Beruflich Dokumente
Kultur Dokumente
Raymundo F. Resurreccion, MD
From the PCS-MMC 34th Post Grad Course on Surgical Infections
August 16 19, 2016
Objectives
Review key concepts in sepsis
Discuss new definitions in sepsis
Highlight changes in the sepsis diagnostic criteria
Summarize findings of recent EGDT trials and their
implications in sepsis resuscitation
Demonstrate the impact of sepsis pathway in local
clinical practice
Sepsis
Harmful systemic reaction to infection
Infectious etiology + response that results in
hypofunction of uninfected organs
Incomplete understanding of pathobiology
Early activation
of both pro- and
anti-inflammatory
responses
Major
modifications in
non-immunologic
pathways
Organ failure occurs when vital organs stop working, causing nearly half of all
deaths in the ICU, but little can be done t treat or prevent it today.
Sepsis-3: Definition
Sepsis is a life-threatening organ dysfunction
caused by a dysregulated host response to infection
Sepsis-3: Definition
Sepsis is a life-threatening organ dysfunction
caused by a dysregulated host response to infection
As opposed to the
regulated host response
that characterizes the non-septic response to
infection
Sepsis-3 Consensus
SEPSIS
Sepsis-3 definition
Septic shock is a subset of sepsis in which
underlying circulatory, cellular, and metabolic
abnormalities re associated with a greater risk of
mortality than sepsis alone
Who is septic?
Should prompt:
Rivers
March 1997 March 2000
Single-center
Adult with SIRS + SBP < 90 after fluid challenge OR
lactate > 4
EGDT x >/= 6 hours
Standard care
60-day in-hospital mortality
Protocoliz
ed
Managem
ent in
Sepsis
(ProMISe)
(April
2015)
Protocoliz
ed Care
for Early
Septic
Shock
(ProCESS)
(May
2014)
Resuscita
tion in
Sepsis
Evaluatio
n (ARISE)
Is EGDT obsolete?
Conclusion:
In-hospital survival with usual care = EGDT
Continuous ScvO2 monitoring and strict protocolization do not
improve outcomes
Updated Bundles in
Response to New Evidence
With publication of 3 trials (2, 3, 4) that do not demonstrate
superiority of required use of a central venous catheter (CVC) to
monitor central venous pressure (CVP) and central venous oxygen
saturation (ScvO2) in all patients with septic shock who have
received timely antibiotics and fluid resuscitation compared with
controls or in all patients with lactate > 4 mmol/L, the SSC
Executive Committee has revised the improvement bundles as
follows:
To be completed within 3 hours of time of presentation:
* Time of presentation is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest
chart annotation consistent with all elements of severe sepsis or septic shock entertained through chart review.
Updated Bundles in
Response to New Evidence
With publication of 3 trials (2, 3, 4) that do not demonstrate
superiority of required use of a central venous catheter (CVC) to
monitor central venous pressure (CVP) and central venous oxygen
saturation (ScvO2) in all patients with septic shock who have received
timely antibiotics and fluid resuscitation compared with controls or in
all patients with lactate > 4 mmol/L, the SSC Executive Committee
has revised the improvement bundles as follows:
To be completed within 6 hours of time of presentation:
Apply vasopressors (for hypotension that does not respond to initial fluid
resuscitation) to maintain a mean arterial pressure (MAP) >/= 65 mmHg
In the event of persistent hypotension after initial fluid resuscitation (MAP < 65
mmHg) or if initial lactate was >/= 4 mmol/L, re-assess volume status and tissue
perfusion and document findings according to Table 1.
Re-measure lactate if initial lactate elevated.
International
Guidelines for
Management of
Severe Sepsis and
Septic Shock: 2012
Fluid therapy
Initial fluid challenge in
sepsis-induced
hypoperfusion with
hypovolemia to achieve a
minimum of 30 ml/kg of
crystalloid [1C]
More rapid administration
and greater amounts of
fluid may be needed in
some patients [1C]
Diagnosis
Obtain appropriate cultures before starting antibiotics.
[1C]
Perform imaging studies promptly in order to confirm
and sample any source of infection. [UG]
Antibiotic therapy
Administer IV antibiotics within the first hour of
recognizing severe shock [1B] and severe sepsis without
shock [1C].
Broad spectrum: one or more agents active against
likely bacterial/fungal pathogens, and with good
penetration into presumed source.[1B]
Source control
A specific anatomical diagnosis of infection should be
established as rapidly as possible. [1C]
Formally evaluate patient for a focus of infection
amenable to emergent source control measures [1C]
Undertake intervention for source control within the first
12 hours after diagnosis is made, if feasible. [1C]
qSOFA implications
Patients with suspected infection who are likely to have
a prolonged ICU stay or to die in the hospital can be
promptly identified at the bedside with qSOFA (HAT)
Hypotension: SBP less than or equal to 100 mmHg
Altered mental status (any GCS less than 15)
Tachypnea: RR >/= 22
References
Levy MM, Fink MP, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G. 2003. 2001 SCCM/ESICM/ACCP/ATS/SIS
International Sepsis Definitions Conference. Intensive Care Med (2003) 29:530-538
Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, Rubenfeld G, Kahn JM, Shankar-Hari M, Singer M, Deutschman CS, Escobar
GJ, Angus DC. 2016. Assessment of clinical criteria for sepsis for the Third International Consensus Definitions for Sepsis and Septic
Shock (Sepsis-3). JAMA 2016; 315(8): 762-774
Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall c, Sakr Y, Reinhart K. 2009. International study of
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(16): 1496-1506
ProCESS Investigators. 2014. A randomized trial of protocol-based care for early septic shock. NEJM 370 (18): 1683-1693
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Angus DC, Van der Poll T. 2013. Severe sepsis and septic shock. NEJM 369 (9): 841-851
Kaukonen KM, Bailey M, Pilcher D, Cooper J, Bellomo R. 2015. Systemic inflammatory response syndrome criteria in defining severe
sepsis. NEJM 372 (17): 1629-1638
Surviving Sepsis campaign. 2012. international Guidelines for Management of Severe Sepsis and septic Shock 2012. Critical care Med
2013 41 (2): 580-637
Thank you!