Recent Advances in Sepsis Management

Golden Hours

What do u think of pre hospital empiric antibiotic therapy

 2,154 septic shock patients Received antibiotics after the onset of recurrent or persistent hypotension Each hour of delay over 6 hrs was associated with 7.6% decrease in survival.

Lactate clearance and repeating it in 4 hours

Initial lactate- later lactate Initial lactate

Early lactate clearance

60

53
50

42
40 30 20 10 0 1 2 3 4

29

16
Debaker,2006

Goal Directed Septic Shock

CNS and Systemic VO2 - Stress - Pain - Hyperthermia - Shivering - Work of breathing

Endpoints of Resuscitation

Cardiac Optimization - Preload (CVP) - Afterload (MAP, SVR) Contractility (SV) - Heart Rate (BPM) - Coronary Perfusion Pressure

DO2 - PaO2 -Hemoglobin - Cardiac Output

Microcirculation

Sepsis is a Spectrum of Disease

MAP SVR Volume CVP, SVV Normal Flow CO, ScvO2 Lactate Treatment and Comments

Hypovolemia

Variable

Variable

Volume Vasopressors Adrenal Dysf.

Compensated and vasodilatory

Myocardial supression Impairment of

Variable

Correct anemia Inotropic Therapy Vasodilators

Variable

Normal

O2 utilization

Fluid Responsiveness Marik meta-analysis from Chest 2008

No outcome difference

Mortality Prediction at 48 hours

SAFE trial provides enough data to suggest using albumin?

Mechanical ventilation

Use of low dose vasopressin in moderate to severe sepsis to replenish the reserves?

Steroids in shock?

Effect of Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients with Septic Shock (Annane JAMA 2002) 229 Non-responders Randomized Design: Randomized, double-blind, multi-center 115 Treatment & 114 controls Patients: Septic shock Intervention:Hydrocortisone (50 mg every six hours) Fludrocortisone (50 ug once per day)

10% decrease in 28-day mortality

Main Outcome: 28-day survival in nonresponders to CST

17% reduction in vasopressors use

Now what should I do about steroids?

The Original Trial 8 hour time frame Minimal steroid use 56% mortality

The Corticus Trial 72 hour time frame Excluded patients treated over 50% Less severe patients 30 - 40% mortality Similar benefit with higher mortality

14.5% Reduction in Vasopressor Use if Optimized with EGDT

Hold steroid use until the patient has been resuscitated and endpoints met (6-8 hours)

Timing of echo

Global Tissue Hypoxia

Inflammatory Mediators

Early Goal-Directed Therapy for Sepsis in Patients With Preexisting Left Ventricular Dysfunction:
A Retrospective Comparison of Outcomes Based Upon Protocol Adherence

Shah S, Ouellette DR. Chest 2010;138:897A.

Sepsis Data Base of 1287 Patients

183 with echo documented systolic dysfunction (EF< 50%)

135 patients did not meet EGDT

48 patients met EGDT

Mortality 36.3%

Mortality 17%

Mrs S
Suspected sepsis Lactate of 10 & oligouric BNP-4324 BUN- 77 Creatinine-3.2

CXR
ECHO

Future of sepsis management