mariana bridi costa, brazilian model pope john-paul ii etta james, singer all of them died secondary...

Mariana Bridi Costa, Brazilian

model

Pope John-Paul II

Etta James, singer

All of them died

secondary to

sepsis

PRACTICAL SEPSIS

Curtis J. Merritt D.O.Chief Internal Medicine Resident Danville Regional Medical Center

Danville Virginia

With that in mind the single goal of this presentation is to demonstrate a stepwise approach to make sepsis practical

Target Audience

Primary Care Providers Hospitalists Medical Students Residents Hospital Administrators Specialists

Disclosures

No pertinent financial disclosures

SEPSIS

A brief review of the last 12 years…

By The Numbers

Annual cost = $16.7 billion in the US in 2000

1,400 people die each day from sepsis Roughly 2 million cases per year 30% dying within one month of diagnosis 80% of patients who die from major

injuries are actually killed by sepsis

Survivingsepsis.org

12 years ago Dr. Emanuel Rivers published in the NEJM an article that would change our approach to sepsis

In that study, Dr. Rivers and colleagues proved that early recognition and aggressive treatment of severe sepsis and septic shock resulted in a 16% reduction in absolute mortality.

That translates to NNT = 6 - 8

N Engl J Med 2001; 345:1368-1377: November 8, 2001

If you fancy a journey…

1. We have to be willing to evolve with the evidence based medicine and be able to look at it critically

2. We have to be open to the idea of aggressive management

3. We have to put away our old notions of the “look” of sepsis

There’s the rub…

The Rub

Many physicians do not use the current definition of sepsis despite attempts to standardize terminology and diagnostic criteria. Indeed, only 17% of clinicians agree on a definition of sepsis (12), and this disparity results in missed diagnosis and delayed treatment. The challenges include: Lack of awareness of frequency and mortality rate of sepsis No universally accepted definition of sepsis No single or combination of tests or markers for a reliable

diagnosis of sepsis Need for earlier diagnosis and treatment of septic patients Lack of adequate healthcare professional training in the

diagnosis and treatment of sepsis

*http://www.survivingsepsis.org/Background/Pages/barcelona_declaration.aspx

Sepsis model

To understand the definition we have to understand the process

The River…

What do you notice about the river?

-fast

-churning

-high rate of aeration

-large volume in a confined

space

-faces of horror

This river is very similar to normal physiology

-fast turn over

-adequate O2

-adequate volume

Now picture that same volume in that river after the rock walls have been removed and the width of the channel is much larger

Much like a stagnant swamp

Now that same volume is moving through a much larger area

So…

What happens to flow?

What happens to O2 content?

What happens to the fish?

In sepsis, toxins and cytokines produce a profound vasodialation and the venous side of the circulator system experiences a low-flow, low O2 state

But that’s not the whole story…

Orthogonal polarization spectral imaging

Used to visualize sublingual microcirculation


Rev. bras. ter. intensiva vol.23 no.3 São Paulo July/Sept. 2011

Normal

No embolisms

Flow speed is adequate that individual RBCs can’t be seen

Normal vessel caliber



Septic Shock

Microthrombi Stagnant flow Small caliber



This is why peripheral hypoxia (i.e. SvO2) can continue despite normal vitals, CVP etc.

How to define something seemingly amorphous

First things first

We have to put our old definitions of sepsis away

We have to realize that sepsis is often difficult to diagnose without a stepwise approach

SEPSIS STEPS

SIRSSystemic Inflammatory Response Syndrome (SIRS) with 2 of the following:

Temp: >38 C (100.4 F)<36 C (96.8 F)

Heart Rate: >90 beats/min

Resp Rate: >20 breaths/min

PCO2: <32 mmHg

WBC: >12,000<4,000>10% BandsN Engl J Med 2001; 345:1368-1377 November 8, 2001

SEPSIS STEPS

T: >100.4 F < 96.8 FRR: >20HR: >90WBC: >12,000 <4,000 >10% bandsPCO2 < 32 mmHg

SIRS

SEPSIS SYNDROME

2 SIRS CRITERIA

An infection or

suspected infection

+

SEPSIS STEPS


SIRS2 SIRS

+Confirmed

or suspected infection

SEPSIS

Sepsis Syndrome

Hypotension (Systolic BP <90)

Lactate >4

End Organ Damage

+

SEVERE SEPSIS

SEVERE SEPSIS

Sepsis Syndrome


Lactate >4

End Organ Damage

+

SEPSIS STEPS


SIRS2 SIRS

+Confirmed


SEPSIS

Sepsis +

Signs of End Organ Damage

Hypotension (SBP <90)

Lactate >4 mmol

SEVERESEPSIS

SEPTIC SHOCK

SEVERE SEPSIS

Persistent


Lactate >4

End Organ Damage

Refractory to IVF Challenge

+

SEPSIS STEPS


SIRS2 SIRS

+Confirmed


SEPSIS

Sepsis +



Lactate >4 mmol

SEVERESEPSIS

SEPTIC SHOCKSevere Sepsis with persistent:

Hypotension


Lactate >4 mmol

Case 1: Jimmy

Case 1: “Jimmy”

Jimmy is a 45 year old gentleman who presents to the local urgent care with a complaint of cough

It began 4 days ago, steadily has worsened, producing thick green/yellow sputum

He complains of subjective fevers and chills and a general feeling of un-wellness

Case 1: “Jimmy”

PMHxJimmy is a smoker of 10 years ½ ppd

Denies alcohol or drug use

No past medical history

No surgeries

He takes no medications

Case 1: “Jimmy”

He is evaluated by a moonlighting resident

Vital SignsBP: 109/89HR: 101Temp: 102.1RR: 16SpO2 98%

Case 1: “Jimmy”

Physical exam of the right lung base reveals rhonchi but is otherwise unremarkable

Chest X-ray demonstrates:

Case 1: “Jimmy”

His lab work at the urgent care is:

Na 140 (135-148 mEq/L)K 4.0 (3.5-5.3 mEq/L)Cl 107 (95-108 mEq/L)CO2 11 (25-35 mEq/L)BUN 27 (6-19 mEq/L)Cr 2.1 (0.7-1.5 mg/dL)Glucose 152 (70-105 mg/dL)

Case 1: “Jimmy”

He is sent home with a diagnosis of:Right Lower Lobe PneumoniaDehydrationCough

He is prescribed moxifloxacin 400 mg daily x 7 days and told to drink plenty of fluids

Case 1: “Jimmy”

He arrives at the hospital 8 hours later unresponsive

Vital SignsBP: 80/61HR: 115Temp: 102.0RR: 30SpO2 81% on 15L NRB

Case 1: “Jimmy”

Within 30 mins of arriving:

He has been intubatedHe has a central lineHe has an arterial lineHe has been cultured (U/B/S) and labs

drawnHe has started to receive:

3.375 gm of pipercillian/tazobactam 1.25 gm of vancomycin

Case 1: “Jimmy”

Within 2 hours:

3 liters of normal saline 1 liter in the ambulance 2 liters (500 cc every 30 mins)

Vital SignsBP: 105/72HR: 101Temp: 99.9RR: 16 (on vent)SpO2 97% FIO2 of 80%

Case 1: “Jimmy”

He is stabilized in the ED and transferred to the ICU for further care

Throughout his 6 day stay in the hospital, Jimmy suffers from acute renal failure, persistent hypoxemia, and an NSTEMI

He is discharged home with home health services and eventually makes a full recovery

Case 1: “Jimmy”

Question:

When was Jimmy Septic?

Remembering our steps…

SEPSIS STEPS


SIRS2 SIRS

+Confirmed


SEPSIS

Sepsis +



Lactate >4 mmol

SEVERESEPSIS

SEPTIC SHOCKSevere Sepsis with persistent:

Hypotension


Lactate >4 mmol

Case 1: “Jimmy”

Question:

When was Jimmy septic?

Answer:

At urgent care.

Barcelona, Spain

2nd October 2002

THE SEVERE SEPSIS BUNDLES:

SSC/IHI 2009 6 Hour Bundle Measure serum lactate Blood Cultures prior to antibiotics Broad spectrum antibiotics within

3 hours of presentation, 1 hour in hospital

Initial fluid resuscitation with 20-40 mL/kg crystalloid (or equivalent colloid) if hypotensive (SBP < 90 mmHg or MAP < 70) or lactate > 4 mmol/L

Vasopressors If septic shock or lactate > 4

mmol/L: CVP and ScvO2 or SvO2

measured CVP maintained 8-12 mm Hg

Inotropes (and/or PRBCs if Hct < 30%) delivered for ScvO2 <70% or SvO2<65% if CVP > 8 mmHg

24 Hour Bundle Glucose control maintained <

150 mg/dL Steroids given for septic

shock requiring continued use of vasopressors for > 6 hours

Lung protective strategy with plateau pressures < 30 cm H2O for mechanically ventilated patients

http://www.ihi.org

Everyday

But what does that mean for us practically when we see a patient presumed to be sick from an infection?

VITAL SIGNS

THROUGH THE LENS OF SIRS

CRITERIA

The Orders

Sepsis with end organ damage, hypotension or lactate > 4 Central Line Arterial Line Early Intubation

Labs (ACC CLUE) ABG CMP/CBC/Coags CXR/Cardiac

Enzymes

Cultures (B/U/S) Lactate UA EKG

Remembering that…

Are all physical exam signs of

end organ damage

THE SEVERE SEPSIS BUNDLES:

SSC/IHI 2009 6 Hour Bundle Measure serum lactate Blood Cultures prior to antibiotics Broad spectrum antibiotics within

3 hours of presentation, 1 hour in hospital

Initial fluid resuscitation with 20-40 mL/kg crystalloid (or equivalent colloid) if hypotensive (SBP < 90 mmHg or MAP < 70) or lactate > 4 mmol/L

Vasopressors If septic shock or lactate > 4

mmol/L: CVP and ScvO2 or SvO2

measured CVP maintained 8-12 mm Hg

Inotropes (and/or PRBCs if Hct < 30%) delivered for ScvO2 <70% or SvO2<65% if CVP > 8 mmHg

24 Hour Bundle Glucose control maintained <

150 mg/dL Steroids given for septic

shock requiring continued use of vasopressors for > 6 hours

Lung protective strategy with plateau pressures < 30 cm H2O for mechanically ventilated patients

http://www.ihi.org

The Orders Cont.

Broad spectrum antibiotics covering the organisms that affect the infected area

Volume Resuscitation

But how much do you give?

Here is where the central venous catheter comes into play

Recommendation is 500 cc

bolus of normal saline every 30 mins until you reach a CVP of

8-12

Vasopressors

Norepinephrine vs Dopamine

Neither has shown replicable superiority

Either may be first line agent of choice

When to use?

Then check SVO2

And if < 70% transfuse to a HCT 30%

And if still <70% add dobutamine to increase cardiac output

Steroids intially showed a 10% decrease in mortality

CORTICUS had patients whose mortality was 30-40% vs the JAMA article which had mortality 56%

In addition, a subset analysis showed that patient with a similar severity level to the original trial in JAMA had a similar 10% outcome benefit.

Steroids

Conclusion: If a patient is adequately volume resuscitated and isn’t on pressors, they don’t need steroids

Steroids should be withheld for 6-8 hours until you can gauge adequately whether the patient is volume replete or not

What do these all have in common?

CHEST September 2010 vol. 138 no. 3 476-480

$$$ In a recent multicenter

preimplementation (n = 1,554) and postimplementation (n = 4,801) study, hospital length of stay was reduced by 5.02 days, and hospital charges were $47,923 less between groups (P < .0001).

A hospital seeing 250 patients per year can realize a cost savings of > $11.98 million per year and an average decrease in hospital length of stay of 5 days or 1,250 bed days saved per year by implementing EGDT. CHEST September 2010 vol. 138 no. 3 476-

480

Should we adhere to EGDT, and does it matter? Yes. The real question is why we are continuing to accept the old paradigm because by doing so, we not only are depriving our patients of the best and most cost-efficient care but also are accepting death as an alternative.

CHEST September 2010 vol. 138 no. 3 476-480

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