EBM EGDT 每次都是RCT.有點煩 本來想簡單處理 那些年我們曾經打拼過的~~ By Maxy Lu 這次想要放鬆一下~~ EGDT (Early goal-directed therapy) Early go to ICU

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1 EBM By Maxy Lu 每次都是RCT.有點煩 這次想要放鬆一下~~ 本來想簡單處理 EGDT (Early goal-directed therapy) 那些年我們曾經打拼過的~~ EGDT Early go to ICU

2 想說這下開心了 Best practice Not Standard of care Screening and practice improvement Routinely screen potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (1C) Implement hospital-based performance improvement efforts in severe sepsis (UG) Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system Fluid therapy-(1) Grade 1 (strong) we recommend, Grade 2 (weak) we suggest, Quality of evidence : Give crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (1B) Do not use hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (1B) (A) High: high-quality RCTs Give albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of (B) Moderate: downgraded RCTs crystalloids (2C) (C) Low : welldone observational studies HAEZS out, Albumin in!! (D) Very low: downgraded observational studies or expert opinion Fluid therapy-(2) Initial fluid challenge in 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) (1C) A fluid challenge technique may be applied when 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, pulse rate) variables* (UG)

3 Blood cultures-(1) Obtain appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay (>45 minutes) in the start of antimicrobials administration (1C) Obtain at least 2 sets of blood cultures (both aerobic and anaerobic bottles) before antimicrobial therapy, with at least 1 obtained percutaneously and 1 through each vascular access device, unless the device was recently (<48 hours) inserted (1C) Antimicrobial therapy-(3) Initiate antiviral therapy as early as possible in patients with severe sepsis or septic shock of viral origin (2C) Avoid the use of antimicrobial agents for patients with severe inflammatory states determined to be of noninfectious cause (UG) Blood cultures-(2) Blood cultures can be obtained at the same time if they are from different sites (1C) Cultures of other sites such as urine, CSF, wounds, respiratory secretions, or other body fluids that may be the source of infection, should also be obtained before antimicrobial therapy if doing so does not cause significant delay in antibiotic administration (1C) Resuscitation goals Protocolized, quantitative resuscitation for sepsis-induced tissue hypoperfusion (hypotension persisting after initial fluid challenge or blood lactate concentration 4 mmol/l) (1C) Goals during the first 6 hour of resuscitation : -CVP 8 12 mm Hg -MAP 65 mm Hg -Urine output 0.5 ml/kg per hour -ScvO2 or mixed Svo2 70% or 65%, respectively In patients with elevated lactate levels, target resuscitation to normalize lactate as rapidly as possible (2C) Antimicrobial therapy-(1) Administer effective intravenous antimicrobials < 1 hour of recognition of septic shock (1B) and severe sepsis without septic shock (1C) Choose initial empiric anti-infective therapy of 1 or more drugs that have activity against all likely pathogens (bacterial or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (1B) Lactate clearance Lactate normalization As a marker of tissue hypoperfusion 2 RCTs : lactate clearance 10%, 20% 2C suggestion Antimicrobial therapy-(2) Combination empirical therapy (2B) -Neutropenic patients with severe sepsis -Difficult-to-treat, multidrug-resistant bacterial pathogens (Acinetobacter and Pseudomonas) -Severe infections with respiratory failure and septic shock : (A) P. aeruginosa : extended spectrum b-lactam + aminoglycoside/fluoroquinolone (B) Strept. Pneumoniae : B-lactam and macrolide Vasopressors-(1) Use vasopressors initially to target a MAP of 65 mmhg (1C) Use norepinephrine as the first-choice vasopressor (1B) Consider administration of epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure (2B)

4 Vasopressors-(2) Consider addition of vasopressin 0.03 U/min to norepinephrine to increase MAP or decrease norepinephrine dosage (UG) Avoid low-dose vasopressin as the single initial vasopressor (UG) Reserve vasopressin doses higher than U/min for salvage therapy (failure to achieve adequate MAP with other vasopressor agents) (UG) Select dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (low tachyarrhythmias and absolute or relative bradycardia) risk of (2C) Do not use low-dose dopamine for renal protection (1A) 再一下下就到了 Vasopressors-(3) Do not use phenylephrine in the treatment of septic shock except in circumstances in which (A) Norepinephrine is associated with serious arrhythmias (B) Cardiac output is high and blood pressure persistently low (C) Salvage therapy when combined inotrope/vasopressor drugs and low-dose vasopressin have failed to achieve MAP target (1C) Place an arterial catheter in all patients requiring vasopressors as soon as practical if resources are available (UG) 升壓劑界的一王四后? Blood products-(1) Norepinephrine (1B) Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances (MI, severe hypoxemia, acute hemorrhage, or ischemic heart disease), transfuse Epinephrine (2B) RBCs only when hemoglobin concentration decreases to <7.0 g/dl to target Phenylephrine (1C) g/dl in adults (1B) Dopamine (2C) Do not use erythropoietin as a specific treatment of anemia associated with severe sepsis (1B) Vasopressin (UG) Do not use FFP to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (2D) Inotropic therapy Consider dobutamine infusion up to 20 mg/kg/min or Blood products-(2) added to vasopressor (if in use) in the presence of (A) Myocardial dysfunction : suggested by elevated cardiac filling pressures and low cardiac output (B) Ongoing signs of hypoperfusion despite achieving adequate (A) <10,000/mm3 in the absence of apparent bleeding. (B) <20,000/mm3 with significant risk of bleeding. (C) Higher platelet counts (>50,000/mm3) : advised for active intravascular volume and adequate MAP (1C) Do not use inotropes as a strategy to increase cardiac index to predetermined supranormal levels (1B) In severe sepsis, administer platelets prophylactically if platelets counts bleeding, surgery, or invasive procedures (2D) Do not use antithrombin for the treatment of severe sepsis and septic shock (1B)

5 Corticosteroids Activated protein C Do not use intravenous hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If not achievable intravenous hydrocortisone at a dose of 200 mg/day (2C) Taper hydrocortisone when vasopressors are no longer required (2D) Do not administer corticosteroids for the treatment of sepsis in the Entlassen!! absence of shock (1D) When hydrocortisone is administered, use continuous flow (2D) Do not use the ACTH stimulation test (2B) Conclusions Source control Consider and exclude specific anatomic diagnoses of infection requiring emergency source control as rapidly as possible, and intervene for source control within the first 12 h after the diagnosis physiologic targets. (1C) is made. (1C) Preferential use of norepinephrine. (1B) Lactate clearance as a marker of tissue hypoperfusion. (2C) Use the effective intervention associated with the least physiologic Decreased emphasis on the use of corticosteroids (2C) insult (eg, Removal of activated protein C tissues has occurred (2B) percutaneous rather than surgical drainage of an abscess) (UG) 但是 EBM 就跟男人一樣 Mechanical ventilation Tidal volume : 6 ml/kg (predicted body weight) in sepsis induced ARDS (grade 1A vs 12 ml/kg) 翻臉比翻書還快. 昨是而今非 都照著guideline Higher PEEP for sepsis-induced moderate or severe ARDS (2C) Elevate the head of the bed to degrees to limit aspiration risk and to prevent VIP in mechanically ventilated patients (1B) Apply PEEP to avoid alveolar collapse at end expiration (atelectotrauma) (PEEP: >5 cm H2O) (1B) Preferential use of crystalloids (+/- albumin) for volume resuscitation. (1B) Infected peripancreatic necrosis is identified, delay definitive intervention until adequate demarcation of viable and nonviable Protocolized quantitative resuscitation with specific Use NIV in that minority of sepsis-induced ARDS patients for whom 做了 but. the benefits of NIV have been carefully considered and are thought to outweigh the risks (2B) Blood glucose control March 18, 2014 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. (other than 110 mg/dl) (1A) Monitor blood glucose values Q1 2 h until glucose values and insulin infusion rates are stable and then Q4h thereafter (1C) Interpret glucose levels obtained with point-of-care testing of capillary blood with caution because such measurements may not accurately estimate arterial blood or plasma glucose values (UG)

6 No significant benefit to the mandated use of central venous catheterization and central hemodynamic monitoring in all patients Protocolized Care for Early Septic Shock (ProCESS) RCT Multicenter, in U.S 2005,05~2013,05 31 hospitals (ED : >40,000 patients/year) 1351 patients, adult Study design Early recognition of sepsis 1.Protocol-based EGDT : by Rivers. (2001 NEJM) Early treatment with antimicrobial agents 2.Protocol-based standard therapy : Conservative transfusion thresholds Low tidal-volume ventilation Moderate glycemic control Three groups : Take home messages Less aggressive EGDT CVP is not required Transfusion if Hb<7.5g/L 3.Usual care Crystalloids, norepinephrine, and lactate clearance The ProCESS Trial A New Era of Sepsis Management. March 18, 2014, at NEJM.org. Lactate V.S. CVP Lactate Serial measurement of blood lactate level is noninferior to catheter-derived measurements. Less costly Lower-risk The ProCESS Trial A New Era of Sepsis Management. March 18, 2014, at NEJM.org.

7 有時候覺得查 EBM 就像 有時候又覺得這些會不會都是