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Bassel Ericsoussi, MDPulmonary & Critical Care SpecialistCURRENT	  INTERNATIONAL	  GUIDELINES	  FOR	  MANAGEMENT	  OF	  SE...
FINANCIAL	  DISCLOSURE	  	  	  	  NONE	  
REFERENCE	  	  
SEPSIS	  SEVERE	  SEPSIS	  	  SEPTIC	  SHOCK	  
Ini7al	  Resuscita7on	  Early	  Goal-­‐directed	  Therapy	  EGDT	  	  •  Should	  be	  ini/ated	  EARLY	  as	  soon	  as	 ...
CVP	  AS	  A	  MARKER	  OF	  INTRAVASCULAR	  VOLUME	  STATUS	  AND	  RESPONSE	  TO	  FLUIDS	  •  CVP	  is	  NOT	  RELIABLE...
Assessment	  of	  Fluid	  Status	  and	  Measures	  of	  Volume	  Responsiveness	  IVC	  Diameter	  Varia7on	  •  Measure	...
IVC	  Evalua/on	  Bassel	  Ericsoussi,	  MD	   9	  
Normal:	  IVC	  diameter	  1-­‐3	  cm	  Bassel	  Ericsoussi,	  MD	   10	  •  Subcostal	  view	  of	  	  the	  IVC	  passin...
Volume	  Responsive:	  IVC	  diameter	  <1	  cm	  Bassel	  Ericsoussi,	  MD	   11	  
Bassel	  Ericsoussi,	  MD	   12	  Not	  Responsive:	  IVC	  diameter	  >3	  cm	  
Assessment	  of	  Fluid	  Status	  and	  Measures	  of	  Volume	  Responsiveness	  Pulse	  pressure	  varia7on	  	  
LIMITATIONS	  OF	  IVC	  AND	  PULSE	  PRESSURE	  VARIATIONS	  •  All	  pa/ents	  must	  be:	  – Passively	  ven/lated	  –...
Assessment	  of	  Fluid	  Status	  and	  Measures	  of	  Volume	  Responsiveness	  Passive	  Leg	  Raising	  and	  Stroke	...
Assessment	  of	  Fluid	  Status	  and	  Measures	  of	  Volume	  Responsiveness	  Passive	  Leg	  Raising	  and	  Artery	...
MIXED	  VENOUS	  OXYGEN	  SATURATION	  (SVO2)	  	  •  Target	  SvO2	  –  	  >	  70%:	  SVC	  –  	  >	  65%:	  True	  mixed...
 We	  suggest	  targe/ng	  resuscita/on	  to	  normalize	  lactate	  in	  pa/ents	  with	  elevated	  lactate	  levels	  a...
•  Rou/ne	  screening	  of	  poten/ally	  infected	  seriously	  ill	  pa/ents	  	  •  Early	  iden/fica/on	  of	  sepsis	 ...
•  Associated	  with	  improved	  pa/ent	  outcomes	  •  Tradi/onal	  con/nuing	  medical	  educa/on	  efforts	  	  •  Appl...
•  Administra/on	  of	  effec/ve	  intravenous	  an/microbials	  within	  the	  first	  hour	  of	  recogni/on	  of	  severe...
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  Hemodynamic	  Support	  and	  Adjunc7ve	  Therapy	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  Hemodynamic	  Support	  and	  Adjunc7ve	  Therapy	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  Hemodynamic	  Support	  and	  Adjunc7ve	  Therapy	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  Hemodynamic	  Support	  and	  Adjunc7ve	  Therapy	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  Hemodynamic	  Support	  and	  Adjunc7ve	  Therapy	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  SUPPORTIVE	  THERAPY	  OF	  SEVERE	  SEPSIS	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  SUPPORTIVE	  THERAPY	  OF	  SEVERE	  SEPSIS	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  SUPPORTIVE	  THERAPY	  OF	  SEVERE	  SEPSIS	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  SUPPORTIVE	  THERAPY	  OF	  SEVERE	  SEPSIS	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  SUPPORTIVE	  THERAPY	  OF	  SEVERE	  SEPSIS	  	  	  •  Glycemic	  control	  <	  180	  ...
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  SUPPORTIVE	  THERAPY	  OF	  SEVERE	  SEPSIS	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  SUPPORTIVE	  THERAPY	  OF	  SEVERE	  SEPSIS	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  SUPPORTIVE	  THERAPY	  OF	  SEVERE	  SEPSIS	  	  	  
MANAGEMENT	  OF	  SEVERE	  SEPSIS	  SUPPORTIVE	  THERAPY	  OF	  SEVERE	  SEPSIS	  	  	  
CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK
CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK
CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK
CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK
CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK
CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK
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CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK

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CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK

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CURRENT INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK

  1. 1. Bassel Ericsoussi, MDPulmonary & Critical Care SpecialistCURRENT  INTERNATIONAL  GUIDELINES  FOR  MANAGEMENT  OF  SEVERE  SEPSIS  AND  SEPTIC  SHOCK    FRANCISCAN  ALLIANCE  SEPSIS  CARE  SUMMIT    
  2. 2. FINANCIAL  DISCLOSURE        NONE  
  3. 3. REFERENCE    
  4. 4. SEPSIS  SEVERE  SEPSIS    SEPTIC  SHOCK  
  5. 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. 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      
  7. 7. 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%  
  8. 8. IVC  Evalua/on  Bassel  Ericsoussi,  MD   9  
  9. 9. 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.  
  10. 10. Volume  Responsive:  IVC  diameter  <1  cm  Bassel  Ericsoussi,  MD   11  
  11. 11. Bassel  Ericsoussi,  MD   12  Not  Responsive:  IVC  diameter  >3  cm  
  12. 12. Assessment  of  Fluid  Status  and  Measures  of  Volume  Responsiveness  Pulse  pressure  varia7on    
  13. 13. 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  
  14. 14. 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  
  15. 15. 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%  
  16. 16. 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)    
  17. 17.  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  
  18. 18. •  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        
  19. 19. •  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        
  20. 20. •  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      
  21. 21. MANAGEMENT  OF  SEVERE  SEPSIS  Hemodynamic  Support  and  Adjunc7ve  Therapy      
  22. 22. MANAGEMENT  OF  SEVERE  SEPSIS  Hemodynamic  Support  and  Adjunc7ve  Therapy      
  23. 23. MANAGEMENT  OF  SEVERE  SEPSIS  Hemodynamic  Support  and  Adjunc7ve  Therapy      
  24. 24. MANAGEMENT  OF  SEVERE  SEPSIS  Hemodynamic  Support  and  Adjunc7ve  Therapy      
  25. 25. MANAGEMENT  OF  SEVERE  SEPSIS  Hemodynamic  Support  and  Adjunc7ve  Therapy      
  26. 26. MANAGEMENT  OF  SEVERE  SEPSIS  SUPPORTIVE  THERAPY  OF  SEVERE  SEPSIS      
  27. 27. MANAGEMENT  OF  SEVERE  SEPSIS  SUPPORTIVE  THERAPY  OF  SEVERE  SEPSIS      
  28. 28. MANAGEMENT  OF  SEVERE  SEPSIS  SUPPORTIVE  THERAPY  OF  SEVERE  SEPSIS      
  29. 29. MANAGEMENT  OF  SEVERE  SEPSIS  SUPPORTIVE  THERAPY  OF  SEVERE  SEPSIS      
  30. 30. 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  
  31. 31. MANAGEMENT  OF  SEVERE  SEPSIS  SUPPORTIVE  THERAPY  OF  SEVERE  SEPSIS      
  32. 32. MANAGEMENT  OF  SEVERE  SEPSIS  SUPPORTIVE  THERAPY  OF  SEVERE  SEPSIS      
  33. 33. MANAGEMENT  OF  SEVERE  SEPSIS  SUPPORTIVE  THERAPY  OF  SEVERE  SEPSIS      
  34. 34. MANAGEMENT  OF  SEVERE  SEPSIS  SUPPORTIVE  THERAPY  OF  SEVERE  SEPSIS      

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