SEPSIS & SEPTIC SHOCK 10.15. 2009

SEPSIS & SEPTIC SEPSIS & SEPTIC SHOCKSHOCK 10.15. 10.15. 2009 2009

Jaime Palomino, MDJaime Palomino, MDPulmonary & Critical Care MedicinePulmonary & Critical Care Medicine

Tulane University Health Sciences CenterTulane University Health Sciences CenterNew Orleans, LouisianaNew Orleans, Louisiana

EpidemiologyEpidemiology

Sepsis yearly incidence Sepsis yearly incidence 50 – 95 cases / 50 – 95 cases / 100,000100,000

Increasing by 9% each yearIncreasing by 9% each year 2% hospital admissions2% hospital admissions 9% sepsis 9% sepsis severe sepsis severe sepsis 3% severe sepsis 3% severe sepsis septic shock septic shock

10% of ICU admissions10% of ICU admissions

Annane D et al. Lancet 2005;365:63-78

Russell J. NEJM 2006;355:1699-713

Septic Shock – TreatmentSeptic Shock – Treatment

Initial Resuscitation Initial Resuscitation

Rivers E et al. NEJM 2001;345:1368-1377


What are the recommended vasopressors What are the recommended vasopressors in septic shock patients?in septic shock patients? MAP MAP ≥ 65 mmHg≥ 65 mmHg Norepinephrine and Dopamine Norepinephrine and Dopamine initial initial

vasopressors of choicevasopressors of choice Epinephrine Epinephrine first alternative when BP is first alternative when BP is

poorly responsive to Norepinephrine or poorly responsive to Norepinephrine or DopamineDopamine


VasopressorsVasopressors VasopressinVasopressin

• May be subsequently added to Norepinephrine May be subsequently added to Norepinephrine (Dose: 0.03units/min) with anticipation of an effect (Dose: 0.03units/min) with anticipation of an effect equivalent to Norepinephrine alone.equivalent to Norepinephrine alone.

Russell J et al. NEJM 2008;358:877-887

Povoa P et al. CCM 2009;37:410-416


VasopressorsVasopressors Comparison of Dopamine and Norepinephrine as the Comparison of Dopamine and Norepinephrine as the

First Vasopressor Agent in the Management of ShockFirst Vasopressor Agent in the Management of Shock De Backer D. NCT00314704De Backer D. NCT00314704 Primary Outcome Measures: 28 day survivalPrimary Outcome Measures: 28 day survival Estimated Enrollment: 1600 Estimated Enrollment: 1600 Study Start Date: December 2003 Study Start Date: December 2003 Estimated Study Completion Date: December 2010Estimated Study Completion Date: December 2010


SteroidsSteroids

Sprung et al. NEJM 2008;358:111-24

Relative Adrenal Insufficiency DiagnosisRelative Adrenal Insufficiency Diagnosis

Thomas Z et al. Ann Pharmacother 2007;41:1456-65

Dellinger R et al. Crit Care Med 2008; 36:296-327

Annane et al. JAMA 2009;301:2362-2375


Glucose ControlGlucose Control

Van Den Berghe G et al. NEJM 2001;345:1359-1367

Van Den Berghe G et al. NEJM 2006;354:449-461

Brunkhorst FM et al. NEJM 2008;358:125-139

NEJM 2009;360:1283-97

Septic Shock– TreatmentSeptic Shock– Treatment

Activated Protein CActivated Protein C

Bernard GR et al. NEJM 2001;344:699-709

Abraham E et al. NEJM 2005;353:1332-1341

Dellinger R et al. Crit Care Med 2008; 36:296-327

Early Versus Delayed Enteral Feeding and Omega-3 Fatty Early Versus Delayed Enteral Feeding and Omega-3 Fatty Acid/Antioxidant Supplementation for Treating People With Acid/Antioxidant Supplementation for Treating People With Acute Lung Injury or Acute Respiratory Distress SyndromeAcute Lung Injury or Acute Respiratory Distress Syndrome

(The EDEN-Omega Study) (The EDEN-Omega Study)

This study has been terminated. This study has been terminated. ( The Omega arm of this study was ( The Omega arm of this study was

stopped for futility. The EDEN arm stopped for futility. The EDEN arm continues to recruit patients as a separate continues to recruit patients as a separate independent study. )independent study. )

http://clinicaltrials.gov/ct2/show/study/NCT00609180

Early Versus Delayed Enteral Feeding and Omega-3 Fatty Early Versus Delayed Enteral Feeding and Omega-3 Fatty Acid/Antioxidant Supplementation for Treating People With Acid/Antioxidant Supplementation for Treating People With Acute Lung Injury or Acute Respiratory Distress SyndromeAcute Lung Injury or Acute Respiratory Distress Syndrome

(The EDEN-Omega Study) (The EDEN-Omega Study)

Interim analysis:Interim analysis: Mortality @ day 60:Mortality @ day 60:

• 26.6% Omega-3 Vs 16.3% Control26.6% Omega-3 Vs 16.3% Control Ventilator-Free days (within 28 days): Ventilator-Free days (within 28 days):

• 14.6 days Omega-3 Vs 17.4 days Control14.6 days Omega-3 Vs 17.4 days Control ICU-Free days (within 28 days):ICU-Free days (within 28 days):

• 13.9 days Omega-3 Vs 16.8 days Control13.9 days Omega-3 Vs 16.8 days Control

Chest Physician. August 2009. Elsevier.

Septic Shock – DiagnosisSeptic Shock – Diagnosis

Serum MarkersSerum Markers

Nobre V et al. AJRCCM 2008;177:498-505

Tang B et al. AJRCCM 2007;176:676-684

Wurfel M et al. AJRCCM 2008;178:710-720

Cinel I et al. CCM 2009;37:291-304

Russell J. NEJM 2006;355:1699-713


Last but not less important…Last but not less important… Sedation protocolSedation protocol

• Sedation GoalSedation Goal• Daily awakening trialsDaily awakening trials• Avoid NMBAs as much as possibleAvoid NMBAs as much as possible

DVT prophylaxisDVT prophylaxis Stress Ulcer (GI) prophylaxisStress Ulcer (GI) prophylaxis Consideration for Limitation of SupportConsideration for Limitation of Support

SEPSIS & SEPTIC SHOCK 10.15. 2009

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