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Sepsis Management
SEPSIS
Steffen Rex Department of Anesthesiology University Hospitals Leuven [email protected]
Sepsis Management
Dombrowskiy V Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: A trend analysis from 1993 to 2003. Crit Care Med 2007; 35:1244–1250
Epidemiology
Sepsis Management
Epidemiology: Current trends in incidence
Lagu T et al. Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007. Crit Care Med 2012; 40:754–761
Sepsis Management
Germany: ~154.000 / year
Engel C et al. Epidemiology of sepsis in Germany: results from a national prospective multicenter study. ICM 2007; 33(4):606-18
Epidemiology: Prevalence
Sepsis Management
1 Angus DC et al; Crit Care Med 2001; 29: 1303-1310 2 Martin GS et al, N Engl J Med 2003;348:1546-54
0
50
100
150
200
250
300
350 In
cide
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tant
s)
Epidemiology: Incidence in the USA
Sepsis Management
! 1,5 million patients with severe sepsis
Today
• Increasing number of older patients
• Life-sustaining technologies • Invasive techniques and
procedures • Nosocomial infections • Antibiotic resistance
Future
Linde-Zwirble et al. Crit Care Med 1999; 27: A33 Opal und Cohen, Crit Care Med 1999; 27: 1608
Epidemiology: Incidence in the future
Sepsis Management
For comparison: Myocardial infarction: 4-10%
Epidemiology: Mortality
Engel C et al. Epidemiology of sepsis in Germany: results from a national prospective multicenter study. ICM 2007; 33(4):606-18
Sepsis Management
Epidemiology: Mortality USA vs. Europe
Levy MM et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study. Lancet Infect Dis 2012;12: 919–24
Sepsis Management
Epidemiology: Current trends in severity / mortality
Lagu T et al. Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007. Crit Care Med 2012; 40:754–761
Sepsis Management
" Dysregulation of the immune response
" Endothelial dysfunction: " Capillary leak " Vasoplegia
" Dysregulation of the coagulation system
" Cardiovascular Dysfunction: " Relative/absolute hypovolemia " Septic cardiomyopathy
" Microcirculatory failure
" Cytopathic hypoxia, endocrine dysregulation, ...
Pathophysiology: Hallmarks
Sepsis Management
Riedemann N. Novel strategies for the treatment of sepsis. Nature Medicine 2003
Vasodilation Endothelial Dysfunction Capillary Leakage DIC Cardiovascular Dysfunction Cytopathic Hypoxia Apoptosis
MODS
Failure of local control mechanisms
Sepsis: Pathophysiology
Sepsis Management
�Eine Sepsis liegt dann vor, wenn sich innerhalb des Körpers ein Herd gebildet hat, von dem aus konstant oder periodisch pathogene Bakterien in den Blutkreislauf gelangen, derart, daß durch diese Invasion subjektiv oder objektiv Krankheits-erscheinungen ausgelöst werden.�
Trias of Schottmüller: Source – Spreading – Systemic effect
H. Schottmüller, 1914
Diagnosis and Definition
Sepsis Management
SIRS (>2 of the following) " Temperature >38°C or < 36°C " HR > 90/min " Respiratory rate
> 20/min or PaCO2 < 33mmHg
" Leucocytes >12.000/mm3 or < 4000/mm3 or >10% immature forms
Infection Suspected or proven
Diagnosis and Definition
+
SEPSIS =
Sepsis Management
Infection Suspected/proven
SEPSIS +
Inflammation SIRS
+ Organ dysfunction
SEVERE SEPSIS
Diagnosis and Definition
Sepsis Management
Diagnosis and Definition: Organ Failure
Septic encephalopathy
Wer reitet so spät durch Nacht und Wind?
Es ist der Vater mit seinem Kind.
Er hat den Knaben wohl in dem Arm,
Er faßt ihn sicher, er hält ihn warm.
Mein Sohn, was birgst du so bang dein Gesicht? -
Siehst Vater, du den Erlkönig nicht!
Den Erlenkönig mit Kron� und Schweif? -
Mein Sohn, es ist ein Nebelstreif. -
„Du liebes Kind, komm geh� mit mir!
Gar schöne Spiele, spiel ich mit dir,
Manch bunte Blumen sind an dem Strand,
Meine Mutter hat manch gülden Gewand.�
Mein Vater, mein Vater, und hörest du nicht,
Was Erlenkönig mir leise verspricht? -
Sei ruhig, bleibe ruhig, mein Kind,
In dürren Blättern säuselt der Wind. -
„Willst feiner Knabe du mit mir geh�n?
Meine Töchter sollen dich warten schön,
Meine Töchter führen den nächtlichen Reihn
Und wiegen und tanzen und singen dich ein.�
Mein Vater, mein Vater, und siehst du nicht dort
Erlkönigs Töchter am düsteren Ort? -
Mein Sohn, mein Sohn, ich seh� es genau:
Es scheinen die alten Weiden so grau. -
„Ich liebe dich, mich reizt deine schöne Gestalt,
Und bist du nicht willig, so brauch ich Gewalt!�
Mein Vater, mein Vater, jetzt faßt er mich an,
Erlkönig hat mir ein Leids getan. -
Dem Vater grauset�s, er reitet geschwind,
Er hält in den Armen das ächzende Kind,
Erreicht den Hof mit Mühe und Not,
In seinen Armen das Kind war tot.
Sepsis Management
Diagnosis and Definition: Organ Failure
Ware LB and Matthay MA The Acute Respiratory Distress Syndrome.
NEJM 2000, 342: 1334-1349
Levy MM et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study. Lancet Infect Dis 2012;12: 919–24
USA Europe
Sepsis Management
Diagnosis and Definition: Organ Failure
Schrier RW, Wang W Acute Renal Failure and Sepsis.
N Engl J Med 2004;351:159-69.
USA Europe
Levy MM et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study. Lancet Infect Dis 2012;12: 919–24
Prerenal AKF
Renal AKF
Sepsis Management
Diagnosis and Definition
Dellinger RP et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 Crit Care Med 2013; 41:580–637
Sepsis Management
Diagnosis and Definition
Infection Suspected/proven
SEPSIS
Inflammation +
+ Organ dysfunction SEVERE SEPSIS
+ Hypotension > 1h " SAP < 90mmHg " MAP < 70mmHg " Despite adequate fluid
resuscitation SEPTIC SHOCK
Sepsis Management
Sepsis Management: The Guidelines
: 2004
Goal: Decrease in sepsis mortality
by 25% in 5 years
Sepsis Management
Sepsis Management: SSC-Guidelines Initial Resuscitation
1. Protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion (defined as hypotension persisting after initial fluid challenge or blood lactate concentration ≥ 4 mmol/L).
Goals during the first 6 hrs of resuscitation: a) Central venous pressure 8–12 mm Hg (12-15mmHg in ventilated patients) b) Mean arterial pressure (MAP) ≥ 65 mm Hg c) Urine output ≥ 0.5 mL/kg/hr d) Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C).
2. In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).
Sepsis Management
Sepsis Management: SSC-Guidelines Initial Resuscitation: MAP
Urinary !output (mL)! 49 +18! 56 + 21! 43 +13! .60/.71!
Capillary blood flow (mL/min/100 g)! 6.0 + 1.6! 5.8 + 11! 5.3 + 0.9! .59/.55!
Red Cell !Velocity (au)! 0.42 + 0.06! 0.44 +016! 0.42 + 0.06! .74/.97!
Pico2 (mm Hg)! 41 + 2! 47 + 2! 46 + 2! .11/.12!
Pa-Pico2 (mm Hg)! 13 + 3! 17 + 3! 16 + 3! .27/.40!
75 mm Hg!65 mm Hg! 85 mm Hg! F/LT!MAP
LeDoux et al. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 2000; 28:2729-2732
Sepsis Management
Sepsis Management: SSC-Guidelines Initial Resuscitation
Howell et al. Occult hypoperfusion and mortality in patients with suspected infection.
Intensive Care Med (2007) 33:1892–1899
Pressure is not enough!!!
Sepsis Management
Sepsis Management: SSC-Guidelines Initial Resuscitation: ScvO2
Adequacy of DO2 (= CO * caO2)
DO2 ↓
O2-ER ↑
S(c)vO2 ↓
Diuresis ↓ Lactate ↑
Sepsis Management
Rivers E et al.
New Engl J Med 2001
345:1368-77
EGDT
Rivers E. et al. EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC SHOCK. N Engl J Med 2001;345:1368-77
ScvO2
PreSep™ Katheter
Sepsis Management
Mortality
49,2
Patients (%)
49,2 %
33,3 %
56,9 %
46,5 %
30,5 %
44,3 %
50 30 10 0
In-Hospital
28-days
60-days
*
*
*
Standard EGDT
Sepsis Management: SSC-Guidelines Initial Resuscitation: ScvO2
Rivers E. et al. EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT
OF SEVERE SEPSIS AND SEPTIC SHOCK. N Engl J Med 2001;345:1368-77
Sepsis Management
CO = VO2 / avDO2
VO2 = CO · avDO2
CO = VO2
caO2 – cvO2
CO ≈ VO2
(SaO2 • Hb • 1,39) – (SvO2 • Hb • 1,39)
SvO2 ≈ VO2
HR • SV • Hb • 1,39 SaO2 -
Sepsis Management: SSC-Guidelines Initial Resuscitation: ScvO2: Limitations
Significantly decreased during anesthesia/sedation
S(c)vO2: reflects adequacy of oxygen delivery but: not a „poor man‘s CO-monitor“
Sepsis Management
Sepsis Management: SSC-Guidelines Initial Resuscitation: ScvO2: Limitations
Trzeciak S et al. Clinical manifestations of disordered microcirculatory perfusion in severe sepsis. Critical Care 2005 Vol 9 Suppl 4
Sepsis: No oxygen debt ! instead: Capillary shunting (# increase in ScvO2)
Sepsis Management
Sepsis Management: SSC-Guidelines Initial Resuscitation: ScvO2: Limitations
Van Beest P. et al. The incidence of low venous oxygen saturation on admission to the intensive care unit: a multi-center observational study in The Netherlands. Critical Care 2008, 12:R33
Sepsis Management
Jones A.E. et al. Lactate Clearance vs Central Venous Oxygen Saturation as Goals
of Early Sepsis Therapy. JAMA. 2010;303(8):739-746
Sepsis Management: SSC-Guidelines Initial Resuscitation: Lactate clearance
Sepsis Management
Jones A.E. et al. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy. JAMA. 2010;303(8):739-746
Sepsis Management: SSC-Guidelines Initial Resuscitation: Lactate clearance
Sepsis Management
Osman D. et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 2007; 35:64–68
Pre-
Infu
sion
ΔCI > 15% ΔCI < 15%
Sepsis Management: SSC-Guidelines Initial Resuscitation: CVP
Sepsis Management
Marik P et al.
Does Central Venous Pressure Predict Fluid Responsiveness? A Systematic Review of the Literature and the Tale of Seven Mares.
CHEST 2008; 134:172–178
Sepsis Management: SSC-Guidelines Initial Resuscitation: CVP
Sepsis Management
Sepsis Management: Diagnosis
1. Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted (grade 1C). 2. Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection. 3. Imaging studies performed promptly to confirm a potential source of infection (UG).
Sepsis Management
Sepsis Management: Antimicrobial Therapy
Kumar A. et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock Crit Care Med 2006; 34:1589–1596
Each hour of delay in antimicrobial administration: Average decrease in survival of 7.6%
Sepsis Management
Sepsis Management: Source Control
There is no medicine for bad surgery.
Sepsis Management
Sepsis Management: Fluid Therapy
1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).
2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B).
3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C).
4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid may be needed in some patients (grade 1C).
5. Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic (eg, change in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart rate) variables (UG).
Sepsis Management
Sepsis Management: Fluid Therapy
Zarychanski R. et al. 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;309(7):678-688
Sepsis Management
Sepsis Management: Fluid Therapy
Zarychanski R. et al. 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;309(7):678-688
Sepsis Management
Sepsis Management: Fluid Therapy
Finfer S. et al. A Comparison of Albumin and Saline for Fluid
Resuscitation in the Intensive Care Units. N Engl J Med 2004;350:2247-56
Sepsis Management
Sepsis Management: Vasopressors
1. Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65 mm Hg (grade 1C).
2. Norepinephrine as the first choice vasopressor (grade 1B).
3. Epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure (grade 2B).
4. Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage (UG).
5. Low dose vasopressin is not recommended as the single initial vasopressor for treatment of sepsis-induced hypotension and vasopressin doses higher than 0.03-0.04 units/minute should be reserved for salvage therapy (failure to achieve adequate MAP with other vasopressor agents) (UG).
6. Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (grade 2C).
7. Phenylephrine is not recommended in the treatment of septic shock except in circumstances where (a) norepinephrine is associated with serious arrhythmias, (b) cardiac output is known to be high and blood pressure persistently low or (c) as salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target (grade 1C).
8. Low-dose dopamine should not be used for renal protection (grade 1A).
9. All patients requiring vasopressors have an arterial catheter placed as soon as practical if resources are available (UG).
Sepsis Management
De Backer et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. N Engl J Med 2010;362:779-89
Sepsis Management: Vasopressors
Sepsis Management
Landry et al. THE PATHOGENESIS OF VASODILATORY SHOCK. N Engl J Med, Vol. 345, No. 8 August 23, 2001
Vasopressin Rationale: • Endogenous hormone • Released from pituitary gland during hypotension • Depletion of neurohypophyseal stores in sepsis
Normal 1 h of shock
Sepsis Management: Vasopressors
Sepsis Management
N = 778 Dosis: 0.01-0.03 U/min
Sepsis Management: Vasopressors
Sepsis Management
Sepsis Management: Inotropic Therapy
1. A trial of dobutamine infusion up to 20 micrograms/kg/min be administered or added to vasopressor (if in use) in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP (grade 1C).
2. Not using a strategy to increase cardiac index to predetermined supranormal levels (grade 1B).
* p <0.05
7,1 7,2 7,3 7,4
0 1 6 12 24
pHi
* * *
50 60 70 80 90
100 110
0 1 6 12 24
MAP (mmHg)
Time (h)
3,5 4
4,5 5
5,5
0 1 6 12 24
CI (l/min/m2)
NA/Dobutamine Adrenaline
Levy et al (1997) Intensive Care Med 23:282
Sepsis Management
Annane D. et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial Lancet 2007; 370: 676–84
Articles
680 www.thelancet.com Vol 370 August 25, 2007
coronary events, limb ischaemia or skin necrosis, and acute cerebrovascular events (whether haemorrhagic or ischaemic). These events were deemed to be related to catecholamine infusion when they occurred while patients were receiving study drugs.
Pharmacoeconomic analysis was done on the basis of a model that computes the medical cost of patients in intensive care.18 This model takes into account the rate of invasive or surgical procedures and estimates the mean medical cost per patient in intensive care.
The data and safety monitoring board met three times during the study to analyse the conduct of the study, the results of interim analyses, and to review serious adverse events. Interim analyses were done on Nov 18, 2002, and Oct 1, 2003, after the assessment of 185 and 232 patients, respectively. After each analysis, the independent data and safety monitoring board advised the study chairmen to continue the study. A diagnosis validation committee also met three times during the study to grade, without knowledge of treatment allocation, the patients as having defi nite septic shock, probable septic shock, and probable non-septic shock,19 and to assess the appropriateness of antibiotic treatments.
Statistical analysisWe expected an all-cause mortality rate at day 28 of 60% in the epinephrine group, on the basis of data from another trial we were doing in patients with septic shock when we planned this protocol.20 We calculated that we would need a sample size of 340 patients to be able to detect, in a two-sided test done with a 0·05 type I error, an absolute reduction of 20% in the mortality rate at day 28 with 95% probability.
The two interim analyses were planned with an O’Brien and Fleming stopping boundary.21 With this
procedure, the diff erences between the two groups were considered signifi cant if the critical Z values were higher than 3·471, 2·454, and 2·004 at the fi rst, second, and fi nal analyses, respectively (corresponding to nominal two-sided p values of <0·0005, <0·0141, and <0·0451).
The statistical analysis, prospectively defi ned, was done by intention to treat (ie, in all analyses, patients were grouped according to their original randomised treatment) with SAS statistical software (version 8.2; Cary, NC, USA). For continuous variables, the means and SD or the median (IQR), in case of signifi cant non-normality of the distribution, are reported. The number of patients in each category and the corresponding percentages are given for categorical variables.
The eff ects of treatments on the frequency of fatal events (mortality rates at day 7, day 14, day 28, at discharge from intensive care or from hospital, and day 90) were compared between groups by χ² tests. Corresponding relative risks (RR), together with their 95% CI, were estimated. Cumulative event curves (censored endpoints) were estimated with the Kaplan-Meier procedure. The eff ects of treatments on these endpoints were compared between groups with the log-rank test. For the primary endpoint, we did additional analyses with logistic and Cox regression models, adjusting for the main baseline factors that predict outcomes22 (ie, McCabe and Jackson classifi cation, SAPS II, SOFA, arterial lactate concentrations, and appropriateness of antibiotic treatments).23 For these analyses, continuous variables were broken into two classes on the basis of their median values. Odds ratios (OR) and hazard ratios (HR), together with 95% CI, were estimated with these models. For day 90 survival, patients who were still alive at 90 days were treated as censored. For time to vasopressor therapy withdrawal, among patients who had more than one outcome event during the 28 days from randomisation, time to fi rst event was used in the analyses. For this endpoint, the patients who died before vasopressor therapy could be withdrawn and those for whom vasopressor therapy could not be withdrawn during the 28 days from randomisation were treated as censored. The frequency of serious adverse events was compared between groups with the χ² test or Fisher’s exact test as appropriate. In the pharmacoeconomic analysis, the rates of invasive or surgical procedures were compared between groups by the χ² test and the mean medical costs per patient in intensive care were compared between groups by the Wilcoxon test. All reported p values are two-sided.
This trial is registered with ClinicalTrials.gov, number NCT00148278.
Role of the funding sourceThe funding source had no role in the conduct of the study, the collection and interpretation of the data, or in the drafting of the report. All authors had full access to all the data of the study, and all agreed to submit the fi nal manuscript for publication.
00 10
0·1
0·2
0·3
0·4
0·5
0·6
0·7
0·8
0·9
1·0
Surv
ival
pro
babi
lity
Mortality at 3 monthsEpinephrine: 84/161 (52%)Norepinephrine plus dobutamine: 85/169 (50%)χ²=0·12p=0·73
Log-rankχ²=0·39p=0·53
20 30 40 50 60 70 80 90
Number at risk Epinephrine 161 117 102 96 88 84 81 79 79 74Norepinephrine 169 131 117 108 98 92 91 85 84 84plus dobutamine
Time (days)
EpinephrineNorepinephrine plus dobutamine
Figure 3: Survival from randomisation to day 90
Sepsis Management: Inotropic Therapy
Sepsis Management
Sepsis Management: Corticosteroids
1. Not using intravenous hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (see goals for Initial Resuscitation). In case this is not achievable, we suggest intravenous hydrocortisone alone at a dose of 200 mg per day (grade 2C).
2. Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone (grade 2B).
3. In treated patients hydrocortisone tapered when vasopressors are no longer required (grade 2D).
4. Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grade 1D).
5. When hydrocortisone is given, use continuous flow (grade 2D).
Sprung C. et al. Hydrocortisone Therapy for Patients with Septic Shock.
N Engl J Med 2008;358:111-24
Sepsis Management
Sepsis Management: Blood Product Administration
1. Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration decreases to <7.0 g/dL to target a hemoglobin concentration of 7.0 –9.0 g/dL in adults (grade 1B).
2. Not using erythropoietin as a specific treatment of anemia associated with severe sepsis (grade 1B).
3. Fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).
4. Not using antithrombin for the treatment of severe sepsis and septic shock (grade 1B).
5. In patients with severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding. We suggest prophylactic platelet transfusion when counts are < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding. Higher platelet counts (≥50,000/mm3 [50 x 109/L]) are advised for active bleeding, surgery, or invasive procedures (grade 2D).
Sepsis Management
Sepsis Management: Mechanical Ventilation
Sepsis Management
Sepsis Management: Glucose Control
1. A protocolized approach to blood glucose management in ICU patients with severe sepsis commencing insulin dosing when 2 consecutive blood glucose levels are >180 mg/dL. This protocolized approach should target an upper blood glucose ≤180 mg/dL rather than an upper target blood glucose ≤ 110 mg/dL (grade 1A).
2. Blood glucose values be monitored every 1–2 hrs until glucose values and insulin infusion rates are stable and then every 4 hrs thereafter (grade 1C).
3. Glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution, as such measurements may not accurately estimate arterial blood or plasma glucose values (UG).
< 180 mg/dl
< 81 - 108 mg/dl
Finfer S. et al. Intensive versus Conventional Glucose Control
in Critically Ill Patients. N Engl J Med 2009;360:1283-97
Sepsis Management
SEPSIS
Antimicrobial therapy
Adjunctive
Therapy
Supportive
Therapy
Source control
" Debridement of infected tissue
" Removal of invasive devices
" Absces drainage
" Hydrocortisone?
" rhAPC
" Selenium
" Immunemodulators
" Empirical
" Calculated
" Targeted
" Volume resuscitation
" Vasopressors/Inotropes
" Lung-protective
ventilation
" Nutrition
" Glucose homeostasis
" RRT
Sepsis Management The cornerstones
Sepsis Management
Sepsis Management: Summary: Protocolized Approach
Sepsis Management
Sepsis Management: Summary: Protocolized Approach
Levy M.M. et al. The Surviving Sepsis Campaign: results of an
international guideline-based performance improvement program targeting severe sepsis.
Intensive Care Med (2010) 36:222–231
Sepsis Management Thank you very much for your attention