Shock and Sepsis2 of 2

William Whitehead, M.D., Ph.D.

Department of Anesthesiology

Management

“Surviving Sepsis Campaign”:

An international group of experts published in 2004 the first guidelines for the bedside clinician to use to improve outcomes in severe sepsis and septic shock.

Therapeutic Bundles

What are “bundles”?

A group of interventions related to a disease that,when implemented together, result in betteroutcomes than when implemented individually.

The science behind the elements of the bundle is sowell-established that their implementation should beconsidered a generally accepted practice.

Bundle components can easily be measured ascompleted or not completed.

As such, the overall bundle – all the elements takentogether – can also be measured as completed or notcompleted.

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Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012.Dellinger, R; Levy, Mitchell; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; MD, PhD; Opal, Steven; Sevransky, Jonathan; Sprung, Charles; Douglas, Ivor; Jaeschke, Roman; Osborn, Tiffany; MD, MPH; Nunnally, Mark; Townsend, Sean; Reinhart, Konrad; Kleinpell, Ruth; PhD, RN-CS; Angus, Derek; MD, MPH; Deutschman, Clifford; MD, MS; Machado, Flavia; MD, PhD; Rubenfeld, Gordon; Webb, Steven; MB BS, PhD; Beale, Richard; Vincent, Jean-Louis; MD, PhD; Moreno, Rui; MD, PhD

Critical Care Medicine. 41(2):580-637, February 2013.DOI: 10.1097/CCM.0b013e31827e83af

Figure 1 . Surviving Sepsis Campaign Care Bundles.

Critical Care Medicine 36(1):296-327 (2008)

Patient randomized

N=263Early goal directed therapy

N=130

Standard therapy N=133

CVP > 8-12 mm HgMAP > 65 mm Hg

Urine Output > 0.5 ml/kg/hr

CVP > 8-12 mm HgMAP > 65 mm HgUrine Output > 0.5 ml/kg/hrScvO2 > 70%SaO2 > 93%Hct > 30%

Antibiotics given at discretion of

treating clinicians

As soon as possible Mean 6.2hrs

ICU MDs blinded to study treatment NEJM 2001;345:1368-77.

At least 6 hoursof EGDTMean 8hrs

Transfer to ICU

Therapy Across the Sepsis Continuum

Chest 1992;101:1644..

SepsisSIRS

Severe Sepsis

SepticShock

Early Goal Directed Therapy

Antibiotics and Source Control

Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand

*

CVP:

MAP:

ScvO2:

Hgb:

CVP: central venous pressure

MAP: mean arterial pressure

ScvO2: central venous oxygen saturation

Early Goal-Directed Therapy

NEJM 2001;345:1368-77.

Lactate: An Indicator of Tissue Perfusion

Serum lactate levels are used to assess the disease severity and adequacy of global tissue perfusion

By-product of anaerobic metabolism if tissue hypoxia exists

Interpretation of elevated blood lactate levels in sepsis is limited by several important factors1: Production of elimination

Increasing glycolysis

Inhibition of pyruvate metabolism

Global changes

Bakker J, Gris P, Conerfils M, et al. Serial Blood Lactate Levels Can Predict the Development of Multiple Prgan Failure Following Septic Shock, Am J Surg 1996; 171:221-226.

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Figure 2 . Algorithm for time sensitive, goal-directed stepwise management of hemodynamic support in infants and children. Reproduced from Brierley J, Carcillo J, Choong K, et al: Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666-688.