SepsisIan Turner Sept 2014

SepsisWhat it isWhat worksWhat doesn’tWhat’s next

Severe Sepsis and Septic Shock. N Engl J Med. 2013 Aug;369(9):840-51.

Language

Sepsis

Severe sepsis

Septic shock

Severity

More organ systems = more badness

~20% increase in mortality with each failing organ

6 major systems that fail

CVS : Resp : Renal : Hepatic : CNS : Haem

Australian Stats2000: 35% mortality

2012: 18.4% mortality

Sites: 50.3% pulmonary19.3% intra-abdominal

Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patient in Australia and New Zealand. JAMA. 2014 Apr;311(13):1308-1316

Adult-population Incidence of Severe Sepsis in Australia and New Zealand Intensive Care Units. Intensive Care Med. 2004 Apr;30(4):589-96.

Emergency Role

We treat these patients

We are sometimes looking after them for longer

Text

Sepsis Six Pack

Antibiotics(+ airway)

BroadCultureAvoid delayDe-escalate

Duration of Hypotension Before Initiation of Effective Antimicrobial Therapy is the Critical Determinant of Survival in Human Septic Shock. CCM 2006 Jun;34(6): 1589-96

one

BreathingLow tidal volumesModest fluid resuscitation

Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for ALI and the ARDS. N Enlg J Med. 2000; 342:1301-1308.Comparison of Two Fluid-management Strategies in Acute Lung Injury. N Enlg J Med. 2006 Jun;354(24):2564-75.

two

CirculationEnd-pointsEarly goal-directed therapyFluid choicesVasopressor choices

three

CirculationEnd-points:CVPMAPUO

three

LactateScvO2

CirculationEarly goal-directed therapy2001: 30.5% vs 46.5% mortality2014: No difference, lower mortalities (~20-29%)

Early Goal-directed Therapy in the Treatment of Severe Sepsis and Septic Shock. N Engl J Med. 2001 Nov;345(19):1368-77A Randomised Trial of Protocol-based Care for Early Septic Shock. N Engl J Med. 2014 May;370(18):1683-93Goal-directed Resuscitation for Patients with Early Septic Shock. N Engl J Med. 2014 Oct;371:1496-1506Trial of Early, Goal-Directed Resuscitation for Septic Shock. N Engl J Med. 2014 Apr;372:1301-1311

three

CirculationFluid choicesConflicting evidenceToo much = bad lungsToo little = reliance on vasopressorsAfrican experienceCrystalloid or colloidNo starches

Mortality After Fluid Bolus in African Children with Severe Infection. N Engl J Med 2011;364:2483-2495.A Comparison of Albumin and Saline for Fluid Resuscitation in the ICU. N Engl J Med. 2004 May;350(22):2247-56.Hydroxyethyl Starch 130/0.42 Versus Ringer’s Acetate in Severe Sepsis. N Engl J Med. 2012 Jul;367(2):124-34.Association of Hydroxyethyl Starch Administration with Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation: a Systematic Review and Meta-analysis. JAMA. 2013 Feb;309(7):678-88.

three

CirculationVasopressor choicesNoradrenaline then maybe vasopressin

Comparison of Dopamine and Norepinephrine in the Treatment of Shock. N Engl J Med. 2010 Mar;362(9):779-89.Vasopressin Versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med. 2008 Feb;358(9):877-87.

three

CirculationYou can start noradrenaline peripherallyArms obs

Central or Peripheral Catheters for Initial Venous Access of ICU Patient: a RCT. Crit Care Med 2013 Sep;41(9):2108-15.

three

DrugsInsulinCorticosteroidsActivated Protein C

four

DrugsInsulinTight control has been debunkedAim to keep <10mmol/L

Intensive Insulin Therapy in Critically Ill Patients. N Engl J Med. 2001 Nov;345(19):1359-67.Intensive Versus Conventional Glucose Control in Critically Ill Patients. N Engl J Med. 2009 Mar;360(13):1283-97.

four

DrugsCorticosteroidsOften given when noradrenaline requirements are high (>20mcg/min)

Effect of Treatment with Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients with Septic Shock. JAMA. 2002 Aug;288(7):862-71.Hydrocortisone Therapy for Patients with Septic Shock. N ENGL J Med. 2008 Jan;358(2):111-24.

four

DrugsActivated Protein CAnti-inflammatoryAnti-thromboticPro-fibrinolytic2001: 24.7% vs 30.8% mortality

Efficacy and Safety of Recombinant Human Activated Protein C for Severe Sepsis. N Engl J Med. 2001 Mar;344(10):699-709.

four

DrugsActivated Protein C2012No mortality benefit at 28 or 90 days

Drotrecogin Alfa (Activated) in Adults with Septic Shock. N Engl J Med. 2012 May;366(22):2055-64.

four

Source controlClinicallyImagingDon’t delay ABs

five

Source controlIntervene within first 12 hours of diagnosis being madeThe least physiologically insulting intervention

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637.

five

SupportiveHead-upSedation and analgesiaDVT prophylaxisStress ulcer prophylaxisNutritionCare goals

six

SummaryWe are getting betterRecognise earlyGive fluid but not too much2014 trilogy of sepsis trialsRemember the 20% rule-of-thumb when talking to patient and familiesCarry a six-pack with you