SEPSIS: Seeing Through the. W. Graham Carlos MD, MSCR, ATSF, FACP
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1 SEPSIS: Seeing Through the W. Graham Carlos MD, MSCR, ATSF, FACP
2 Objectives Forget everything you have known about sepsis Learn new things
3 Objectives Define sepsis Explain why Early Goal Directed Therapy is no longer advocated Identify when to use qsova and SIRS to help diagnose sepsis Understand why LR is now favored over NS for resuscitation Identify targets to monitor volume of resuscitation
4 What is sepsis? Inflammatory state resulting from a systemic response to bacterial infection In septic shock there is critical reduction in tissue perfusion leading to acute failure of one or more organs
5 How I learned to treat sepsis
6 How I learned to treat sepsis Harry Potter and the Philosopher's Stone The Lord of the Rings: The Fellowship of the Ring Monsters, Inc. Shrek Ocean's Eleven Pearl Harbor The Mummy Returns Jurassic Park III Planet of the Apes Hannibal A Beautiful Mind
7 2001 Rivers study Early Goal Directed Therapy CVP MAP ScvO2 Dobutamine Blood
8 CVP?
9
10 ScvO2?
11 HgB? (2014 TRISS Trial)
12 Lower threshold <7 did better, saved blood
13
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15 Sepsis Campaign Updated.
16 New guidelines 2016 Check Lactate Send Blood Cultures Give Antibiotics 30mL/kg IVF (if low BP/High Lactate)
17 New guidelines 2016 Check Lactate Send Blood Cultures Give Antibiotics 30mL/kg IVF (if low BP/High Lactate) Re assess Volume Status and Tissue Perfusion within 6 hours * CVP * ScvO2 * Cardiac US (IVC) * Passive Leg Raise
18 New Guidelines 2018 In the first hour of recognition thou shalt
19 Quality of Evidence.
20 Rebel Physician Fighters SSC
21 October 2018!
22
23
24 Back to basics
25 Back to basics 1. Recognition
26 Recognition: SIRS Criteria (need 2/4): 1. T >38 or <36 2. HR >90 3. RR >20 4. WBC >12 or <4 Q SOFA Criteria (need 2/3): 1. Alter mental status (GCS <15) 2. SBP < RR >22
27 Recognition: SIRS Criteria (need 2/4): 1. T >38 or <36 2. HR >90 3. RR >20 4. WBC >12 or <4 Q SOFA Criteria (need 2/3): 1. Alter mental status (GCS <15) 2. SBP < RR >22 Source
28
29 Back to basics 1. Recognition 2. Identification
30 Blood cultures Proper selection of antibiotics to Decrease side effects Decrease resistance rates Decrease costs Gain epidemiologic information
31 Other blood tests Lactate CMP CBC w/ diff Procalcitonin? Not good in: ESRD, hypothermia, trauma Better for stopping abx then not starting esp in septic appearing pts
32 Back to basics 1. Recognition 2. Identification 3. Resuscitation
33 What fluid and how much? What fluid to give? How do we know if our patient has been adequately fluid resuscitated?
34 NS is not normal!!! Hypertonic Causes hyperchloremic acidosis LR is safe in hyperkalemia NS may not be NS can cause kidney injury Hyperchloremia causes renal vasoconstriction SALT ED trial NEJM ,300 pts median 1L NS vs. LR 37.6% vs 28% adverse kidney events (p<0.001) SMART trial NEJM ,800 pts 15.4% vs. 14.3% death or renal injury (p<0.04)
35
36
37 How much is too much?
38 The Ultimate Goal! PERFUSION
39 The Ultimate Goal! PERFUSION Oxygen Content (CaO2) = [Oxygen on HgB] + [Oxygen in plasma] CaO 2 (ml O 2 /dl) = (1.34 x hemoglobin concentration x SaO 2 ) + ( x PaO 2) Oxygen Delivery (DO2) = Cardiac Output x Oxygen Content DO 2 (ml/min) = Q x CaO CO = HR x SV
40 Malperfusion Clinical Exam Signs Cap refill Mental Status Urine Output MALPERFUSION Skin mottling Blood Pressure Heart Rate
41 Resuscitation targets Urine Output 0.5 ml/kg/hr Mean Arterial Pressure Lactate PERFUSION SVV Stroke Volume Variation Central Venous Pressure / Preload IVC US
42 SVV
43 Ultrasound of the IVC
44 What about Vitamin C? Marick et al (2016 CHEST) EHR retrospective study Treatment: vitamin c, hydrocortisone, thiamine within 24 hrs ICU sepsis admission Findings: No treatment group pts died from sepsis complications Promising results but only a hypothesis generating study needs external validation before routine implementation
45 Conclusion 1. Recognition 2. Identification 3. Resuscitation
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