PowerPoint Presentation

Shozab AhmedNew Era In The Treatment of Septic & Occult Shock

ObjectivesDefine septic and occult shockReview the current literature in management of septic shockImportance of volume resuscitation How to assess volume status?Old and new protocol used at UNMH

Septic shockSepsis plus hypotensionSBP 90 or 30 drop from baseline

[Bone RC, et al. Chest 1992; 101: 1644-55

3DEFINITIONOccult shockSepsis with elevated lactate >4High mortality

Howell , Int care Med 2007

Mikkelsen CCM 2009

Frustrations with the protocolCVP?? As a measure of volume status and responsiveness??InvasiveComplications

BACKGROUNDEarly aggressive resuscitation of critically ill patients

Limit and/or reverse tissue hypoxiaLimit progression to organ failureImprove outcome

Chest 2004; 124 (Suppl.):120S

BACKGROUNDOverzealous fluid resuscitationIncreased complicationsIncreased length of ICUIncreased hospital stay

N Engl J Med2006; 354: 256475.

BACKGROUND Only 50% of hemodynamically unstable critically ill patients are volume responsive

Crit Care Med2009; 37: 26427.

BACKGROUND

Annals of Intensive Care 2011, 1:1

Systematic review of the literature to determine the following

Relationship between CVP and blood volume Ability of CVP to predict fluid responsiveness

24 studieshuman adult subjectshealthy control subjectsICU and operating room patients803 patients5 studies compared CVP with measured circulating blood volume19 studies determined the relationship between CVP/CVP and change in cardiac performance following a fluid challenge

ConclusionsThis systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/CVP to predict the hemodynamic response to a fluid challenge

CVP should not be used to make clinical decisions regarding fluid management

The only study we could find demonstrating the utility of CVP in predicting volume status was performed in seven standing, awake mares undergoing controlled hemorrhage!

SCCM GuidelinesInitial Resuscitation Protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration 4 mmol/L). Goals during the first 6 hrs of resuscitation:

Central venous pressure 812 mm Hg Mean arterial pressure (MAP) 65 mm Hg ) Urine output 0.5 mL/kg/hr d) Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C)

In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

Crit Care Med. 2013; 41:580-637

PROCESS TRIAL31 Emergency Departments in US1341 patients6 hours of resuscitationRandomly assigned patients to 3 gpsProtocol based EGDTProtocol based standard therapy Usual careEnd pointsPrimary End Point60 day in hospital mortalitySecondary End PointsLonger term mortalityNeed for organ support

Usual care is not bad huh..?No central lines for CVP measurementsNo ScVO2 measurementsNo blood transfusionsNo Dobutamine infusionsBut usual care was carried out by intensivist and ER physiciansIn our unit and ER care is provided by trainee physiciansObjective marker of volume responsiveness

So if not CVP then what?

BACKGROUND

Other measures of volume assessmentIVC Trained (not all residents and interns can do it)Repitition q15 mins by doctors ( never gonna happen )

PLR

PASSIVE LEG RAISINGSelf-volume challengeReversible Non intubated patientsBreathing spontaneouslyArrhythmias

PASSIVE LEG RAISING

Annals of Intensive Care 2011, 1:1PASSIVE LEG RAISING

Critical Care 2009, 13:R11145PASSIVE LEG RAISING

Intensive Care Medicine 2010: 36, 1475-1483 LimitationHow to perform PLROur wedge failed terribly

Instead of PLR, we used fluid challenge500cc bolus followed by SV change measurement with flo-trac and if responsive, continue with volume assessment till volume unresponsive and if still hypotensive use pressorsIndications:1. Septic Shock2. Lactate of 4 3. Initiate protocol after 3L in the first 3hrs of SMITE protocol given1. 500cc Bolus (over 10 minutes) No Pump2. Check SV (no. 2) 1. Arterial Line for hemodynamic monitoring2. Flo Trac 3. Record SV (no. 1)SV: Stroke VolumeNS: Normal SalineLIP: Licensed Independent PractitionerResponsive 10% increase in SV from baseline(from SV no.1 and SV no.2)If the pt is hypotensive start vasopressorsNot ResponsiveYesHypotensionNoContinue to monitorStart VasopressorsInform MD/LIP

Sepsis Fluid Responsiveness Protocol1Hour

6 Hour

1.Record SV ( no.2)2. 500 cc NS bolus (over 10 minutes)3.Record SV( no.3)4. If responsive (from SV no.2 and SV no.3) continue with 500 cc boluses (over 10 minutes) with SV before and after each bolus to check responsiveness. Stop at 3L . Inform MD/LIP

THE CHANGE PROCESSTime 0Hour 6Hour 3Hour 5Hour 4Hour 2Hour 1Pt. #Admit DateSepsis Report1635 Resus Rm AMS Fluid Running 3LT37.7, HR123, RR22, BP 142/801 55y Male7/1 18411700 Bolus 2L1801 Abx (86) ordered @ 17521736 Lact 4.2 (44 Minutes)2002 A-Line Placed1807 MICU @ BS1652 Bcx Lact OrderedED Resident BarkhuffED Attending MillerED RN A Ulibarri

MICU Fellow AssadMICU Attending AhmedMICU RN A Martinez

2049 SV = 871700 Lact 4.01 (iSTAT)1747 MICU Called1958 CVC Placed RIJ2015 Trans to MI 82130 Bolus 1L2049 Bolus 500mL2059 SV = 86 -1%EGDT UnmetPreventableSepsis ScorecardBcxAbxBolusFluid ResponseVPs

TIPSAlways be aware of T0Have the charge nurse involved soonerPlease do not block anyone with lactate of >4(infection or no infection) without discussing the case with the attending. Day or nightAlways go with the first lactateKnow your patients baseline BPMake sure that SMITE protocol got initiatedClick the levophed orderIf there is reason that the patient has a surgical issue, please do whats best for the patientQUESTIONS?CASE # 148 y.o male with PMH of HTN, DM, HLD, COPD coming in with increasing SOBHR- 101, BP-100/55, RR-24, T-38CXR with a RLL infiltrateLactate 1.8s.p 3L of IVF bolus BP is 110/58

What are we going to do?CASE #266 y.o female with no PMH coming in with increasing urinary frequency, some suprapubic tenderness, and feverHR-88, BP-115/75, RR-18, Temp-37.8UA is positive for LCE, WBC of 55Lactate of 6.5

What should we do now?

CASE # 345 y.o male with DM, HTN, coming in with fever, and with LLE cellulitis and swellingHR-120, BP-100/65, RR-18, Temp-38.4Leukocytosis present

What should be the course of action?

CASE # 3Flo trac was attached, patient is fluid responsive. He is getting fluid boluses, however his BP is still with MAPS in the 55 range

What should we do now?Questions???