SEPTIC SHOCK AND MULTIORGAN FAILURE

SEPTIC SHOCK A ND MULTIORGA N FA ILURE RECOMMENDATIONS FROM THE SURVIVING SEPSIS CAMPAIGN (Crit Care Med 2008; 36:296-327) Joe Heit, MSc, MD, FA CP DEFINITIONS: SIRS: temperature - >38 or 90 respirations - > 20 - or PaCO2 12,000 or < 4,000 - or < 10% bands (immature PMN) SEPSIS: SIRS + evidence of infection Trauma Bacteria Burns Infection Viral Sepsis SIRS Fungal Other Protozoa Pancreatitis DEFINITIONS: SEPSIS: SIRS + evidence of infection SEVERE SEPSIS: sepsis + evidence of organ dysfunction SEPTIC SHOCK: sepsis + systolic BP < 90 after adequate volume replacement DEFINITIONS: MULTIORGAN FAILURE (MOF) Evidence of dysfunction in more than one organ No universally recognized parameters, but the following markers utilized often PO2/FiO2 Creatinine Platelet count Glascow coma score Serum bilirubin LACTATE INSULT Severe infection (sepsis) SIRS Inflammation Proinflammatory system Antiinflammatory system Cellular injury Cellular repair MODS Recovery MA NA GEMENT (SURVIVING SEPSIS CAMPAIGN GUIDELINES) • • • • • Early goal directed therapy (first hours) Diagnosis Antibiotics Source - identify and control measures Supportive strategies EA RLY GOA L DIRECTED THERA PY Low blood pressure = Shock EGDT: Resuscitation for shock (within the first hours) •CVP 8-12 cm (12-15cm if ventilated) •MAP > 65 mm Hg •MVO2 > 65% (>70% if from SVC) •Urine Output > 0.5cc/Kg/hr EGDT: resuscitation (within the first hours) • Fluids can be crystalloids or colloids – No evidence to prefer either choice – Generally 1000cc NS or 300-500 cc colloids • Transfuse to hematocrit of 30% – Only within the first hours • Consider dobutamine if inadequate response to the above interventions A NTIBIOTICS • • First challenge is to get appropriate cultures Second challenge is to balance these 2: • • Initiation of antibiotics that are broad enough and effective enough (mortality cost if initial antibiotics are not active enough against pathogens) Avoidance of unnecessarily broad and unnecessary numbers of antibiotics Third challenge is to deescalate antibiotics as soon as appropriate (usually after culture results) Fourth challenge is to avoid continuing antibiotics too long (generally stop after 7-10 days) SOURCE CONTROL •4 D’s –Drainage (chest, abdomen, joints) –Debridement (devitalized/infected tissue) –Device Removal (IV, urinary catheters, shunts, any foreign body) –Definitive control (usually means surgical resection) FLUIDS •Adequate vascular access •Administer to goals - CVP, MAP, urine output •We usually underestimate volume needed –Remember EGDT recommendations •FCCS guidelines allow administering fluids until something good (meeting targets as above) or something bad (hypoxia starts or worsens or chest exam worsens) •Auto transfuse by lifting legs an quick, reversible way to give a ‘colloid’ challenge V A SOPRESSORS When adequate fluids are not enough When early transfusion is not enough Even when dobutamine is not enough When all else fails, VASOPRESSORS! V A SOPRESSORS •First concern - adequate IV access; the risk and possible diminished effectiveness of peripheral access for administration makes central access a priority •Second concern - Know which receptors you’re stimulating with which drug –SSC guidelines recommend dopamine or norepinephrine as first line vasopressors for septic shock –Vasopressin as a second line agent –Epinephrine as a second line agent –Neosynephrine as a third line agent V A SOPRESSORS •Target MAP 65 mm Hg or greater •Target should also be improved end organ function and drop in serum lactate central line, arterial line STEROIDS Short answers: •No proven mortality benefit for steroids in septic shock or MOF (CORTICUS study) •Mortality cost for high dose steroids in septic shock •Acceptable to utilize stress dose steroids (150-300 mg/day of hydrocortisone if shock not responsive to all other interventions •ACTH stimulation tests should not be used GLY CEMIC CONTROL •Recommend Insulin to maintain glucose at < 150mg/dl Optimal range for control not known Optimal protocol for glycemic control not established Only randomized control trial that showed decreased mortality with tight control was in Cardiovascular surgery patients Only RCT in a Medical ICU showed no decreased mortality with tight glycemic control, but there was a morbidity benefit and a lower LOS in the ICU and hospitalization There was a mortality benefit with tight glycemic control I several non-randomized trials GLY CEMIC CONTROL Cautions with tight glycemic control:  Increased mortality with hypoglycemic events  Fingerstick methods of glucose measurement (point of care testing) may overestimate actual blood glucose levels GI PROPHY LA X IS Recommendations are:  All critically ill patients should receive GI prophylaxis  H-2 blockers first line  Proton pump inhibitors second line  Sulcrafate less effective than H-2 blockers or PPI DV T PROPHY LA X IS Recommendations are: All patients with severe sepsis receive DVT prophylaxis •UFH or LMWH appropriately dosed Mechanical compression devices used if UFH or LMWH contraindicated RENA L REPLA CEMENT Recommendations are: No evidence of a mortality benefit when CRRT compared to HD in this patient population Some studies suggested that fluid management was improved with CRRT RECOMBINA NT HUMA N A CTIV A TED PROTEIN C Recommendations are: Use in patients with MOF and/or APACHE II score >25 • large trials (PROWESS, ADDRESS, ENHANCE) • A RCT currently underway in Europe of rhAPC v placebo • Bleeding risk BLOOD PRODUCT A DMINISTRA TION Recommendations are: Maintain Hgb 7-9 g/dl •No mortality benefit with higher Hgb (10-12) •Accumulating evidence of increased morbidity (nosocomial infection) with blood product administration Erythropoietin not be used in these patients unless anemia secondary to other causes that have EPO indications (e.g Renal failure) Use FFP to correct bleeding or if planned procedures with bleeding risk, NOT solely to correct elevated INR THESE STEPS Y OU CA N INSTITUTE … TOMORROW [...]... greater •Target should also be improved end organ function and drop in serum lactate central line, arterial line STEROIDS Short answers: •No proven mortality benefit for steroids in septic shock or MOF (CORTICUS study) •Mortality cost for high dose steroids in septic shock •Acceptable to utilize stress dose steroids (150-300 mg/day of hydrocortisone if shock not responsive to all other interventions •ACTH... not established Only randomized control trial that showed decreased mortality with tight control was in Cardiovascular surgery patients Only RCT in a Medical ICU showed no decreased mortality with tight glycemic control, but there was a morbidity benefit and a lower LOS in the ICU and hospitalization There was a mortality benefit with tight glycemic control I several non-randomized trials GLY CEMIC... VASOPRESSORS! V A SOPRESSORS •First concern - adequate IV access; the risk and possible diminished effectiveness of peripheral access for administration makes central access a priority •Second concern - Know which receptors you’re stimulating with which drug –SSC guidelines recommend dopamine or norepinephrine as first line vasopressors for septic shock –Vasopressin as a second line agent –Epinephrine as a second... challenge is to get appropriate cultures Second challenge is to balance these 2: 1 2 • • Initiation of antibiotics that are broad enough and effective enough (mortality cost if initial antibiotics are not active enough against pathogens) Avoidance of unnecessarily broad and unnecessary numbers of antibiotics Third challenge is to deescalate antibiotics as soon as appropriate (usually after culture results)... compared to HD in this patient population Some studies suggested that fluid management was improved with CRRT RECOMBINA NT HUMA N A CTIV A TED PROTEIN C Recommendations are: Use in patients with MOF and/ or APACHE II score >25 • 3 large trials (PROWESS, ADDRESS, ENHANCE) • A RCT currently underway in Europe of rhAPC v placebo • Bleeding risk BLOOD PRODUCT A DMINISTRA TION Recommendations are: Maintain... increased morbidity (nosocomial infection) with blood product administration Erythropoietin not be used in these patients unless anemia secondary to other causes that have EPO indications (e.g Renal failure) Use FFP to correct bleeding or if planned procedures with bleeding risk, NOT solely to correct elevated INR THESE STEPS Y OU CA N INSTITUTE … TOMORROW