Update in Management of Septic Shock day/Session 1/LAST.pdf · Sepsis The systemic inflammatory...

Update in Management of

Septic Shock

Prepared by :

Dr. Ibraheem Doom

Terminology Systemic Inflammatory Response Syndrome (SIRS)

Presence of at least two of : Temp > 38 or < 36

HR > 90

RR > 20 or PaCO2 < 32

WBC > 12 or < 4 or Bands > 10%

Sepsis The systemic inflammatory response to infection.

Severe Sepsis Organ dysfunction secondary to Sepsis.

e.g. hypoperfusion, hypotension, acute lung injury,

encephalopathy, acute kidney injury, coagulopathy.

Septic Shock Hypotension secondary to Sepsis that is resistant to adequate

fluid administration and associated with hypoperfusion.

Infection

Parasite

Virus

Fungus

Bacteria Trauma

Burns

Sepsis SIRS Severe

Sepsis

Severe

SIRS

Adapted from SCCM ACCP Consensus Guidelines

shock

BSI

Surviving Sepsis Campaign

Guidelines for Management of

Severe Sepsis/Septic Shock

Surviving Sepsis Campaign

A global program to:

Reduce mortality rates

Improve standards of care

Secure adequate funding

evidence-based guidelines

Grading System

Initial Resuscitation

A: Airway

B: Breathing

C: Circulation

D:DIAGNOSIS/Disability

AIRWAY

Ensure and maintain

patency of Airway

BREATHING

All patients in shock need Oxygen

supplementation

And some need Mechanical

Ventilation Support

CIRCULATION

sepsis-induced hypoperfusion : Lactic acidosis

Confusion ,Delirium

Oligouria

Decrease capillary refilling time

Hypotension

CIRCULATION

So early restoration of perfusion is

necessary to prevent or limit multiple organ

dysfunction, as well as reduce mortality .

Tissue perfusion should be promptly

restored using:

intravenous fluids

Vasopressors & inotropes

possibly red blood cell transfusions

Early Goal-Directed Therapy

Goals during first 6 hours:

Central venous pressure: 8–12 mm Hg

Mean arterial pressure 65 mm Hg

Urine output 0.5 mL kg-1/hr-1

Central venous (CvO2) or mixed venous oxygen [SvO2] saturation 70%

Grade: B

In-hospital mortality

(all patients)

0

10

20

30

40

50

60 Standard therapy

EGDT

28-day mortality

60-day mortality

NNT to prevent 1 event (death) = 6-8

Mo

rta

lity

(%

)

if Central venous or mixed venous O2

sat persist < 70% after CVP of 8–12 mm Hg • Packed RBCs if Hct < 30%

• Dobutamine to max 20 g/kg/min

Grade: B

Serum Lactate Level

Recent evidence show that serum Lactate

levels are used as diagnostic and

prognostic factor in sepsis .

Serum Lactate marker is beneficial as well

as other markers of early goal -target .

Serum Lactate Level

Recent evidence show that measurement

of serum Lactate levels at presentation

Repeat lactate within 6 hours if initial

lactate > 2.0

.

Serum Lactate Level

The target of serum Lactate in

management of sepsis < 2 mg/dL

If serum lactate > 4 indicate sever sepsis

If serum lactate > 6 or persist high despite

of therapy indicate poor prognosis

Serum Lactate Level

Clearance of lactate is associated with

improved survival

NEW Algorithms of care based on lactate

clearance appear to work as well or better

than other approaches.

Fluid Therapy

Fluid therapy may consist of :

Crystalloids

Colloids (Natural or artificial )

Grade: C

Fluid Therapy

Fluid challenge over 30 min

• 500–1000 ml crystalloid

• 300–500 ml colloid

Repeat based on response and tolerance

Grade: E

Fluid Therapy

Liberal replacement :

Can use 6 Liters .

Better in first 6 hour .

Adjust by fluid and CVS status .

RL > N/S

Conservative replacement :

Use maintenance fluid replacement .

Better in the next 48-72 hours .

Fluid Replacement Strategy in the Critically ill

Vasopressors

Either norepinephrine or dopamine administered through a central catheter is the initial vasopressor of choice.

• Failure of fluid resuscitation

• During fluid resuscitation

Grade: D

Vasopressors

Do not use low-dose dopamine for

renal protection.

Grade: B

Vasopressors

In patients requiring vasopressors,

place an arterial catheter as soon as

possible.

Grade: E

Circulating Vasopressin Levels in Septic Shock

Vasopressors Vasopressin

Not a replacement for norepinephrine or dopamine as a first-line agent

Consider in refractory shock despite high-dose conventional vasopressors

If used, administer at 0.01-0.04 units/minute in adults

Grade: E

During Septic Shock

10 Days Post Shock

Diastole Systole

Diastole Systole

Inotropic Therapy

Consider dobutamine in patients with measured low cardiac output despite fluid resuscitation.

Continue to titrate vasopressor to mean arterial pressure of 65 mm Hg or greater.

Grade: E

Therapeutic End-points

Capillary refill < 2 sec

Warm extremities

Urine output > 0.5 ml/kg/hr

Normal mental status

Central venous O2 saturation > 70%

Serum Lactate < 2 mg/dL

DIAGNOSIS

Early diagnosis of Sepsis and Septic

shock based on high clinical suspicion and

clinical parameters .

Sepsis mortality can be reduced with early

detection & rapid initiation of treatment&

support of organ failure or dysfunction:

Diagnosis

Appropriate cultures

Minimum 2 blood cultures

• 1 percutaneous

• 1 from each vascular access 48 hrs

Cutures from other possible sites of infection

Grade: D

Antibiotic Therapy

Begin intravenous antibiotics within

first hour of recognition of severe

sepsis.

Grade: E

Antibiotic Therapy

Recommended empirical broad spectrum

antibiotics

Choose one or more Antibiotics active

against likely bacterial or fungal

pathogens.

Consider microorganism susceptibility

patterns in the community and hospital.

(LOCAL POLICY)

Grade: D

Antibiotic Therapy

Reassess antimicrobial regimen at 48-72 hrs • Microbiologic and clinical data

• Narrow-spectrum antibiotics

• Non-infectious cause identified

• Prevent resistance, reduce toxicity, reduce costs

Grade: E

SOURCE OF INFECTION

Identification and treatment of the site

of infection are essential

Control of sites of infection by

appropriate methods as: removal of

vascular line ,drainage of abscess

,debridement and So on …

Grade: E

Culture Negative

20%

Lung 47%

Abdomen 15%

Urine 10%

Other 8%

Steroids

Indications of Steroids is controversial .

It is indicated to patients who still require vasopressors despite fluid replacement .

Low dose Hydrocortisone 200-300 mg/day, for 7 days in three or four divided doses or by continuous infusion.

Grade: C

Steroids

Optional:

Decrease steroid dose if septic

shock resolves.

Grade: E

Steroids

Optional:

Taper corticosteroid dose at

end of therapy.

Grade: E

Steroids

Optional:

Add fludrocortisone (50 µg orally

once a day) to this regimen.

Grade: E

Steroids

Do not use corticosteroids >300

mg/day of hydrocortisone to treat

septic shock.

Grade: A

Thrombin

Thrombomodulin

Protein

C (Inactive) Protein C Activity

Blood Vessel Blood Flow

Protein C

Receptor

Protein

S

Recently NOT recommended based on

new trial, the (PROWESS-SHOCK TRIAL ) :

rhAPC did not improve 28-day

mortality

So this drug is withdrawal from the market

Blood Product Administration

packed RBCs

Transfuse < 7.0 g/dl to maintain Hb 7.0-9.0 g/dL

In some circumstances :( )

Coronary artery disease

Acute hemorrhage

refractory Lactic acidosis

Grade: B


Do not use Erythropoietin to treat sepsis-

related anemia. Erythropoietin may be

used for other accepted reasons.

Grade: B


Fresh frozen plasma

• Bleeding

• DIC

Grade: E


• Do not use antithrombin therapy.

Grade: B


Platelet administration

Transfuse for < 5000/mm3 -

Transfuse for 5000/mm3 – 30,000/mm3 with significant bleeding risk

Transfuse < 50,000/mm3 for invasive procedures or bleeding

Grade: E

Mechanical Ventilation in

Septic Shock

LUNG PROTECTIVE VENTILATION

Reduce tidal volume over 1–2 hrs to 6 ml/kg predicted body weight

Maintain inspiratory plateau pressure < 30 cm H20

Grade: B

Peak Airway

Pressure

Inspiratory Plateau

Pressure

PEEP (5 cm

H2O 5

0

Mechanical Ventilation of Severe Sepsis

Semirecumbent position unless contraindicated with head of the bed raised to 45o

Grade: C

Mechanical Ventilation of Septic Patients

Use weaning protocol and a spontaneous breathing trial (SBT), at least daily

Grade: A

Prior to SBT

a) Arousable

b) Hemodynamically stable (without vasopressor agents)

c) No new potentially serious conditions

d) Low ventilatory and end-expiratory pressure requirements

e) Requiring levels of FIO2 that could be safely delivered with a face mask or nasal cannula

Consider extubation if SBT is successful

Sedation and Analgesia in Sepsis

AVOID EXESSIVE SEDATION

SEDATION SHOULD BE TITARED USING

OBEJECTIVE ASSESSMENT or

INTERMITTENT BOLUS .

Light sedation is better than heavy sedation

DAILY INTERRUPTION of sedation.

Grade: B

Neuromuscular Blockers

Should be avoided if possible

Grade: E

Glycaemic Control

Target Blood Glucose in Septic Patient Glucose < 150 mg/dL

Continuous infusion insulin and glucose

Monitoring of blood glucose : • Initially every hour

• After stabilization q4h

Grade: D

Intensive insulin therapy in critically

ill patients

Tight glycaemic control= 80-110 mg/dl (4.4-6.1 mmol/l)

Renal Replacement

Hemodynamic instability: CVVH preferred

Hemodynamic stability: Intermittent hemodialysis and

continuous venovenous filtration equal (CVVH)

Grade B

Bicarbonate therapy not recommended to improve hemodynamics in patients with lactate induced pH >7.15

Grade: C

Bicarbonate Therapy

Deep Vein Thrombosis Prophylaxis

Heparin (UH or LMWH)

Contraindication for heparin

Mechanical device

High risk patients

Combination Heparin and mechanical

Grade: A

Stress Ulcer Prophylaxis

H2 receptor blockers

Role of proton pump inhibitors

Grade: C

NUTRITION

Enteral nutrition is generally safer and

more effective than total parenteral

nutrition, but total parenteral nutrition is

sometimes required in patients with

abdominal sepsis, surgery, or trauma.

PREVENTION

Handwashing

Elevation of head of the bed

Sterile techniques for the insertion of catheters, and

possibly the use of antibiotic-impregnated catheters. New

catheter insertion sites for catheter changes

Isolation of patients who have resistant organisms

Isolation of significantly immunocompromised patients

Preventing the progression from sepsis to septic shock

requires early diagnosisand aggressive resuscitation. Early

goal-directed therapy, lung-protectiveventilation,

antibiotics, are critical therapies in early septic shock

Sepsis Resuscitation Bundle

Identify Sepsis as early as possible

Serum lactate measured

Blood cultures obtained prior to

antibiotic administration

Quickly administer appropriate

antibiotics and source control

Hemodynamic Support

Hemodynamic profile may be variable

Establish institutional goals for physiologic

resuscitation

Early goal target therapy should be achieved

Monitor for signs and symptoms of

hypoperfusion and achieve end-targets

points .

Target Hb is 7-9 mg/dL

Sepsis Management Bundle

Low-dose steroids* administered for septic shock in accordance with a standardized ICU policy

(activated pc) RECENTLY NOT RECOMMENDED


Glucose control maintained lower limit

of normal, but < 150 mg/dl (8.3 mmol/L)

Lung Protective Ventilator Strategies

Inspiratory plateau pressures

maintained < 30 cm H2O for

mechanically ventilated patients.

Sedation, Daily Awakenings &

Spontaneous breathing Trials


Monitor for and prevent recurrence of sepsis

Infection Control Practices.

Nutritional Support

Early Mobilization

Success with these measures is most likely with a multi-

disciplinary approach.


A clinician, armed with the sepsis bundles, attacks the three heads

of severe sepsis: Hypotension, Hypoperfusion and Organ

Dysfunction.

Sponsoring Organizations

American Association of Critical Care Nurses

American College of Chest Physicians

American College of Emergency Physicians

American Thoracic Society

Australian and New Zealand Intensive Care Society

European Society of Clinical Microbiology and Infectious Diseases

European Society of Intensive Care Medicine

European Respiratory Society

International Sepsis Forum

Society of Critical Care Medicine

Surgical Infection Society

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