Frank Sebat, MD - June 29, 2006

Transcription

1 Types of Shock Hypovolemic Shock Low blood volume decreasing cardiac output. AN INTEGRATED SYSTEM OF CARE FOR PATIENTS AT RISK SHOCK TEAM and RAPID RESPONSE TEAM Septic or Distributive Shock Decrease in vascular tone. Cardiogenic Shock/ Obstructive Shock 1 Decrease cardiac function or Obstruction of blood flow. Anaphylactic Shock A form of distributive shock as a result of allergen Hypoxic / Respiratory Shock 1 o respiratory failure or acute change in neurologic status leading to respiratory failure Respiratory Failure Acute Change in Neurologic Status } Cycle of Shock 1. Hypovolemic S 2. Septic H O 3. Cardiogenic CK 4. Anaphylactic 5. Hypoxic Death Blood Flow (C.O.) or Blood Pressure Early Treatment Multiorgan Failure UNTREATED SHOCK IS 100% FATAL organ perfusion Blood Flow or Pressure Neurologic, Respiratory, and Cardiovascular function EARLIER RECOGNITION AND EARLY GOAL DIRECTED THERAPY WILL INTERUPT THE CYCLE Hospital Mortality decreased from 46.5 to 30.7; p =.009 Hemodynamic Optimization Before Organ Failure in High Risk Patients Hemodynamic Optimization Kern and Shoemaker, CC Medicine, 2002, Vol 30 Efficacy of Early Antibiotic Administration 2151 Septic Shock Pts at 10 Hosp Kumar CC Med June 2006 Improved survival for septic patients with effective Antibiotic administration Control 7.6 % in mortality for each hour delay 83% survival ½ hr 80% survival 1 hr 60% survival 6 hr 35% survival 12 hr 10% survival 24hr

2 Effect of Early Administration of Activated Protein C ENHANCE: single-arm, open-label, international study of 2378 adult patients with severe sepsis who received Xigris Why a Program at Your Facility? Mortality of 862 pts with APACHE II 25 Based on Time to Treatment 60 Mortality (%) % Day One* N=430 P=0.019 * APC infusion started 24 hrs. from onset of acute organ dysfunction ** APC infusion started 24hrs. from onset of acute organ dysfunction 41% 50% pt 50% pt Day Two** N=432 A standardized and systematic approach to critical illness will lead to: Early Recognition Early Initiation of Best Practice Improved Outcomes! How to Implement a Program at Your Facility Education Education Education Recognition of Critical illness Sometimes obvious, but frequently subtle Tachypnea almost always present, non specific, but very sensitive Hypotension not necessarily present or not detected Development & Education for the Program ) Shock resuscitation algorithms: in pre-hospital; emergency department; general ward; ICU 500 health care providers received standardized teaching, slide presentation, interactive classes, exam and Mock Shock Alerts Activation criteria cards given to all healthcare workers and posters placed in all units Ongoing education based on needs assessment The Ten Signs of Vitality Essential physiologic signs of life Essential assessment for treatment of critical illness Early assessment and intervention will: Decrease morbidity & mortality Reduce unexpected cardiac arrests

3 Classic Vital Signs New Vital Signs Temperature Pulse Blood pressure Pain the fifth vital sign (American Pain Society 1995) Level of conscious (LOC) O 2 saturation Urine output Capillary refill Respirations The 'Lady-in-Chief', Florence Nightingale ScVO2 / SVO2 Communication Significant Clinical Alteration The Ten Signs of Vitality 10 SOV Complete assessment of the 9 Signs of Vitality Use SBAR communication: S = situation B = background A = assessment (9 SOV) R = recommendation S Patient s chart available for information and orders Temperature Pulse Respiratory rate Blood pressure Pain Level of consciousness Oxygen saturation Urine output Capillary refill ScVO2 / SVO2 ALL SHOCK Skin Manifestations of Shock: Livedo reticularis Leads to cardiogenic shock

4 Alert Inclusion Criteria Activation Criteria (continued) Hypotension SBP < 90, MAP < 60 with one or more. or of the Normotension following with three or more. } and not corrected with one liter rapidly infused crystalloid: 1. Temperature < 36 C 4. Cool extremities or or 96.8 F skin mottling, cap refill > 3sec 2. RR > 20 bpm 5. Oliguria < 30 cc/hour 3. Altered mental status 6. Lactic Acid > 2.0 or BE < -5 mmol/l Primary respiratory failure: RR > 30, with O2 requirement Significant deterioration neurological status: GCS>2 or GCS of < 8 or RR <8 and SaO 2 <90 Resuscitation Goals SaO 2 > 92% Decreased work of breathing MAP > 70 UO > 30 cc/hr Improved skin perfusion (cap < 3sec) SvO 2 > 60 or ScvO 2 > 70 Standardized Best Practice: V. I. P.P. S. Approach to Bedside Management of Shock Weil MH; Shubin H. JAMA 1969 Jan 13 V I P P S entilation/oxygenation nfusion of VOL ressors / Pump harmacy pecific Current Shock Shock Screening Criteria Hypotension SBP<90, MAP< 60 and one or more of the following: Normotension with three or more of the following: agitation, lethargy or coma - Respirations > 20 bpm - Lactic acid > - Anxiety, apathy, 2.0 or BE < -5 mmol/l - Cool extremities or skin mottling - Oliguria < 30 cc/hour - Temperature < 36 o C Exclusion Criteria - Trauma as cause of shock - Acute MI as cause of shock - Patients who are not candidates for aggressive treatment by advanced directive, or pre-existing diagnosis - Patients in critical care units already receiving ACLS therapy Initiate 500 cc Fluid Increments (2) 16 gauge IV or central line Up to 2000 cc per protocol Fluid Bolus 1000 cc for ER patients 250 cc for floor patients Screening Criteria still met and Exclusion Criteria do not apply CALL SHOCK ALERT Notify Primary MD Shock team, cart, lab panel, and ICU bed activated PATIENT IN SHOCK Goals: - MAP > 70 - UO > 30 Cc/hr - Decreased work - Improve skin or of breathing peripheral perfusion Goals Not Met: Continue Fluid Challenge Start Dopamine or Levophed MAP < 70 Add Dobutamine if MAP > 70 Rapid Transfer ICU or OR Goals not met or increase in pressor requirement or deteriorating oxygenation Intubate and check ScvO 2 * Consider PA catheter for cardiogenic shock Additional Goals (Years 0-1): - SvO 2 > Cardiac Index SaO 2 > 92 > 2.5 (cardiogenic) 2 Transfuse to Hb 10 > 2.7 (hypovolemic) 3 Dobutamine > 3.0 (septic and anaphylactic) 4 Respiratory Support SaO 2 > 92 Decrease work of breathing Early intubation Years 2-5 SvO 2 > 60 ScvO 2 >70 1 CI > 2.7 (cardiogenic) 2 CI > 3.0 (hypovolemic) 3 CI > 4.5 (septic and anaphylactic) 4 For All Critical illness After VIPPS Insulin for tight glucose control DVT prophylaxis GI prophylaxis Lower TV ventilation 8cc/kg HOB> 30 Kinetic therapy Sedation vacation/weaning protocol Duodenal feeding, ASAP Hypovolemic Shock Transfusion and Coag Factor s Septic Shock and Antibiotic s Consider APC* Cardiogenic Shock Anaphylactic Shock

5 Other Protocals Median Treatment Intervals SVT protocol Cardiogenic shock Anaphylactic shock Sedation Ventilator/weaning DVT/GI prophylaxis Insulin infusion minutes X p = <.05 ICU Arrival Antibiotics / Septic Only 2L Fluid Central Line Alert Time Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 patients w/alerts 0% 67.7% 76.8% 68.9% 87.2% 86.2% Shock Alert vs. Mortality 2 Liters Fluid Intervention vs. Mortality 40.0% 40.0% % Hospital Mortality 30.0% 20.0% 10.0% % Mortality 30.0% 20.0% 10.0% 0.0% 0-30 Minutes Minutes > 90 Minutes Time to Shock Alert 0.0% 0-30 Minutes Minutes > 90 Minutes Time to 2 Liters Fluid Antibiotic Administration vs. Mortality Septic Patients Only ICU Admission vs. Mortality 40% Time to Antibiotics Therapy vs. % Mortality (64 missing) 40.0% % Mortality 30% 20% 10% % Mortality 30.0% 20.0% 10.0% 0% minutes >120 minutes Time to Antibiotic Therapy 0.0% 0-60 Minutes Minutes > 180 Minutes Time to ICU Admission

6 APACHE III Scores & Total Mortality % Mortality by Shock Type Control Year Year 2 Year 3 Year 4 Year 5 50% 40% Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 34% 50% 33% 38% % 25% 26% % 10% 14% 13% 12% 14% 20% 10% 0.0 n Apache III Score Mortality % P <.05 0% HYPOVOLEMIC SEPTIC n 11/32 11/44 6/42 4/30 5/43 6/44 18/36 16/49 17/45 9/34 5/25 3/29 A comprehensive educational program and a protocalized systems approach to early identification of critical illness results in: Rapid initiation of protocol driven goal directed treatment Decreases the time to the initiation of fluids, antibiotics, intensivist involvement and ICU arrival Decreases time to hemodynamic optimization Decreases organ failure Decreases mortality