Sepsis Combine experience and Evidence. Eran Segal, MD Director General ICU, Sheba Medical Center, Israel

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Trevor Hensley
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1 Sepsis Combine experience and Evidence Eran Segal, MD Director General ICU, Sheba Medical Center, Israel

2 The Science of Sepsis A complex and diverse clinical entity Outcome is affected by: Infecting organism Infected organ Host response Genetics Immune state Adequate and early therapy

3 Genetic impact on outcome from sepsis Genetic polymorphism and effect on TNF levels and outcome Stuber, Crit Care Med, 1996 Survival of patients with severe sepsis according to Protei n C genotype Walley, Crit Care Med, 2007

4 Components of therapy Early and adequate antibiotics Early and adequate surgical treatment Optimal ventilatory support Some specific therapies: Corticosteroids Activated Protein C Optimal symptomatic treatment of hemodynamics, oxygen delivery and tissue perfusion

5 Sepsis therapies

7 Sprung et al, NEJM 2008

8 Hemodynamics Early optimization of hemodynamics is an important goal in the management of severe sepsis and septic shock Russell, NEJM, 2006

11 Dr. Edward Frank (Boston) DR. JOHN H. SIEGEL (Bronx, N. Y.)

12 Surgery, 1964

13 How should the patient in septic shock be monitored? Pressures? Blood pressure CVP Urine output ScvO2 Lactate

14 Are there patients with high ScvO2 and a normal CVP who are still hypovolemic? Are there patients with a normal lactate and high ScvO2 who don t have adequate tissue perfusion? Are there patients who have signs of hypovolemia but in fact do not need more fluid?

15 To assess and prepare a plan for these patients we need information regarding Cardiac output Preload Fluid responsiveness Afterload Contractility Pulmonary edema

17 To assess and prepare a plan for these patients we need information regarding Cardiac output Preload Fluid responsiveness Afterload Contractility Pulmonary edema

20 A.B YO man with fever and hypotension Previous medical history notable for IHD, S/A MI, CHF, DM, PVD Admitted to the ICU from the ER complaints of 5 days of weakness, confusion Temp 34.8 C BP 86/36 mmhg WBC -3200

21 Foot is clearly infected CVP 8 cmh2o Lactate 3.2 HR - 76 Urine output 10ml/4 hours Patient is taken to the OR and undergoes an above knee amputation. Microscopy of tissue shows Gram+cocci (culture is Group A Streptococci)

22 The following day Blood pressure: 104/66 mmhg HR: 86 BPM CVP: 11cmH2O Lactate: 2.3 No urine output ScvO2: 80%

23 CO 3.4 (4-8) ITBI 719 ( ) SVR 900 ( ) EVLWI (7-10) SVV 21%

24 M.F. A 34 YO man with extreme calf pain Patient is admitted to dermatology with the diagnosis of cellulitis Is diagnosed with necrotizing fasciitis After surgery for debridment of the calf and thigh he is admitted to the ICU with hypotension, fever and multiple organ failure

25 In the ICU HR BP 76/39 CVP - 15 Lactate 2.2 ScvO2-76

26 How should we treat his hemodynamics? Inotropes? Vassopressors? Blood? Fluid? We need more information: If his CO is low What is his preload? What is his SVR? Is he fluid responsive? Maybe nothing needs to be done Most parameters are adequate

28 Lactate is normal CVP is 15 - adequate Blood pressure is moderately low ScvO2 is 76 normal So is everything OK? Patient has no urine output Clearance of ICG using the LIMON is 4.5% VERY LOW

29 With increasing fluids and inotropes, the patient s clearance of ICG increased. This was accompanied by an inc rease in urine output and hemodynamic improvement

30 C.D. A 78 YO man with pneumonia PMH is notable for IHD, CHF with EF of 20% Patient is admitted to medical ward with large infiltrate, hypoxemia and hypercarbia. He is febrile and hypotensive Is intubated and transferred to the ICU

31 Initial assessment is that the patient has a pneumonia on top of cardiogenic pulmonary edema He is started on a furosemide infusion and fluid balance over the first three days is -150 to 300ml/24 hours On the third day his hypoxemia worsens, he is hypotensive

32 On physical examination he is not edematous Blood pressure is systolic CVP is 4-6 mmhg Urine output is low, Una is 6meq/L Lactate - 1, Urea - 210, Sodium - 160

degree of pulmonary edema all indicate that he does not

33 So, he is dehydrated and requires fluid BUT loading A normal to high cardiac output, a high preload state, a significant degree of pulmonary edema all indicate that he does not require fluids In fact, he is hypervolemic and needs fluid removal

34 Also BNP pg/ml (Normal <100) On echo EF is 20% but ventricular volumes are large

40 There are recognized limitations to ventricular filling pressure estimates as surrogates for fluid resuscitation However, measurement of central venous pressure is currently the most readily obtainable target for fluid resuscitation. There may be advantages to targeting fluid resuscitation to flow and perhaps to volumetric indices (and even to microcirculation changes). Technologies currently exist that allow measurement of flow at the bedside. Future goals should be making these technologies more accessible during the critical early resuscitation period and research to validate utility. These technologies are already available for early ICU resuscitation.

42 Thank You

Rounds in the ICU. Eran Segal, MD Director General ICU Sheba Medical Center

Rounds in the ICU. Eran Segal, MD Director General ICU Sheba Medical Center Rounds in the ICU Eran Segal, MD Director General ICU Sheba Medical Center Real Clinical cases (including our mistakes) Emphasis on hemodynamic monitoring Usually no single correct answer We will conduct