Vasopressors in Septic Shock. Keith R. Walley, MD St. Paul s Hospital University of British Columbia Vancouver, Canada
|
|
|
- Nathan Derek Reed
- 6 years ago
- Views:
Transcription
1 Vasopressors in Septic Shock Keith R. Walley, MD St. Paul s Hospital University of British Columbia Vancouver, Canada
2 Echocardiogram: EF=25% 57 y.o. female, pneumonia, shock
3 Echocardiogram: EF=25% 57 y.o. female, pneumonia, shock
4 Echocardiogram: EF=25% 57 y.o. female, pneumonia, shock
5 Early Goal- Directed Therapy Rivers E et al N Engl J Med 345: , 2001
6 Vasoactive Therapy Use of vasoactive drugs has been ad hoc Recent RCTs of vasopressor drugs in shock / sepsis Vasopressin Low severity of illness Renal Risk category Corticosteroids Assessing vasoactive therapy clinically
7 Which Vasopressor? Recent RCTs Norepinephrine vs. Epinephrine (2007,08) Norepinephrine vs. Dopamine (2010) Norepinephrine vs. Vasopressin (2008)
8 Norepinephrine vs. Epinephrine Annane. CATS Lancet Myburgh. CAT. ICM (n=280) Mortality NE Epi 28 d 26.1% 22.5% p= d 34.3% 30.4% p=0.49
9 Norepinephrine vs. Dopamine De Backer. NEJM
10 Norepinephrine vs. Dopamine De Backer. NEJM p<0.001 Dopamine Norepi All 24.1% 12.4% A fib V tach V fib
11 Norepinephrine vs. Vasopressin (+ open label NE) Russell. VASST. NEJM. 2010
12 Recent RCTs Norepinephrine / Epinephrine: p=ns Annane et al. Lancet 370:676, 2007 (CATS, n=330, SS) NE+d better Myburgh et al. Intens Care Med. 34:2226, 2008 (CAT, n=280, S) NE worse Norepinephrine / Dopamine: p=ns Dopamine more tachydysrhythmias De Backer et al. NEJM, 362: , 2010 (SOAP II, n=1679, S) Norepinephrine / Vasopressin: p = NS Benefit in lower severity of illness stratum Russell et al, NEJM, 358: , (VASST, n=778, SS)
13 Low severity of shock stratum 5 µg/min < NE < 15 µg/min Log-rank statistic p = 0.05 day 28 p = 0.03 day 90
14 High severity of shock stratum NE > 15 µg/min Log-rank statistic p = 0.77 day 28 p = 0.92 day 90
15 Plasma vasopressin levels (n = 107) Vasopressin Off Vasopressin Norepinephrine
16 Norepinephrine-sparing effect of low-dose vasopressin (0.03 U/min) Norepinephrine µg/min Norepinephrine Vasopressin+NE Days
17 Heart rate: norepinephrine-sparing versus direct vasopressin effect Heart Rate Norepinephrine Vasopressin+NE Days
18 Serious adverse events Norepinephrine Vasopressin p (n=382) (n=397) Myocardial infarction / 7 (1.8) 8 (2.0) ischemia 1.00 Cardiac arrest 8 (2.1) 3 (0.8) 0.14 Tachyarrythmia 3 (0.8) 4 (1.0) 1.00 Bradyarrythmia 3 (0.8) 4 (1.0) 1.00 Mesenteric ischemia 13 (3.4) 9 (2.3) 0.39 Digital ischemia 2 (0.5) 8 (2.0) 0.11 Cerebrovascular accident 1 (0.3) 1 (0.3) 1.00 Hyponatremia 1 (0.3) 1 (0.3) 1.00 Other 2 (0.5) 5 (1.3) 0.45 Total 40 (10.5) 41 (10.3) 1.00
19 Relationship to renal function RIFLE Risk Category (Cr 1.5X) Vasopressin Norepinephrine P=0.009 Gordon AC et al. Intensive Care Med. 36:83-91, 2010.
20 Relationship to renal function RIFLE Risk Category (Cr 1.5X) Post-hoc Vasopressin Norepinephrine P=0.009 Gordon AC et al. Intensive Care Med. 36:83-91, 2010.
21 Vasopressin effect in renal Risk Category Decreased progression to renal failure or loss Vasopressin 21.1% Norepinephrine 41.2% (p=0.03) Decreased use of Renal Replacement Therapy Vasopressin 17.0% Norepinephrine 37.7% (p=0.02)
22 Microvascular renal effects Constriction of afferent arteriole: Edwards RM et al. Am J Physiol. 26: F274-F278, 1989
23 Microvascular renal effects Constriction of efferent arteriole: Vasopressin > Norepinephrine
24 Corticosteroids Annane Inclusion: refractory septic shock! 50 mg hydrocortisone q6h Surviving Sepsis Campaign Guidelines CORTICUS Non overall benefit Potentiation of adrenergic signalling Vasopressin x corticosteroid interaction
25 Vasopressin x Steroid Interaction Septic shock survival vasopressin plus steroids 80.9% vs vasopressin without steroids 47.6%, P = Retrospective Baseline differences Controls 4 years older Steroids more CRRT Bauer SR et al. J Crit Care. 23: , 2008
26 Vasopressin X Steroid Interaction Survival Vasopressin Norepinephrine Norepinephrine Russell JA, Walley KR, et al. Crit Care Med. 37:811-8, Survival Interaction P=0.008 Days Vasopressin
27 Vasopressin levels steroid interaction Corticosteroids Vasopressin No corticosteroids Norepinephrine Russell et al. Critical Care Medicine. 37: , 2009.
28 Assessing vasoactive therapy Volemia: CVP, PPV, Echo Mean Arterial Pressure: sufficient to allow flow redistribution Adequacy of oxygen delivery: S CV o 2 Lactate Cardiac output (PAC, dye dilution, Doppler)
29 Potential problem with too much fluid Boyd JH; Forbes J; Nakada TA; Walley KR; Russell JA. Critical Care Medicine. 39(2):259-65, 2011 Feb. 2
30 Vasoactive Therapy Beta-adrenergic agonists increase heart rate and incidence of arrhythmias NE versus Epi NE versus Dopamine Vasopressin versus NE Consider adding vasopressin NE dose is low creatinine is slightly elevated with steroids?
31 Co-investigators Jim Russell John Boyd Databases VASST Investigators and coordinators Funding Heart & Stroke Foundation CIHR Michael Smith Foundation
32 Table 4. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Boyd JH; Forbes J; Nakada TA; Walley KR; Russell JA Critical Care Medicine. 39(2):259-65, 2011 Feb. Table hr fluid balance: Survivors vs. nonsurvivors within CVP groups 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. 2
33 Figure 1. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Boyd JH; Forbes J; Nakada TA; Walley KR; Russell JA Critical Care Medicine. 39(2):259-65, 2011 Feb. Figure 1. A, Daily fluid intake, urine output and fluid balance at 12 hrs and days 1-4. B, Cumulative daily fluid intake, urine output and fluid balance at 12 hrs and days
34 Annane. CATS. Lancet Myburgh. CAT. ICM (n=280) NE Epi 28 d 26.1% 22.5% p= d 34.3% 30.4% p=0.49 De Backer. NEJM Russell. VASST. NEJM. 2010
35 For vasopressin tx: Steroids good for low severity, lack of steroids bad for high severity Less Severe More Severe Received 257/ /400 Steroids 68.0% 82.8% Mortality VP NE P-value VP NE P-value All 52/196 65/182 88/200 85/ % 35.7% % 42.5% 0.77 No steroids 15/65 9/56 19/36 10/ % 16.1% % 30.3% 0.10 Steroids 37/131 56/126 69/164 75/ % 44.4% % 44.9% 0.68 Interaction p-value = 0.002
36 Relationship to renal function RIFLE Criteria GFR criteria Urine output criteria Risk Injury Loss Increased serum creatinine x1.5 or Decreased GFR >25% Increased serum creatinine x2 or Decreased GFR >50% Increased serum creatinine x3 or Decreased GFR >75% or Increased serum creatinine 44µmol/l if baseline 350µmol/l < 0.5ml/kg/h x6 hours < 0.5ml/kg/h x12 hours < 0.3ml/kg/h x24 hours or Anuria x12 hours Failure Persistent acute renal failure = complete loss of renal function for > 4 weeks End stage End-Stage Kidney Disease (>3 months)
37 Baseline demographics Norepinephrine (n=382) Vasopressin (n=396) Age, years 61.8 ± ±16.4 Male sex 229 (59.9) 246 (62.0) Caucasian 320 (83.8) 336 (84.6) Co-morbidities Ischemic heart disease 65 (17.0) 68 (17.1) COPD 72 (18.8) 55 (13.9) Chronic renal failure 48 (12.6) 40 (10.1) Cancer 104 (27.2) 85 (21.4) Pre-existing steroid use 86 (22.5) 82 (20.7) Recent surgery 132 (34.6) 151 (38.0) Time from eligibility to infusion, hrs 11.5 ± ± 8.9 Values are n (%) or mean ± SD, as appropriate
38 Baseline severity of illness Norepinephrine (n=382) Vasopressin (n=396) APACHE II 27.1 ± ± 7.7 New organ dysfunction Cardiovascular 382 (100) 397 (100) Respiratory 341 (89.3) 342 (86.1) Renal 258 (67.5) 264 (66.5) Coagulation 84 (22.0) 118 (29.7) Neurologic 89 (23.3) 101 (25.4) Number of new organ dysfunctions 2.5 ± ± 1.1 Lactate, mmol/l 3.5 ± ± 3.2 Mean arterial pressure, mmhg 73.2 ± ± 9.1 Norepinephrine, µg/min 20.7 ± ± 22.1 (n=329) (n=344) Values are n (%) or mean ± SD, as appropriate
39 Rates and risks of death at day 28 Norepinephrine Vasopressin p Absolute risk reduction % (95% CI) Relative risk of death (95% CI) All 150/ % 140/ % (-2.88 to 10.71) 0.90 (0.75 to 1.08) More severe subgroup 85/ % 88/ % ( to 8.21) 1.04 (0.83 to 1.3) Less severe subgroup 65/ % 52/ % (-0.13 to 18.49) 0.74 (0.55 to 1.01)
Evidence-Based. Management of Severe Sepsis. What is the BP Target?
Evidence-Based Management of Severe Sepsis Michael A. Gropper, MD, PhD Professor and Vice Chair of Anesthesia Director, Critical Care Medicine Chair, Quality Improvment University of California San Francisco
Controversies in Hospital Medicine: Critical Care. Vasopressors, Steroids, and Insulin Therapy
Controversies in Hospital Medicine: Critical Care Vasopressors, Steroids, and Insulin Therapy Douglas Fish, Pharm.D. Professor of Pharmacy, University of Colorado Denver Clinical Specialist in Critical
EFFECT OF EARLY VASOPRESSIN VS NOREPINEPHRINE ON KIDNEY FAILURE IN PATIENTS WITH SEPTIC SHOCK. Alexandria Rydz
EFFECT OF EARLY VASOPRESSIN VS NOREPINEPHRINE ON KIDNEY FAILURE IN PATIENTS WITH SEPTIC SHOCK Alexandria Rydz BACKGROUND- SEPSIS Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated
VOLUME RESPONSIVENESS IS DIFFERENT FROM NEED FOR FLUIDS BLOOD PRESSURE TARGETS IN SEPSIS
Department of Intensive Care Medicine VOLUME RESPONSIVENESS IS DIFFERENT FROM NEED FOR FLUIDS BLOOD PRESSURE TARGETS IN SEPSIS SEPTIC SHOCK : THE CLINICAL SCENARIO HYPOTENSION DESPITE ADEQUATE VOLUME RESUSCITATION
Sepsis and Hemodynamic Support in September 15, 2017 Carleen Risaliti
Sepsis and Hemodynamic Support in 2017 September 15, 2017 Carleen Risaliti Objectives Review fluid resuscitation guidelines in septic shock Discuss volume assessment v. fluid responsiveness Evaluate pros
Vasopressors for shock
Vasopressors for shock Background Reviews and Observational Studies Holler 2015. Nontraumatic Hypotension and Shock in the Emergency Department and Prehospital Setting Prevalence, Etiology and Mortality:
Actualités de la prise en charge hémodynamique initiale Daniel De Backer
Actualités de la prise en charge hémodynamique initiale Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles Past- President European
Efficacy and Outcomes After Vasopressin Guideline Implementation in Septic Shock
669163AOPXXX10.1177/1060028016669163Annals of PharmacotherapyWu et al research-article2016 Research Report Efficacy and Outcomes After Vasopressin Guideline Implementation in Septic Shock Annals of Pharmacotherapy
Surviving Sepsis Campaign Guidelines 2012 & Update for David E. Tannehill, DO Critical Care Medicine Mercy Hospital St.
Surviving Sepsis Campaign Guidelines 2012 & Update for 2015 David E. Tannehill, DO Critical Care Medicine Mercy Hospital St. Louis Be appropriately aggressive the longer one delays aggressive metabolic
Objectives. Management of Septic Shock. Definitions Progression of sepsis. Epidemiology of severe sepsis. Major goals of therapy
Objectives Management of Septic Shock Review of the Evidence and Implementation of Pediatric Guidelines at Christus Santa Rosa Manish Desai, M.D. PL 5 2 nd year Pediatric Critical Care Fellow Review of
Fluid Resuscitation in Critically Ill Patients with Acute Kidney Injury (AKI)
Fluid Resuscitation in Critically Ill Patients with Acute Kidney Injury (AKI) Robert W. Schrier, MD University of Colorado School of Medicine Denver, Colorado USA Prevalence of acute renal failure in Intensive
Cardiovascular Management of Septic Shock
Cardiovascular Management of Septic Shock R. Phillip Dellinger, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Critical Care Medicine and Med/Surg ICU Cooper University Hospital
The syndrome formerly known as. Severe Sepsis. James Rooks MD. Coordinator of critical care education OU College of Medicine, Tulsa
The syndrome formerly known as Severe Sepsis James Rooks MD Coordinator of critical care education OU College of Medicine, Tulsa Disclosures I have no actual or practical conflicts of interest in relation
Sepsis Management: Past, Present, and Future
Sepsis Management: Past, Present, and Future Benjamin Ferrell, MD Tennessee ACP Meeting October 28, 2017 Learning Objectives Identify the most updated definition and clinical criteria for sepsis Describe
Sepsis is an important issue. Clinician s decision-making capability. Guideline recommendations
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 Clinicians decision-making capability Guideline recommendations Sepsis is an important issue 8.7%
Vasopressors in septic shock
Vasopressors in septic shock Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France Questions 1- Why do we use vasopressors in septic shock? 2- Which first-line agent? 3- When
INTENSIVE CARE MEDICINE CPD EVENING. Dr Alastair Morgan Wednesday 13 th September 2017
INTENSIVE CARE MEDICINE CPD EVENING Dr Alastair Morgan Wednesday 13 th September 2017 WHAT IS NEW IN ICU? (RELEVANT TO ANAESTHETISTS) Not much! SURVIVING SEPSIS How many deaths in England were thought
Update in Critical Care Medicine
Update in Critical Care Medicine Michael A. Gropper, MD, PhD Professor and Executive Vice Chair Department of Anesthesia and Perioperative Care Director, Critical Care Medicine UCSF Disclosure None Update
Case year old female nursing home resident with a hx CAD, PUD, recent hip fracture Transferred to ED with decreased mental status BP in ED 80/50
Case 1 65 year old female nursing home resident with a hx CAD, PUD, recent hip fracture Transferred to ED with decreased mental status BP in ED 80/50 Case 1 65 year old female nursing home resident with
Acute Liver Failure: Supporting Other Organs
Acute Liver Failure: Supporting Other Organs Michael A. Gropper, MD, PhD Professor of Anesthesia and Physiology Director, Critical Care Medicine University of California San Francisco Acute Liver Failure
Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE
Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE In critically ill patients: too little fluid Low preload,
Objectives. Epidemiology of Sepsis. Review Guidelines for Resuscitation. Tx: EGDT, timing/choice of abx, activated
Update on Surviving Sepsis 2008 Objectives Epidemiology of Sepsis Definition of Sepsis and Septic Shock Review Guidelines for Resuscitation Dx: Lactate, t cultures, SVO2 Tx: EGDT, timing/choice of abx,
Should we use steroids in sepsis? J.G. van der Hoeven
Should we use steroids in sepsis? J.G. van der Hoeven Why I don t like it It is boring.. It usually results in emotional outcries in the audience If any, the effects on outcome are very small You are not
John Park, MD Assistant Professor of Medicine
John Park, MD Assistant Professor of Medicine Faculty photo will be placed here park.john@mayo.edu 2015 MFMER 3543652-1 Sepsis Out with the Old, In with the New Mayo School of Continuous Professional Development
Sepsis Management Update 2014
Sepsis Management Update 2014 Laura J. Moore, MD, FACS Associate Professor, Department of Surgery The University of Texas Health Science Center, Houston Medical Director, Shock Trauma ICU Texas Trauma
OHSU. Update in Sepsis
Update in Sepsis Jonathan Pak, MD June 1, 2017 Structure of Talk 1. Sepsis-3: The latest definition 2. Clinical Management - Is EGDT dead? - Surviving Sepsis Campaign Guidelines 3. A novel therapy: Vitamin
4/5/2018. Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY. I have no financial disclosures
Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY I have no financial disclosures 1 Objectives Why do we care about sepsis Understanding the core measures by Centers for Medicare
Vasoactive Medications. Matthew J. Korobey Pharm.D., BCCCP Critical Care Clinical Specialist Mercy St. Louis
Vasoactive Medications Matthew J. Korobey Pharm.D., BCCCP Critical Care Clinical Specialist Mercy St. Louis Objectives List components of physiology involved in blood pressure Review terminology related
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Mitchell M. Levy MD, MCCM Professor of Medicine Chief, Division of Pulmonary, Sleep, and Critical Care
Titrating Critical Care Medications
Titrating Critical Care Medications Chad Johnson, MSN (NED), RN, CNCC(C), CNS-cc Clinical Nurse Specialist: Critical Care and Neurosurgical Services E-mail: johnsoc@tbh.net Copyright 2017 1 Learning Objectives
6/5/2014. Sepsis Management and Hemodynamics. 2004: International group of experts,
Sepsis Management and Hemodynamics Javier Perez-Fernandez, M.D., F.C.C.P. Medical Director Critical Care Services, Baptist t Hospital of Miamii Medical Director Pulmonary Services, West Kendall Baptist
Surviving Sepsis. Brian Woodcock MBChB MRCP FRCA FCCM
1 Surviving Sepsis Brian Woodcock MBChB MRCP FRCA FCCM 2 Disclosures No conflicts of interest 3 Sepsis Principles of management of septic shock in the operating room "Surviving Sepsis" guidelines 4 Add-on
towards early goal directed therapy
Paediatric Septic Shock- towards early goal directed therapy Elliot Long Paediatric Acute Care 2011 Conference Outline Emergency Department Rivers Protocol (EGDT) ACCM Sepsis Protocol Evidence Barriers
Timing of Vasopressors in Septic Shock: How Soon is Too Soon?
Timing of Vasopressors in Septic Shock: How Soon is Too Soon? Anand Kumar, MD Sections of Critical Care Medicine and Infectious Diseases Professor of Medicine, Medical Microbiology and Pharmacology University
Septic Acute Kidney Injury (AKI) Rinaldo Bellomo Australian and New Zealand Intensive Care Research Centre (ANZIC-RC) Melbourne Australia
Septic Acute Kidney Injury (AKI) Rinaldo Bellomo Australian and New Zealand Intensive Care Research Centre (ANZIC-RC) Melbourne Australia Things we really, honestly know about septic AKI AKI is common
การอบรมว ทยาศาสตร พ นฐานทางศ ลยศาสตร เร อง นพ.ส ณฐ ต โมราก ล ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาวทยาลยมหดล
การอบรมว ทยาศาสตร พ นฐานทางศ ลยศาสตร เร อง นพ.ส ณฐ ต โมราก ล ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาวทยาลยมหดล Distributive shock Severe sepsis and Septic shock Anaphylactic shock Neurogenic
Pediatric Septic Shock. Geoffrey M. Fleming M.D. Division of Pediatric Critical Care Vanderbilt University School of Medicine Nashville, Tennessee
Pediatric Septic Shock Geoffrey M. Fleming M.D. Division of Pediatric Critical Care Vanderbilt University School of Medicine Nashville, Tennessee Case 4 year old male with a history of gastroschesis repaired
Sepsis overview. Dr. Tsang Hin Hung MBBS FHKCP FRCP
Sepsis overview Dr. Tsang Hin Hung MBBS FHKCP FRCP Epidemiology Sepsis, severe sepsis, septic shock Pathophysiology of sepsis Recent researches and advances From bench to bedside Sepsis bundle Severe sepsis
Managing Patients with Sepsis
Managing Patients with Sepsis Diagnosis; Initial Resuscitation; ARRT Initiation Prof. Achim Jörres, M.D. Dept. of Nephrology and Medical Intensive Care Charité University Hospital Campus Virchow Klinikum
Haemodynamic Support. (getting the blood to go round and round) philippelefevre.com
Haemodynamic Support (getting the blood to go round and round) philippelefevre.com Haemodynamic Support Whats wrong with your patient? What can we do about it? Volume expansion Inotropes, Chronotropes
The Pharmacology of Hypotension: Vasopressor Choices for HIE patients. Keliana O Mara, PharmD August 4, 2018
The Pharmacology of Hypotension: Vasopressor Choices for HIE patients Keliana O Mara, PharmD August 4, 2018 Objectives Review the pathophysiology of hypotension in neonates Discuss the role of vasopressors
Management of Severe Sepsis:
Management of Severe Sepsis: Update from the Surviving Sepsis Campaign Barbara Birriel, MSN, ACNP-BC, FCCM The Pennsylvania State University NONE Disclosures Review evidence-based international sepsis
When options matter. Vasopressor Reloaded. Balance in Haemodynamics - Only Survival Matters
When options matter Vasopressor Reloaded Balance in Haemodynamics - Only Survival Matters Vasopressin Synthesis and Release Physiologic Importance in Septic Shock Hypothalamus Brain Vasopressin deficiency
SEPSIS 2015 DISCLOSURES FINANCIAL DISCLOSURES 9/1/2015. William M. Johnson, MD Nebraska Pulmonary Specialties. William Johnson
SEPSIS 2015 William M. Johnson, MD Nebraska Pulmonary Specialties 1 DISCLOSURES William Johnson No financial interests related to this presentation 2 FINANCIAL DISCLOSURES I do however have 3 children
Back to the Future: Updated Guidelines for Evaluation and Management of Adrenal Insufficiency in the Critically Ill
Back to the Future: Updated Guidelines for Evaluation and Management of Adrenal Insufficiency in the Critically Ill Joe Palumbo PGY-2 Critical Care Pharmacy Resident Buffalo General Medical Center Disclosures
Taiwan Crit. Care Med.2009;10: C 1. CVP 8~12 mmhg 2. MAP 65 mmhg 1. 1B
6 24 1C 1. CVP 8~12 mmhg 2. MAP 65 mmhg 3. 0.5 ml 4. 70% 65% 1 colloid crystalloid 1B SAFE albumin 2 813 386 07-346-8278 07-350-5220 E-mail shoalin01@.gmail.com 21 p=0.09 prospective meta-analysis 3-5
Septic Shock. Rontgene M. Solante, MD, FPCP,FPSMID
Septic Shock Rontgene M. Solante, MD, FPCP,FPSMID Learning Objectives Identify situations wherein high or low BP are hemodynamically significant Recognize complications arising from BP emergencies Manage
Diagnosis and Management of Sepsis and Septic Shock. Martin D. Black MD Concord Pulmonary Medicine Concord, New Hampshire
Diagnosis and Management of Sepsis and Septic Shock Martin D. Black MD Concord Pulmonary Medicine Concord, New Hampshire Financial: none Disclosures Objectives: Identify physiologic principles of septic
Updates in Critical Care Sepsis, Fluids, Epi and Long-Term Outcomes
Updates in Critical Care Sepsis, Fluids, Epi and Long-Term Outcomes Matt Anderson, MD USD SSOM, Clinical Assistant Professor Regional Health, Critical Care Medicine mjanderson972@gmail.com Disclosure(s)
Sepsis is a complicated infectious process that propagates. Use of Vasopressors in Septic Shock. Clinical review
Use of Vasopressors in Septic Shock Megan A. Rech, PharmD, Megan Prasse, PharmD, and Gourang Patel, PharmD, MSc Abstract Objective: To review the latest findings on the use of vasopressor agents in septic
NE refractoriness: From Definition To Treatment... Prof. Alain Combes
NE refractoriness: From Definition To Treatment... Prof. Alain Combes Service de Réanimation ican, Institute of Cardiometabolism and Nutrition Hôpital Pitié-Salpêtrière, AP-HP, Paris Université Pierre
Prevention of Acute Renal Failure Role of vasoactive drugs and diuretic agents
of Acute Renal Failure Role of vasoactive drugs and diuretic agents Armand R.J. Girbes Prof.dr. A.R.J. Girbes Chairman department of Intensive Care VU University Medical Center Netherlands (Failure of)
What works in sepsis. Topics. EGDT: Severe Sepsis/ Shock. Sepsis
What works in sepsis Eric Schmidt, MD Denver Health Medical Center University of Colorado School of Medicine Topics Understanding and implemen@ng early goal directed therapy (EGDT) Ac@vated Protein C should
Albumina nel paziente critico. Savona 18 aprile 2007
Albumina nel paziente critico Savona 18 aprile 2007 What Is Unique About Critical Care RCTs patients eligibility is primarily defined by location of care in the ICU rather than by the presence of a specific
Sepsis Combine experience and Evidence. Eran Segal, MD Director General ICU, Sheba Medical Center, Israel
Sepsis Combine experience and Evidence Eran Segal, MD Director General ICU, Sheba Medical Center, Israel The Science of Sepsis A complex and diverse clinical entity Outcome is affected by: Infecting organism
Inflammatory Pathways in Sepsis: TLRs and Innate Immunity. Keith R. Walley, MD St. Paul s Hospital University of British Columbia Vancouver, Canada
Inflammatory Pathways in Sepsis: TLRs and Innate Immunity Keith R. Walley, MD St. Paul s Hospital University of British Columbia Vancouver, Canada Early Goal-Directed Therapy Rivers E et al. NEJM 345:1368-77,
Low Cardiac Output in the Pediatric Patient
Low Cardiac Output in the Pediatric Patient Jeffrey Burns, M.D., M.P.H. Chief, Division of Critical Care Medicine Children s Hospital Boston Associate Professor of Anesthesia and Pediatrics Harvard Medical
Sepsis Bundle Project (SEP) Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: April 2015 Most recent Revision: December 2018
Sepsis Bundle Project (SEP) Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: April 2015 Most recent Revision: December 2018 Objectives 1. To identify the symptom of severe sepsis and septic shock syndrome.
JUST SAY NO? THE LATEST LOOK AT ACLS MEDICATIONS BRIDGETTE SVANCAREK, MD
JUST SAY NO? THE LATEST LOOK AT ACLS MEDICATIONS BRIDGETTE SVANCAREK, MD OBJECTIVES Review the progression of the American Heart Association s ACLS cardiac arrest medication guidelines Identify the latest
Renal failure in sepsis and septic shock
Renal failure in sepsis and septic shock Dr. Venugopal Reddy. MD, EDIC, FCARCSI Associate Professor of Anesthesiology and Critical Care medicine Department of Anaesthesia and CCM Penn State College of
Sepsis and septic shock Practical hemodynamic consequences. Intensive Care Training Program Radboud University Medical Centre Nijmegen
Sepsis and septic shock Practical hemodynamic consequences Intensive Care Training Program Radboud University Medical Centre Nijmegen Septic cardiomyopathy Present in > 50% and often masked by low vascular
Steroid in Paediatric Sepsis. Dr Pon Kah Min Hospital Pulau Pinang
Steroid in Paediatric Sepsis Dr Pon Kah Min Hospital Pulau Pinang Contents Importance of steroid in sepsis Literature Review for adult studies Literature Review for paediatric studies Conclusions. Rationale
R2R: Severe sepsis/septic shock. Surat Tongyoo Critical care medicine Siriraj Hospital
R2R: Severe sepsis/septic shock Surat Tongyoo Critical care medicine Siriraj Hospital Diagnostic criteria ACCP/SCCM consensus conference 1991 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference
Initiation Strategies for Renal Replacement Therapy in ICU
Initiation Strategies for Renal Replacement Therapy in ICU The Artificial Kidney Initiation in Kidney Injury trial AKIKI Stéphane Gaudry Réanimation médico-chirurgicale Hôpital Louis Mourier, Colombes
Making vasopressors safer
Making vasopressors safer Requirements for safe vaspressor use In an ideal world 1. Knowledge of what constitutes optimal vasopressor dosing 2. A culture of cautiousness regarding vasopressors What do
BC Sepsis Network Emergency Department Sepsis Guidelines
The provincial Sepsis Clinical Expert Group developed the BC, taking into account the most up-to-date literature (references below) and expert opinion. For more information about the guidelines, and to
Supplementary Appendix
Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for
Full Disclosure. The case for why it matters. Goal-directed Fluid Resuscitation
Goal-directed Fluid Resuscitation Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care University of California, San Francisco I own no stocks Full Disclosure The case for why
Fluids in Sepsis Less is more. Dr Anand Senthi Joondalup Health Campus ED MBBS, MAppFin, GradCertPubHlth,
Fluids in Sepsis Less is more Dr Anand Senthi Joondalup Health Campus ED MBBS, MAppFin, GradCertPubHlth, FRACGP @drsenthi Summary Discussion of the evidence for/against fluid resuscitation in septic shock
Sepsis: Identification and Management in an Acute Care Setting
Sepsis: Identification and Management in an Acute Care Setting Dr. Barbara M. Mills DNP Director Rapid Response Team/ Code Resuscitation Stony Brook University Medical Center SEPSIS LECTURE NPA 2018 OBJECTIVES
Pediatric Sepsis Treatment:
Disclosures Pediatric Sepsis Treatment: (treat) Early & (reevaluate) Often None June 11, 2018 Leslie Dervan, MD MS Pacific Northwest Sepsis Conference 1 Agenda Sepsis: pathophysiology at-a-glance Pediatric
Tailored Volume Resuscitation in the Critically Ill is Achievable. Objectives. Clinical Case 2/16/2018
Tailored Volume Resuscitation in the Critically Ill is Achievable Heath E Latham, MD Associate Professor Fellowship Program Director Pulmonary and Critical Care Objectives Describe the goal of resuscitation
Dilemmas in Septic Shock
Dilemmas in Septic Shock William Janssen, M.D. Assistant Professor of Medicine National Jewish Health University of Colorado Denver Health Sciences Center A 62 year-old female presents to the ED with fever,
Blood purification in sepsis
Blood purification in sepsis Joannes-Boyau O Dept of anesthesiology and intensive care, University Hospital of Bordeaux, France 1 Types of Blood Purification hemofilters regular pore size (MW < 40,000D)
No conflicts of interest
Robert M. Rodriguez, MD FAAEM Clinical Professor of Medicine and Emergency Medicine, UCSF No conflicts of interest Major Points Most ICU patients start in ED Chain of critical care starting in field and
Early Goal-Directed Therapy
Early Goal-Directed Therapy Where do we stand? Jean-Daniel Chiche, MD PhD MICU & Dept of Host-Pathogen Interaction Hôpital Cochin & Institut Cochin, Paris-F Resuscitation targets in septic shock 1 The
Updates in Sepsis 2017
Mortality Cases Total U.S. Population/1,000 Updates in 2017 Joshua Solomon, M.D. Associate Professor of Medicine National Jewish Health University of Colorado Denver Background New Definition of New Trials
Objectives. Outline. Sepsis Incidence and Outcomes. Definitions
Objectives Evaluate recent literature on the management of sepsis Apply new and potentially controversial recommendations from the Surviving Sepsis Guidelines to patient cases. Surviving Sepsis Campaign
The Use of Metabolic Resuscitation in Sepsis
The Use of Metabolic Resuscitation in Sepsis Jennifer M. Roth, PharmD, BCPS, BCCCP Critical Care Clinical Specialist - Surgical Trauma ICU Baylor University Medical Center Disclosures No conflicts of interest
Dr Nick Taylor Visiting Emergency Specialist Teaching Hospital Karapitiya
Dr Nick Taylor Visiting Emergency Specialist Teaching Hospital Karapitiya Senior Specialist and Director ED Training Clinical Lecturer, Australian National University Canberra Hospital, Australia Inotropes
Vasoactive Drugs Do I have to choose? Dr. Vandewiele Bert 20 February 2012
Vasoactive Drugs Do I have to choose? Dr. Vandewiele Bert 20 February 2012 What is what? Inotrope A substance that alters the force of muscular contraction (positive/negative) Vasopressor An agent producing
Dr. F Javier Belda Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia (Spain) Pulsion MAB
State of the Art Hemodynamic Monitoring III CO, preload, lung water and ScvO2 The winning combination! Dr. F Javier Belda Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia
Failure of the circulation to maintain Tissue cellular. Tissue hypoperfusion Cellular hypoxia SHOCK. Perfusion
Shock SHOCK Failure of the circulation to maintain Tissue cellular Perfusion Organs Syndrome RR
Sepsis: Update on Diagnosis, Evaluation and Management
Sepsis: Epidemiology Sepsis: Update on Diagnosis, Evaluation and Management Michael J. Apostolakos, MD Professor of Medicine Director of Adult Critical Care University of Rochester ~ 750,000 cases per
Sepsis and septic shock
Sepsis and septic shock Practical hemodynamic consequences Intensive Care Training Program Radboud University Medical Centre Nijmegen Septic cardiomyopathy Present in > 50% and often masked by low vascular
What is the right fluid to use?
What is the right fluid to use? L McIntyre Associate Professor, University of Ottawa Senior Scientist, Ottawa Hospital Research Institute Centre for Transfusion Research CCCF, November 2, 2016 Disclosures
Swans and Pressors. Vanderbilt Surgery Summer School Ricky Shinall
Swans and Pressors Vanderbilt Surgery Summer School Ricky Shinall Shock, Swans, Pressors in 15 minutes 4 Reasons for Shock 4 Swan numbers to know 7 Pressors =15 things to know 4 Reasons for Shock Not enough
Swans and Pressors. Vanderbilt Surgery Summer School Ricky Shinall
Swans and Pressors Vanderbilt Surgery Summer School Ricky Shinall SHOCK Hypotension SHOCK Hypotension SHOCK=Reduction of systemic tissue perfusion, resulting in decreased oxygen delivery to the tissues.
THE CRITICALLY ILL OLDER PERSON WITH: SEPTIC SHOCK
THE CRITICALLY ILL OLDER PERSON WITH: SEPTIC SHOCK Older people carry the burden of sepsis Older people carry the burden of sepsis Immunosenescence Co-morbidity Endothelial / mucosal atrophy Dependence
CORTICOSTEROID USE IN SEPTIC SHOCK THE ONGOING DEBATE DIEM HO, PHARMD PGY1 PHARMACY RESIDENT VALLEY BAPTIST MEDICAL CENTER BROWNSVILLE
CORTICOSTEROID USE IN SEPTIC SHOCK THE ONGOING DEBATE DIEM HO, PHARMD PGY1 PHARMACY RESIDENT VALLEY BAPTIST MEDICAL CENTER BROWNSVILLE 1 ABBREVIATIONS ACCP = American College of Chest Physicians ARF =
PEER REVIEW HISTORY ARTICLE DETAILS TITLE (PROVISIONAL)
PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (see an example) and are provided with free text boxes to
The changing face of
The changing face of sepsis. @SepsisUK Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance Special Adviser (maternal sepsis) to WHO Breast cancer Cognitive impairment Mild 3.8 7.1
Prehospital treatment of sepsis Christopher W. Seymour, MD MSc
Prehospital treatment of sepsis Christopher W. Seymour, MD MSc The CRISMA Center Assistant Professor of Critical Care Medicine & Emergency Medicine University of Pittsburgh School of Medicine Disclosures
Early-goal-directed therapy and protocolised treatment in septic shock
CAT reviews Early-goal-directed therapy and protocolised treatment in septic shock Journal of the Intensive Care Society 2015, Vol. 16(2) 164 168! The Intensive Care Society 2014 Reprints and permissions:
Sepsis: Management ANUPOL PANITCHOTE, MD. Division of Critical Care Medicine Department of Medicine, Khon Kaen University, Thailand
Sepsis: Management ANUPOL PANITCHOTE, MD. Division of Critical Care Medicine Department of Medicine, Khon Kaen University, Thailand Vital signs Symptoms LAB BT > 38.3 or < 36 ๐ C HR > 90 bpm RR > 20 /min
Nothing to disclose 9/25/2017
Jessie O Neal, PharmD, BCCCP Critical Care Clinical Pharmacist University of New Mexico Hospital New Mexico Society of Health-System Pharmacists 2017 Balloon Fiesta Symposium Nothing to disclose 1 Explain
9/25/2017. Nothing to disclose
Nothing to disclose Jessie O Neal, PharmD, BCCCP Critical Care Clinical Pharmacist University of New Mexico Hospital New Mexico Society of Health-System Pharmacists 2017 Balloon Fiesta Symposium Explain
Approach to Severe Sepsis. Jan Hau Lee, MBBS, MRCPCH. MCI Children s Intensive Care Unit KK Women s and Children's Hospital, Singapore
Approach to Severe Sepsis Jan Hau Lee, MBBS, MRCPCH. MCI Children s Intensive Care Unit KK Women s and Children's Hospital, Singapore 1 2 No conflict of interest Overview Epidemiology of Pediatric Severe
EARLY GOAL DIRECTED THERAPY : seminaires iris. Etat des lieux en Daniel De Backer
EARLY GOAL DIRECTED THERAPY : Etat des lieux en 2017 Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles Past-President European
Looking for sepsis. Sepsis: Update. Prevalence of High Profile Dzs. Screening and risk stratification. Mortality of High Profile Diseases
Sepsis: Update Prevalence of High Profile Dzs Edward A. Panacek, MD, MPH Professor and Chair, Emergency Medicine USA Medical Center, Mobile, AL NDAFP Conference Big Sky. 2016 Syllabus Angus Crit Care Med