CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK

1. Bassel Ericsoussi, MD
Pulmonary & Critical Care Specialist
CURRENT
INTERNATIONAL
GUIDELINES
FOR
MANAGEMENT
OF
SEVERE
SEPSIS
AND
SEPTIC
SHOCK
FRANCISCAN
ALLIANCE
SEPSIS
CARE
SUMMIT

2. FINANCIAL
DISCLOSURE
NONE

3. REFERENCE

4. SEPSIS
SEVERE
SEPSIS
SEPTIC
SHOCK

5. Ini7al
Resuscita7on
Early
Goal-­‐directed
Therapy
EGDT
• Should
be
ini/ated
EARLY
as
soon
as
hypoperfusion
is
recognized
• Should
NOT
BE
DELAYED
pending
ICU
admission
• DURING
THE
FIRST
6
HOURS,
the
goals
of
ini/al
resuscita/on
should
include
all
of
the
following:
– CVP
8–12
mmHg
– MAP
>
65
mmHg
– Urine
output
>
0.5
mL/kg/hr
– SvO2
>70%
• Improved
survival
for
emergency
department
pa/ents
presen/ng
with
sep/c
shock
– 16%
absolute
reduc/on
in
28-­‐day
mortality
rate.

6. CVP
AS
A
MARKER
OF
INTRAVASCULAR
VOLUME
STATUS
AND
RESPONSE
TO
FLUIDS
• CVP
is
NOT
RELIABLE
for
judging
intravascular
volume
status
• A
low
CVP
generally
can
be
relied
upon
as
suppor/ng
posi/ve
response
to
fluid
loading
• Target
CVP
8–12
mmHg
• Higher
target
CVP
of
12-­‐15
mmHg
should
be
achieved
– Mechanically
ven/lated
pa/ents
– Decreased
ventricular
compliance
– Pulmonary
artery
hypertension
– Increased
abdominal
pressure

8. Assessment
of
Fluid
Status
and
Measures
of
Volume
Responsiveness
IVC
Diameter
Varia7on
• Measure
proximal
IVC
AP
diameter
3
cm
from
the
RA
• Spontaneous
breathing
q
>
50%
decrease
in
the
IVC
diameter
with
inspira/on
predicts
responsiveness
to
volume
expansion
• Posi/ve
pressure
ven/la/on
q
>
12%
increase
in
the
IVC
diameter
with
inspira/on
predicts
responsiveness
to
volume
expansion
q Max
D
–
min
D
/
average
D
>
12%
q Max
D
-­‐
min
D
/
min
D
>
18%

9. IVC
Evalua/on
Bassel
Ericsoussi,
MD
9

10. Normal:
IVC
diameter
1-­‐3
cm
Bassel
Ericsoussi,
MD
10
• Subcostal
view
of
the
IVC
passing
through
the
liver
and
draining
into
the
right
atrium.

11. Volume
Responsive:
IVC
diameter
<1
cm
Bassel
Ericsoussi,
MD
11

12. Bassel
Ericsoussi,
MD
12
Not
Responsive:
IVC
diameter
>3
cm

13. Assessment
of
Fluid
Status
and
Measures
of
Volume
Responsiveness
Pulse
pressure
varia7on

14. LIMITATIONS
OF
IVC
AND
PULSE
PRESSURE
VARIATIONS
• All
pa/ents
must
be:
– Passively
ven/lated
–
heavily
sedated
– Large
/dal
volume
10-­‐12
ml/kg
– Off
vasopressors
– Sinus
rhythm
– Absence
of
increased
abdominal
pressure
• Good
luck
finding
these
pa/ent
Bassel
Ericsoussi,
MD
14

15. Assessment
of
Fluid
Status
and
Measures
of
Volume
Responsiveness
Passive
Leg
Raising
and
Stroke
Volume
Varia7on
• Straight
leg
raising
test:
Can
be
done
on
any
pa/ent
– Sinus
or
irregular
rhythm
– Spontaneous
breathing
or
on
ven/lator
– On
pressors
or
off
pressors
• Use
apical
5
chamber
view
and
measure
the
aor/c
blood
flow
(stroke
volume)
• Raise
legs
to
45
degree
(you
have
just
given
a
“blood
bolus”
500
ml
blood
in
legs
returned
to
the
heart)
• Wait
30-­‐60-­‐90
sec
(highest
values
within
90
sec)
• Recheck
the
stroke
volume
– SVV
>
12%
Bassel
Ericsoussi,
MD
15

16. Assessment
of
Fluid
Status
and
Measures
of
Volume
Responsiveness
Passive
Leg
Raising
and
Artery
Peak
Velocity
• Doppler
evalua/on
of
arterial
peak
velocity
varia/on
q In
the
responder
pa/ent,
passive
leg
raising
induced
an
increase
of
arterial
peak
velocity
by
15%

19. MIXED
VENOUS
OXYGEN
SATURATION
(SVO2)
• Target
SvO2
–
>
70%:
SVC
–
>
65%:
True
mixed
venous
in
the
RA
• If
SvO2
<
70%
despite
adequate
intravascular
volume
reple/on
and
in
the
presence
of
persis/ng
/ssue
hypoperfusion:
– Hb
<
10
and/or
Ht
<
30:
Transfuse
PRBCs
to
achieve
a
hematocrit
of
greater
than
or
equal
to
30%
– Dobutamine
infusion
(to
a
maximum
of
20
μg/kg/min)

20.
We
suggest
targe/ng
resuscita/on
to
normalize
lactate
in
pa/ents
with
elevated
lactate
levels
as
a
marker
of
/ssue
hypoperfusion
Prevalence
Of
Severe
Sepsis
Mortality
Hypotension
with
Elevated
Lac/c
Acid
16.6%
46.1%
Hypotension
49.5%
36.7%
Elevated
Lac/c
Acid
5.4%
30%
• SvO2
and
lac/c
acid
both
should
be
used
as
a
combined
end
point
• SvO2
>
70%
• Normal
lac/c
acid

21. • Rou/ne
screening
of
poten/ally
infected
seriously
ill
pa/ents
• Early
iden/fica/on
of
sepsis
• Early
implementa/on
of
evidence-­‐based
therapy
• Improve
outcomes
• Decrease
sepsis-­‐related
mortality
MANAGEMENT
OF
SEVERE
SEPSIS
Screening
for
Sepsis

22. • Associated
with
improved
pa/ent
outcomes
• Tradi/onal
con/nuing
medical
educa/on
efforts
• Applica/on
of
the
sepsis
bundles
-­‐
associated
with
reduced
mortality
MANAGEMENT
OF
SEVERE
SEPSIS
Performance
Improvement

24. • Administra/on
of
effec/ve
intravenous
an/microbials
within
the
first
hour
of
recogni/on
of
severe
sepsis
– Each
hour
delay
in
achieving
administra/on
of
effec/ve
an/bio/cs
is
associated
with
a
measurable
increase
in
mortality
• Ini/al
empiric
an/-­‐infec/ve
therapy
include
one
or
more
drugs
that
have
ac/vity
against
all
likely
pathogens
and
that
penetrate
in
adequate
concentra/ons
into
the
/ssues
presumed
to
be
the
source
of
sepsis
• The
an/microbial
regimen
should
be
reassessed
daily
for
poten/al
de-­‐
escala/on
to
prevent
the
development
of
resistance,
to
reduce
toxicity,
and
to
reduce
costs
• We
suggest
the
use
of
low
procalcitonin
levels
or
similar
biomarkers
to
assist
the
clinician
in
the
discon/nua/on
of
empiric
an/bio/cs
in
pa/ents
who
appeared
sep/c,
but
have
no
subsequent
evidence
of
infec/on
MANAGEMENT
OF
SEVERE
SEPSIS
An7microbial
Therapy

25. MANAGEMENT
OF
SEVERE
SEPSIS
Hemodynamic
Support
and
Adjunc7ve
Therapy

26. MANAGEMENT
OF
SEVERE
SEPSIS
Hemodynamic
Support
and
Adjunc7ve
Therapy

27. MANAGEMENT
OF
SEVERE
SEPSIS
Hemodynamic
Support
and
Adjunc7ve
Therapy

28. MANAGEMENT
OF
SEVERE
SEPSIS
Hemodynamic
Support
and
Adjunc7ve
Therapy

29. MANAGEMENT
OF
SEVERE
SEPSIS
Hemodynamic
Support
and
Adjunc7ve
Therapy

30. MANAGEMENT
OF
SEVERE
SEPSIS
SUPPORTIVE
THERAPY
OF
SEVERE
SEPSIS

31. MANAGEMENT
OF
SEVERE
SEPSIS
SUPPORTIVE
THERAPY
OF
SEVERE
SEPSIS

32. MANAGEMENT
OF
SEVERE
SEPSIS
SUPPORTIVE
THERAPY
OF
SEVERE
SEPSIS

33. MANAGEMENT
OF
SEVERE
SEPSIS
SUPPORTIVE
THERAPY
OF
SEVERE
SEPSIS

34. MANAGEMENT
OF
SEVERE
SEPSIS
SUPPORTIVE
THERAPY
OF
SEVERE
SEPSIS
• Glycemic
control
<
180
mg/dL
is
not
inferior
to
near-­‐normal
glycemia
in
cri/cally
ill
pa/ents
and
is
clearly
safer
• BG
level
of
8.1
mmol/L
(146
mg/dL)
and
below
represents
an
op/mal
level
in
cri/cally
ill
pa/ents

35. MANAGEMENT
OF
SEVERE
SEPSIS
SUPPORTIVE
THERAPY
OF
SEVERE
SEPSIS

36. MANAGEMENT
OF
SEVERE
SEPSIS
SUPPORTIVE
THERAPY
OF
SEVERE
SEPSIS

37. MANAGEMENT
OF
SEVERE
SEPSIS
SUPPORTIVE
THERAPY
OF
SEVERE
SEPSIS

38. MANAGEMENT
OF
SEVERE
SEPSIS
SUPPORTIVE
THERAPY
OF
SEVERE
SEPSIS