Faheem Guirgis MD, FACEPED and Trauma Symposium – February 16th, 2017Co-Chair Sepsis CommitteeAssistant Professor of Emergency MedicineDivision of ResearchDepartment of Emergency MedicineUF Health Jacksonville
Sepsis: Updates,Pearls and Pitfalls
Disclosures
K23GM115690 – National Institute of General Medical Sciences
Society of Critical Care Medicine Weil Grant for Sepsis
Dean’s Grants from UF
Objectives Briefly discuss updated sepsis definitions Discuss principles of early severe sepsis
management Review pearls and tips for sepsis
management Outline common pitfalls to avoid in sepsis Discuss the implications of recent
literature and potential future changes in sepsis care
A. Under-recognized B. Under-treated C. Misunderstood (pathophysiology) D. All of the above
Sepsis 3?
Confused Scrubs
OLD
NEW
Local Infection
Systemic signs?
Organ Dysfunction (dysregulated response)
Shock
+
SOFA
Start Early, Be Aggressive
1. Figure it out EARLY
Sepsis Screening
2. Fill the Tank = Fluids
IVC US, Dynamic measures, PLR
3. Fight the Bugs
AntibioticsSource Control
4. Fix perfusion MAP Organ fx Lactate Inotropes
The 4 F’s
UF Health Jacksonville Sepsis Committee
Institution-Wide Multidisciplinary Approach
Sepsis Screening/Early recognition protocol (Automated)
Early Management Bundle/Order set Continued Care Bundle Education + Re-education = Culture
of change Chart dives Be Data-driven
FILL THE TANK!
Predicting Fluid Responsiveness Echo/IVC Ultrasound Passive Leg Raise
Pulse Pressure Variation
Stroke Volume Variation
Cardiac UltrasoundQUICK ESTIMATION OF EF – GOOD SQUEEZE OR POOR SQUEEZE
IVC Ultrasound1. Use Cardiac
Probe2. Place probe
in the long axis, SubX, just right of midline
3. Find IVC and measure 3 cm distal to RA (at or distal to HV)
4. Can use M-mode
5. Have patient sniff if spontaneously breathing
IVC Collapse – Spontaneously Breathing IVC < 1 cm = give fluids IVC 1-2 cm w/ 50% collapse w/
inspiration= give fluids IVC > 2 cm or w/o collapse = not
fluid responsive Pulmonary Hypertension/RHF may
confound your IVC US Patients on mechanical ventilation –
look for a 15-18% change in IVC diameter
3 cm
ICU population Vasopressor dependent septic shock All on mechanical ventilation Limited Echo (LE) performed w/in 24
hours of ICU admission
Echo-based Strategy for Shock Resuscitation
1. Systolic function: normal, moderate, or severely impaired
2. Assess for pericardial effusion
3. IVC diameter fluctuation < or > 15%
dIVC=[(dI−dE)/dE]×100
<15% dIVC with normal LV fx = stop fluids
>15% dIVC w/ normal LV fx = 20 to 40 mL/kg fluids
>15% dIVC w/ mod to severe LV dysfx = 10 to 20 mL/kg fluids and dobutamine 5 mcg/kg
<15% dIVC w/ mod to severe LV dysfx = dobutamine and no fluids
Passive leg raise. To perform a passive leg raise, a patient is placed in a semi-recumbent position at 45°. The patient’s legs are then elevated to 45° and the hemodynamic variable of interest evaluated after 30−60 seconds.
So you’ve given fluids…
1. Is fluid resuscitation adequate? - Heart, IVC collapse, PPV, SVV
2. Is MAP adequate? - MAP > 65
3. Is Oxygen Delivery adequate? - Lactate normalization vs Lactate clearance?
Now Go Back and Ask 3 Questions…
What about individual measures of organ function?
FIGHT THE BUGS = ABX + Source Control
2016 AntibioticsEffective Abx within 1st hour for sepsis
and septic shock (2016) Every hour of delay in giving Abx is
associated with a measurable increase in mortality (Kumar et al; Ferrer et al)
Mortality significantly increased in patients who received initial antibiotics after shock recognition (n = 172 [59%]) compared with before shock recognition (OR, 2.4; 1.1-4.5) – Puskarich et al
Consider this:
Gram + > Gram - > polymicrobial as the cause of most septic shock
Bolus drugs before infusion drugs Broad coverage guided by local
prevalence patterns All patients should receive a full
loading dose of antibiotics
Terminology
Empiric Therapy – best guess, no bugs yet
Broad Spectrum Therapy – broad spec abx to cover multiple potential bugs
Combination Therapy – Using more than one drug to cover the same bug (largely unproven)
2016 Antibiotic Recs
Empiric combo therapy for initial management of septic shock
No Empiric combo therapy for regular sepsis or bacteremia
No combo therapy for neutropenic sepsis/bacteremia
If combo therapy is used – de-escalate in the first few days if clinical improvement
Source identification
“Trauma is a compulsive search for injuries” – Billy Mallon
“Sepsis is a compulsive search for a source of infection” – Me Treat the patient like a trauma – fully
expose, etc The less the patient can tell you the
more compulsive the search And…the severity of the source
should be proportional to the severity of illness
2016 Source ControlSource control as soon as
possible (Rec 6-12 hrs from time of diagnosis)
If intravascular device is a possible source, it should be promptly removed after other vascular access established
Consider IR or Surgery
Who cares about cultures? Cultures of blood and other sites
(urine, CSF, wounds, respiratory secretions, etc) before abx if possible
Cultures from vascular access and peripheral blood – 10 cc each
If culture from vascular access is positive earlier than peripheral blood then vascular access = infectious source
DO NOT DELAY ANTIBIOTICS > 45 MIN FOR BLOOD
CULTURES
But…
Fix Perfusion
VASOPRESSORS+
Inotropes
Published in CCM in 2015 Dopamine still a bad choice for SSh Greater hospital mortality –
propensity-matched scoring, n = 38,788; 25% vs 23.7%; OR 1.08; 95% CI, 1.02-1.14)
Most commonly used in the South!
2016 Vasopressors
Norepinephrine 1st agent Vaso or Epi as 2nd agent Epi - especially if inotropy required Vaso – need alpha Phenylephrine if inotropy not needed
Norepi causing arrhythmias CO is high and BP is low Salvage therapy
Dobutamine – first choice inotrope
VANISH trial
Vaso +/- HC vs Norepi +/- HC for vasopressor dependent septic shock
Primary outcome – renal failure free days
No difference Demonstrated that Vaso could be
titrated up to a dose of .06units/min
2016 Lactate
Guide resuscitation to normalize lactate Lactate normalization (< 2) Clearance?
2016 Blood
2016 Steroids
Hydrocortisone 200 mg/day When starting your second pressor
Management Pitfalls
Now what?
Management so far: Fluids Abx Source identified and controlled Pressors Lactate level
Risk of Death?
Prevalence Mortality
Lactate > 4 alone
5.4% 30% butPerhaps 20%
Hypotension alone
49.5% 36.7%
Lactate > 4 + Hypotension
16.6% 46.1%
1316 pts w/ sepsis w/in 4 hrs of ED arrival
111 progressed to shock w/in 48 hrs (8.4%)
Females (OR 1.59), nonpersistent hypotension (OR 6.24), bandemia ≥ 10% (OR 2.6), lactate ≥ 4 (OR 5.3), PMH CAD (OR 2.01)
Beyond Mortality…now what? SEPSIS RECIDIVISM
110 ED patients w/ SS/SSh
28-90 days: 17% rate of sepsis readmission
LONG-TERM MORTALITY Initial mortality 18%
(90 survivors) 3 year mortality 48%
(only 53 survivors)
Chronic Critical Illness Disease of the elderly who survive initial sepsis dc LTAC, functionally dependent, die outside of the hospital months to years later (Sepsis P50 – UF)
Sepsis Recidivism?
Fiscal impact of 30 day sepsis readmissionSepsis CHF Acute MI
Initial Hospitalization (2009-11)
240,198 193,153 105,684
Readmission rate 20.4% 23.6% 17.7%Annual costs (California)
$500 million/yr
$229 million/yr
$142 million/yr
The Future?! Improved sepsis diagnostics (biomarkers)
Dys-HDL? Better understanding of pathophysiology
CCI/PICS/CARS (thanks to UF G’ville – Moore, Moldawer, Leeuwenburgh)
Persistent/long-term organ dysfunction – who/why? Sepsis recidivism – why?
Mitochondrial medicine? RACE Trial - L-carnitine (increases cardiac mechanical
efficiency and facilitates mitochondria) Metabolic cocktails? Hypothermia?! ECMO?
CMS Sepsis Definitions? Old definitions SEVERE SEPSIS: SIRS + sepsis-induced organ
dysfunction: SBP < 90 or MAP < 70 mm Hg Creatinine > 2.0 mg/dl or Urine Output < 0.5 ml/kg/hour
for > 2 hours Bilirubin > 2 mg/dl (34.2 mmol/L) Platelet count < 100,000 Coagulopathy (INR >1.5 or aPTT >60 secs) Lactate > 2 mmol/L
SEPTIC SHOCK: Lactate > 4 mmol/L, OR SBP < 90 or MAP < 70 mm Hg, not responsive to fluids
CMS Management A. measure lactate level B. obtain blood cultures prior to antibiotics C. administer broad spectrum antibiotics D. administer 30 ml/kg crystalloid for hypotension
or lactate = 4 mmol/L E. apply vasopressors (for hypotension that does
not respond to initial fluid resuscitation to maintain a mean arterial pressure = 65)
F. in the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was = 4 mmol/L, reassess volume status and tissue perfusion and document findings.*
CMS Reassessment 2/4 of the following
Measure CVP Measure ScvO2 Bedside cardiovascular ultrasound Dynamic assessment of fluid responsiveness with
passive leg raise or fluid challenge OR Focused exam† including vital signs,
cardiopulmonary, capillary refill, pulse and skin findings.
Remeasure lactate if initial lactate is elevated
It’s only the beginning!
But sadly, it’s the end of my lecture
Thank you!
a case
2016 SS Guidelines Changes Fluids - 30 ml/kg in the first 3 hours, crystalloid first, then maybe
albumin, use dynamic markers and/or fluid challenges Goal MAP>65 EGDT is no longer recommended Lactate - attempt to normalize lactate Blood Cultures - get them before antibiotics, if obtaining them will
not delay the provision of antibiotics Antibiotics - Within 1 hour of sepsis or septic shock Vasopressors - Norepi is the first choice, add in epi or vaso, Do not
use dopamine Steroids - 200 mg Hydrocortisone for patients who are still
unstable after fluids and vasopressors Blood - In most circumstances, use a trigger of <7.0 g/dL Glucose - goal is < 180 mg/dL Bicarb - Not recommended if pH is >7.15 (which in no way means
it is recommended for pHs less than that)