose Steroids

Weaning Protocol/SBT

Avoid NMB

PPI PUD Prophylaxis

Crystalloid = Colloid

Limited Transfusion

Low VT for ALI

HOB >45

Intermittent = Continuous sedation

No Antithrombin II

No Erythropoietin

SUMMARY: SEPSIS GUIDELINES 2008

Weak Recommendation (2): Suggested

APC in high risk and non-surgical

A DCB

equivalencyof continuous

veno-veno hemofiltrationor intermittent hemodialysis

Wean Steroids

Low dose steroids for septic shock

B/S < 150

APC for high risk and surgical

PRBCs or Dobutamine

ACTH test not to be done

Prone Position in ARDS

NIV for ALI/ARDS mild/moderate

hypoxemia

SepsisSIRS Severe Sepsis Septic ShockInfection

Insulin and Tight Glucose Control

Early Goal Directed Therapy

Steroids

Antibiotics and Source Control

Chest 1992;101:1644

Therapy Across the Sepsis Continuum

*Drotrecogin Alpha

SepsisSIRS Severe Sepsis Septic ShockInfection

Early Goal Directed Therapy

Therapy Across the Sepsis Continuum

Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand: Fluids, Blood, and Inotropes

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001;345:1368.

CVP > 8-12 mm Hg MAP > 65 mm Hg Urine Output > 0.5 ml/kg/hr ScvO2 > 70% SaO2 > 93% Hct > 30%

*

Rivers E, Nguyen B, Havstad S, et al 2001;345:1368-1377.

49.2%

33.3%

0

10

20

30

40

50

60

Standard Therapy N=133

EGDTN=130

P = 0.01*

*Key difference was in sudden CV collapse, not MODS

Early Goal-Directed Therapy Results:28 Day Mortality

Vascular Collapse

21% vs 10%

p=0.02

MODS

22% vs 16%

P=0.27

NEJM 2001;345:1368-77.

Mortality %

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-DirectedThe Importance of Early Goal-DirectedTherapy for Sepsis-induced HypoperfusionTherapy for Sepsis-induced Hypoperfusion

◦ If venous O2 saturation target not achieved: (2C)

Consider further fluidTansfuse packed red blood cells if required to

hematocrit of ≥30% and/orDobutamine infusion max 20 µg.kg−1 .min−1

Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

First section screens for SIRS SIRS includes objective vital signs data:

Temperature ≥ 100.4 or ≤ 96.8 F Heart Rate ≥ 90 Respiratory Rate ≥ 20 WBC count ≥ 12,000 or ≤ 4,000, or greater than

0.5K/uL bands If the patient has 2 or more of the above, they

screen positive for SIRS

SIRS Screen

Second section screens for infection The patient is screened for infection if they

have SIRS Does the patient have suspected or

documented infection? Has the patient received antibiotics (not

prophylaxis)? If one of the above is confirmed, the patient

is screened for organ dysfunction

Infection Screen

Third section screens for Organ Dysfunction

Respiratory: SaO2 < 90 % Cardiovascular: SBP < 90 Renal: urine output < 0.5ml/hr; creatinine

increase > 0.5mg/dl from baseline CNS: altered LOC, Glascow coma scale ≤ 5

Any one of the above, in addition to positive results from sections 1 and 2, indicates severe sepsis.

Severe Sepsis Screen

The RN should approache the MD, informing him using SBAR technique, that the patient has screened positive for severe sepsis.

SBAR

SBAR Communication Technique

Situation: RN caring for John Smith Screened positive for severe sepsis

Background: Positive for SIRS (describe) Known or suspected infection Organ dysfunction (describe)

Assessment: Share complete VS and SaO2

Recommendation: I need you to come and evaluate the patient

to confirm if they have severe sepsis. It is recommended that I get an ABG,

lactate, and CBC, Can I proceed and get these?

Any other labs you would like me to obtain? If the pt is hypotensive: Can I start an IV

and give a bolus of NS – 20 ml/kg?

SBAR Communication Technique

Resuscitation Goals (Grade 1C)

Central venous pressure (CVP): 8–12mm Hg

Mean arterial pressure (MAP) ≥ 65mm Hg

Urine output ≥ 0.5mL.kg–1.hr –1Central venous (superior vena cava) or

mixed Venous oxygen saturation ≥ 70% or ≥ 65%, respectively

Hemoglobin >10 mg/dLRivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

Initiation of Resuscitation (1C)

Begin resuscitation immediately in patients with CVP < 8, hypotension or elevated serum lactate >4mmol/l;

Do not delay pending ICU admission.

Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

CVP <8 mmHg

Central line placement and CVP monitoring

500 mL 0.9% NaCl bolus every 15 minutes to maintain a CVP goal

Colloids if CVP <4Transfuse 1 unit of PRBC’s if Hg <10

A higher target CVP of 12–15 mmHg is recommended in the presence of

Mechanical ventilationPre-existing decreased ventricular

complianceIncreased intra-abdominal pressure

MAP <65 mmHg

Arterial line placementNorepinephrine 2-20 mcg/minVasopressin 0.04 Unit/minPhenylephrine 40-200 mcg/minHydrocortisone 50 mg IV every 6 hours

ScvO2 <70%

Arterial line placementTransfuse 1 PRBC’s if Hg level <10

mg/dLStart Dobutamine 2.5-20 mcg/kg/min

IV infusionIntubation and ventilation

Critical Care is A Promise

يتقنه أن عمال عمل اذا العبد يحب الله ان

If you are admitted to our ICU with severe sepsis we will:

Obtain blood cultures and lactic acid level Start antibiotics within one hour Target a central venous pressure target to ≥8

mmHg Target a mean arterial blood pressure target

of ≥65 mmHg Target a central venous O2 saturation of ≥

70% Target your urine output to >0.5 mL/Kg/Hour

Thank You