Resuscitation Symposium Resuscitation Literature Update. Abdullah Al Reesi, MD, MSc, FACEP, FRCPC Sr. Consultant and HoD SQUH

Transcription

1 Resuscitation Symposium Resuscitation Literature Update Abdullah Al Reesi, MD, MSc, FACEP, FRCPC Sr. Consultant and HoD SQUH

2 Objectives Review recent articles in sepsis New sepsis definition High versus low blood-pressure target in patients with septic shock Albumin replacement in patients with severe sepsis or septic shock Lower versus higher hemoglobin threshold for transfusion in septic shock Trial of early, goal-directed resuscitation for septic shock. PROMISE trial

3 The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8): doi: /jama.2016

4 New Definitions Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction can be identified as an acute change in total SOFA score 2 points consequent to the infection. The baseline SOFA score can be assumed to be zero in patients not known to have preexisting organ dysfunction. A SOFA score 2 reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection.

5 Sepsis Terminology From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

6 From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8): doi: /jama Table Title: Sequential [Sepsis-Related] Organ Failure Assessment Score a Date of download: 5/1/2016 Copyright 2016 American Medical Association. All rights reserved.

7 From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8): doi: /jama Figure Legend: Operationalization of Clinical Criteria Identifying Patients With Sepsis and Septic ShockThe baseline Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score should be assumed to be zero unless the patient is known to have preexisting (acute or chronic) organ dysfunction before the onset of infection. qsofa indicates quick SOFA; MAP, mean arterial pressure. Date of download: 5/1/2016 Copyright 2016 American Medical Association. All rights reserved.

8 Asfar P, SEPSISPAM Investigators; High versus low blood-pressure target in patients with septic shock.n Engl J Med Apr 24;370(17):

9 Question Among patients with septic shock, whether high target MAP(80-85) OR low target MAP(65-70) is better in reducing mortality

10 METHODS: Multicenter, open-label trial, randomized trial Patients with septic shock after adequate fluid resuscitation MAP target of either 80 to 85 mm Hg or 65 to 70 mm Hg The primary end point was mortality at day 28

11 RESULTS: Sepsis Update

12 Bottom Line Higher MAP target (80 to 85 mm Hg), as compared with lower MAP(65 to 70 mm Hg), in patients with septic shock undergoing resuscitation did not result in significant differences in mortality at either 28 or 90 days

13 Caironi P, ALBIOS Study Investigators, N Engl J Med. Albumin replacement in patients with severe sepsis or septic shock, 2014 Apr 10;370(15):

14 Question To study the efficacy of albumin administration in patients with severe sepsis

15 METHODS: Multicenter, open-label trial Severe sepsis, in 100 ICUs Receive either 20% albumin and crystalloid solution or crystalloid solution alone The primary outcome was death from any cause at 28 days

16 RESULTS: Sepsis Update

17 The Bottom Line: Albumin replacement in addition to crystalloids, as compared with crystalloids alone, did not improve the rate of survival

18 Holst LB, TRISS Trial Group; Lower versus higher hemoglobin threshold for transfusion in septic shock.n Engl J Med.2014 Oct 9;371(15):

19 Question Evaluate the effects on mortality of leukoreduced blood transfusion at a lower versus a higher hemoglobin threshold among patients with septic shock who are in the ICU

20 Methods multicenter, RCT Patients ICU with septic shock transfusion targets at Hb of=< 9 receive and Hb=< 7 g per deciliter The primary outcome: death by 90 days after randomization

21 Results Sepsis Update

22 Bottom line Patients with septic shock, had similar mortality at 90 if received blood transfusion at a higher hemoglobin threshold or at a lower threshold; the latter group received fewer transfusions Applicable mostly to ICU patients

23 Mouncey PR, ProMISe Trial Investigators, Trial of early, goal-directed resuscitation for septic shock, N Engl J Med Apr 2;372(14):

24 Question Whether 6-hour EGDT resuscitation protocol is superior to usual care in patients presenting with early septic shock in reducing mortality at 90 days

25 METHODS: RCT in 56 hospitals in England EGDT (a 6-hour resuscitation protocol) or usual care. The primary clinical outcome was allcause mortality at 90 days.

26 RESULTS: Sepsis Update

27 Bottom line Similar outcome between EGDT and standard of care provided good standard of care

28 Questions