EARLY GOAL DIRECTED THERAPY : seminaires iris. Etat des lieux en Daniel De Backer
|
|
|
- Rudolph Nelson
- 5 years ago
- Views:
Transcription
1 EARLY GOAL DIRECTED THERAPY : Etat des lieux en 2017 Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles Past-President European Society of Intensive Care Medicine
2 HEMODYNAMIC ALTERATIONS IN SEPTIC SHOCK Varpula et al Factors independently associated with poor outcome ICM 31:1066;2005 Continuous hemodynamic measurements during the first 48h of shock (111 consecutive patients)
3 Early goal directed therapy Rationale: Prevent the development of tissue hypoperfusion by achieving specific resuscitation goals: MAP (perfusion pressure) SvO2 (adequacy of flow/o2needs) CVP (minimal preload)
4 2012 Recommendation for Initial Resuscitation. We recommend the protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion. During the first 6 hours of resuscitation, the goals of initial resuscitation should include all of the following as a part of a treatment protocol: a) CVP 8 12 mm Hg b) MAP 65 mm Hg c) Urine output 0.5 ml/kg/hr d) Scvo2 70%.
5 EARLY GOAL DIRECTED RESUSCITATION?
6 Severe sepsis and septic shock Rivers et al NEJM 345:1968;2001 Importance of early hemodynamic optimization (based on SvcO2 monitoring) DDB USI
7 Severe sepsis and septic shock Early hemodynamic optimization Rivers et al NEJM 345:1968; patients: 2 SIRS criteria + TAsyst < 90 mmhg, after 30 ml/kg cryst in 30 min or Lactate > 4 meq/l Randomized 133: classic therapy 130: Early Goal Therapy guided on SvcO2 Emergency room DDB USI
8 EARLY HEMODYNAMIC OPTIMIZATION Mortality, % * 28-Day * 60-Day Rivers et al NEJM 345:1968;2001 Standard Early goal * p<0.05 vs ctrl DDB USI
9 What are the interventions that made the diference? More fluids RBC transfusions Dobutamine and vasodilatory agents Sedation and mechanical ventilation More doctors? Rivers et al NEJM 345:1968;2001
10
11 What are the interventions that made the diference? Rivers et al NEJM 345:1968;2001
12 Timing of fluid resuscitation is essential! Correa T et al CCM 40:2841;2012 Delayed fluid resuscitation is associated with greater activation of inflammation Pigs CLP DDB USI
13 Correction of hypoxia limits the development of inflammation EGDT CTRL Rivers et al CCM 35:2016; patients assigned to EGDT or CTRL group DDB USI
14 Correction of hypoxia limits the development of cellular lesions Rivers et al CCM 35:2016;2007 EGDT CTRL 243 patients assigned to EGDT or CTRL group DDB USI
15 Eltzschig and Carmeliet NEJM 364:656;2011
16 A lot of criticisms Single centre trial Potential confounders A few patients made the difference Resuscitation goals (CVP ) => Need for confirmation in a multicentric RCT
17 We had a dream. DDB USI
18 1pt/month /centre March pts
19 EGDT in septic shock Peake S et al NEJM 2014 ARISE (1600 pts)
20 EGDT in septic shock Mouncey P et al NEJM 2015 PROMISE (1260 pts)
21 ICM 2015
22
23 Most patient already reached target ScvO2 values in the recent trials Rivers et al PROCESS ARISE PROMISE ScvO2 % Rivers et al NEJM 2001 Angus D et al NEJM 2014 Peake S et al NEJM 2014 Mouncey P et al NEJM 2015 Inclusion: refractory hypotension and/or lactate 4 (despite fluids)
24 Peake S et al Most patients reached ScvO2 goal at inclusion NEJM 2014 and the proposed protocol was not able to significantly increase this proportion over time!
25 Major differences in mortality in control arm Mortality % (ctrl) Rivers et al PROCESS ARISE PROMISE ScvO2 % Rivers et al NEJM 2001 Angus D et al NEJM 2014 Peake S et al NEJM 2014 Mouncey P et al NEJM 2015 Inclusion: refractory hypotension and/or lactate 4 (despite fluids)
26 Major differences in mortality in control arm Reflects improvement of care! Reflects improvement of care???? De Backer D et al CCM 2016
27 Major differences in mortality in control arm Reflects patient selection?
28 Prognostic value of lacate and impact of time from diagnosis ARISE Casserly B et al CCM 43:567;20150 ProMISe ProCESS Rivers pts / 218 sites / SSC database
29 Inclusion rates? Angus D et al NEJM Patients/ centre / month (included) 3.9 Patients/ centre / month (screened) (ED with at least admissions/ year) 0.5 Patients/ centre / month (included) 1.6 Patients/ centre / month (screened) 7.4 Patients/ centre / month (included) 8 Patients/ centre / month (screened) (ED with??? admissions/ year) Peake S et al NEJM 2014 Rivers et al NEJM 345:1968;2001
30 => Inclusion mostly during «office hours» => Is the care of the control group similar during «non- office hours»? Mouncey P et al NEJM 2015
31 20 % of these «septic shock» patients were not admitted to the ICU!? Angus D et al ICM 20145
32 And the issue of compliance in the treated arm should not be neglected
33 Issues with compliance Angus D et al ICM 20145
34 Excellent trials but. PROCESS / ARISE / PROMISE Angus D et al NEJM 2014 Peake S et al NEJM Many patients in ctrl group were within targets - When not in target, the protocol failed to put them on target - Limited power (given the lower than expected mortality) - Limited external validity: - Low inclusion rate - Mostly office hours inclusions => This is not the end of EGDT but EGDT should not be applied in all septic patients without discrimination Mouncey P et al NEJM 2015
35 NEJM 2017
36 NEJM 2017
37 NEJM 2017
38 Conclusions from the various studies The conclusions of each of the trials are valid EGDT should not be implemented in less severe patients who already have normalized ScvO2 at baseline There was no proof for harm with EGDT, even in the less severely ill patients EGDT should probably still be implemented in the most severe patients with altered ScvO2
39
40 Rhodes et al ICM 2017 CCM 2017
41 Rhodes et al ICM 2017 CCM 2017
42 What do you recommend to use? Rhodes et al ICM 2017 CCM 2017
43 Variables to use to indicate further fluid administration? Heart rate / blood pressure Skin mottling CVP Lactate Veno-arterial PCO2 gradients Urine output Echo Other available hemodynamic measurements Most of these variables indicate poor tissue perfusion not that the patient will respond to fluids!
44
45 Signs of tissue hypoperfusion? no yes Expect Cardiac output low or inadapted? no Other intervention yes Hemodynamic intervention
46 What are the signs of tissue hypoperfusion that I use at bedside? Hypotension Skin mottling Capillary refill time Lactate Veno-arterial PCO2 gradients Urine output
47 Expect What do I use to evaluate whether cardiac output is low or inadapted? Signs of tissue hypoperfusion? no no Other intervention yes Cardiac output low or inadapted? yes Hemodynamic intervention
48 What do I use to evaluate whether cardiac output is low or inadapted? ScvO2 Cardiac output measurement by echo
49 Which goals? Resolution of signs of tissue hypoperfusion Which interventions? Fluids Vasopressors Inotropes Guided by? ScvO2 CVP Echo Lactate MAP/DAP
50 Limits in the interpretation of SvO2 A high SvO2 can be abnormal (microciculatory alterations and/or mitochondrial dysfunction)
51 Mortality, % ScvO2 <70% 70-90% >90% 619 pts severe sepsis (ED) Pope J et al Ann Emerg Med 15:40;2010
52 Resuscitation should not be guided on signs of cardiac dysfunction in isolation
53 A proposal to replace SvO2 by direct evaluation of preload responsiveness and ejection fraction Bouferrache K et al CCM 40:2821; pts septic shock
54 Divergent information between ScvO2 and EF Should these patients be treated with inotropic agents? 46 pts septic shock Bouferrache K et al CCM 40:2821;2012 No indication for inotropic agents despite low SvO2!
55 Echographic evaluation of LVEF in patients with septic shock Vieillard-Baron et al AJRCCM 168:1270;2003 => Inotropic agents should not be used to correct a low EF
56 Central venous pressure
57 CVP to predict fluid responsiveness Biais M et al Crit Care pts
58 96 pts 150 fluid challenges Central venous pressure 26/81 (32%) Osman et al ICM 35:64; /81 (68%) 8 DDB USI
59 CVP: Never an optimal prediction but still some reasonable guidance when something better cannot be used... Eskesen et al ICM pts
60 The increase in CVP is the price to pay, not a goal in itself!
61
62 Administration of fluids / targets need to be adapted to the situation!
63 Jama 2017
64 Jama 2017 => Patients were reassessed for tolerance, but not for indication!
65
66 Lactate guided therapy?
67 Vincent JL and De Backer D NEJM 369:1726; 2013
68 Prognostic value of lacate and impact of time from diagnosis Casserly B et al CCM 43:567; pts / 218 sites / SSC database
69 Lactate decrease and outcome Lactate decrease > 10% Lactate decrease < 10% Arnold R et al Shock pts with septic shock
70 What is the ideal decrease slope? Nichol et al Crit Care 15:R242; pts (ICU) DDB USI
71 9190 pts with sepsis Liu V et al Annals ATS 2013
72 Lactate guided therapy What goal? N=185 severe sepsis (ED) Puskarich M et al Chest 143:1548; 2013 Lactate at 6h
73 Lactate guided therapy (-20%/2h for 8h) Janssens T et al AJRCCM 2010 N=348
74
75 Our resuscitation strategies should be adapted to time Early phase Vincent JL and De Backer D NEJM 369:1726; 2013 Later stages
76 CONCLUSIONS Should we abandon Early Goal directed therapy? No, but it should be adapted using more physiologic variables and endpoints. Individualization of therapy is probably better than standardization to common minimal endpoints
77
Actualités de la prise en charge hémodynamique initiale Daniel De Backer
Actualités de la prise en charge hémodynamique initiale Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles Past- President European
Mon patient a une bonne pression artérielle il a a donc un bon débit cardiaque! seminaires iris. Daniel De Backer
Mon patient a une bonne pression artérielle il a a donc un bon débit cardiaque! Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles
Early Goal-Directed Therapy
Early Goal-Directed Therapy Where do we stand? Jean-Daniel Chiche, MD PhD MICU & Dept of Host-Pathogen Interaction Hôpital Cochin & Institut Cochin, Paris-F Resuscitation targets in septic shock 1 The
Evidence-Based. Management of Severe Sepsis. What is the BP Target?
Evidence-Based Management of Severe Sepsis Michael A. Gropper, MD, PhD Professor and Vice Chair of Anesthesia Director, Critical Care Medicine Chair, Quality Improvment University of California San Francisco
Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE
Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE In critically ill patients: too little fluid Low preload,
Early Goal Directed Therapy in 2015: What Did the Big Trials Teach us?
Early Goal Directed Therapy in 2015: What Did the Big Trials Teach us? Mitchell M. Levy MD, FCCM Professor of Medicine Chief, Division of Pulmonary, Sleep, and Critical Care Warren Alpert Medical School
Sepsis is an important issue. Clinician s decision-making capability. Guideline recommendations
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 Clinicians decision-making capability Guideline recommendations Sepsis is an important issue 8.7%
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Mitchell M. Levy MD, MCCM Professor of Medicine Chief, Division of Pulmonary, Sleep, and Critical Care
Obligatory joke. The case for why it matters. Sepsis: More is more. Goal-Directed Fluid Resuscitation 6/1/2013
Obligatory joke Keep your eye on the food. Goal-Directed Fluid Resuscitation Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care University of California, San Francisco The
FLUIDS AND SOLUTIONS IN THE CRITICALLY ILL. Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium
FLUIDS AND SOLUTIONS IN THE CRITICALLY ILL Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium Why do we want to administer fluids? To correct hypovolemia? To increase
Monitoring the microcirculation to guide resuscitation
Monitoring the microcirculation to guide resuscitation Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles President European
Fluid Resuscitation and Monitoring in Sepsis. Deepa Gotur, MD, FCCP Anne Rain T. Brown, PharmD, BCPS
Fluid Resuscitation and Monitoring in Sepsis Deepa Gotur, MD, FCCP Anne Rain T. Brown, PharmD, BCPS Learning Objectives Compare and contrast fluid resuscitation strategies in septic shock Discuss available
The Septic Patient. Dr Arunraj Navaratnarajah. Renal SpR Imperial College NHS Healthcare Trust
The Septic Patient Dr Arunraj Navaratnarajah Renal SpR Imperial College NHS Healthcare Trust Objectives of this session Define SIRS / sepsis / severe sepsis / septic shock Early recognition of Sepsis The
Sepsis Management Update 2014
Sepsis Management Update 2014 Laura J. Moore, MD, FACS Associate Professor, Department of Surgery The University of Texas Health Science Center, Houston Medical Director, Shock Trauma ICU Texas Trauma
Sepsis Management: Past, Present, and Future
Sepsis Management: Past, Present, and Future Benjamin Ferrell, MD Tennessee ACP Meeting October 28, 2017 Learning Objectives Identify the most updated definition and clinical criteria for sepsis Describe
Full Disclosure. The case for why it matters. Goal-directed Fluid Resuscitation
Goal-directed Fluid Resuscitation Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care University of California, San Francisco I own no stocks Full Disclosure The case for why
FLUID RESUSCITATION AND MONITORING IN SEPSIS PROTOCOLIZED VS USUAL CARE DEEPA BANGALORE GOTUR MD, FCCP ASSISTANT PROFESSOR, WEILL CORNELL MEDICAL
FLUID RESUSCITATION AND MONITORING IN SEPSIS PROTOCOLIZED VS USUAL CARE DEEPA BANGALORE GOTUR MD, FCCP ASSISTANT PROFESSOR, WEILL CORNELL MEDICAL COLLEGE NOVEMBER 10 TH 2017 TEXAS SCCM SYMPOSIUM Disclosures
SEPSIS UPDATE WHY DO WE NEED A CORE MEASURE CHAD M. KOVALA DO, FACOEP, FACEP
SEPSIS UPDATE WHY DO WE NEED A CORE MEASURE CHAD M. KOVALA DO, FACOEP, FACEP OBJECTIVES Arise, ProMISE, ProCESS Key points in sepsis management The CMS sepsis core measure COST OF SEPSIS CARE IN US Most
Early goal-directed therapy Where to from here? Rinaldo Bellomo ANZIC Research Centre Melbourne, Australia
Early goal-directed therapy Where to from here? Rinaldo Bellomo ANZIC Research Centre Melbourne, Australia Early goal-directed therapy in septic shock 2001 Proof-of-concept EGDT trial published NEJM 16%
Updates in Sepsis 2017
Mortality Cases Total U.S. Population/1,000 Updates in 2017 Joshua Solomon, M.D. Associate Professor of Medicine National Jewish Health University of Colorado Denver Background New Definition of New Trials
Fluids in Sepsis Less is more. Dr Anand Senthi Joondalup Health Campus ED MBBS, MAppFin, GradCertPubHlth,
Fluids in Sepsis Less is more Dr Anand Senthi Joondalup Health Campus ED MBBS, MAppFin, GradCertPubHlth, FRACGP @drsenthi Summary Discussion of the evidence for/against fluid resuscitation in septic shock
Vasopressors in septic shock
Vasopressors in septic shock Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France Questions 1- Why do we use vasopressors in septic shock? 2- Which first-line agent? 3- When
Nothing to disclose 9/25/2017
Jessie O Neal, PharmD, BCCCP Critical Care Clinical Pharmacist University of New Mexico Hospital New Mexico Society of Health-System Pharmacists 2017 Balloon Fiesta Symposium Nothing to disclose 1 Explain
9/25/2017. Nothing to disclose
Nothing to disclose Jessie O Neal, PharmD, BCCCP Critical Care Clinical Pharmacist University of New Mexico Hospital New Mexico Society of Health-System Pharmacists 2017 Balloon Fiesta Symposium Explain
Sepsis. From EMS to ER to ICU. What we need to be doing
Sepsis From EMS to ER to ICU What we need to be doing NEHAL BHATT, MD ATHENS PULMONARY, CRITICAL CARE AND SLEEP Objectives 1. Define the changes to the definition of Sepsis 2. Describe the assessment,
How can the PiCCO improve protocolized care?
How can the PiCCO improve protocolized care? Azriel Perel Professor and Chairman Department of Anesthesiology and Intensive Care Sheba Medical Center, Tel Aviv University, Israel ESICM, Vienna 2009 Disclosure
Fluid balance and clinically relevant outcomes
Fluid balance and clinically relevant outcomes Rui Moreno, MD, PhD, Professor UCINC, Hospital de São José Centro Hospitalar de Lisboa Central, E.P.E. INSULT PRIMARY MODS SIRS SECONDARY MODS OUTCOME RECOVERY
Early-goal-directed therapy and protocolised treatment in septic shock
CAT reviews Early-goal-directed therapy and protocolised treatment in septic shock Journal of the Intensive Care Society 2015, Vol. 16(2) 164 168! The Intensive Care Society 2014 Reprints and permissions:
Presented by: Indah Dwi Pratiwi
Presented by: Indah Dwi Pratiwi Normal Fluid Requirements Resuscitation Fluids Goals of Resuscitation Maintain normal body temperature In most cases, elevate the feet and legs above the level of the heart
Objectives. Management of Septic Shock. Definitions Progression of sepsis. Epidemiology of severe sepsis. Major goals of therapy
Objectives Management of Septic Shock Review of the Evidence and Implementation of Pediatric Guidelines at Christus Santa Rosa Manish Desai, M.D. PL 5 2 nd year Pediatric Critical Care Fellow Review of
2016 Sepsis Update: Pearls, Pitfalls, and Core Measure Quicksand
2016 Sepsis Update: Pearls, Pitfalls, and Core Measure Quicksand Jack Perkins, MD FACEP, FAAEM, FACP Assistant Professor of Emergency and Internal Medicine Virginia Tech Carilion School of Medicine Why
Cardiovascular Management of Septic Shock
Cardiovascular Management of Septic Shock R. Phillip Dellinger, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Critical Care Medicine and Med/Surg ICU Cooper University Hospital
UTILITY of ScvO 2 and LACTATE
UTILITY of ScvO 2 and LACTATE Professor Jeffrey Lipman Department of Intensive Care Medicine Royal Brisbane Hospital University of Queensland THIS TRIP SPONSORED AND PAID FOR BY STRUCTURE Physiology -
INTENSIVE CARE MEDICINE CPD EVENING. Dr Alastair Morgan Wednesday 13 th September 2017
INTENSIVE CARE MEDICINE CPD EVENING Dr Alastair Morgan Wednesday 13 th September 2017 WHAT IS NEW IN ICU? (RELEVANT TO ANAESTHETISTS) Not much! SURVIVING SEPSIS How many deaths in England were thought
6/5/2014. Sepsis Management and Hemodynamics. 2004: International group of experts,
Sepsis Management and Hemodynamics Javier Perez-Fernandez, M.D., F.C.C.P. Medical Director Critical Care Services, Baptist t Hospital of Miamii Medical Director Pulmonary Services, West Kendall Baptist
UPDATES IN SEPSIS MANAGEMENT Shannon Fry, Pharm.D. Critical Care Pharmacy Specialist St. Joseph Medical Center
UPDATES IN SEPSIS MANAGEMENT Shannon Fry, Pharm.D. Critical Care Pharmacy Specialist St. Joseph Medical Center ShannonFry@fhshealth.org DISCLOSURE I have no financial relationships to disclose OBJECTIVES
The Ever Changing World of Sepsis Management. Laura Evans MD MSc Medical Director of Critical Care Bellevue Hospital
The Ever Changing World of Sepsis Management Laura Evans MD MSc Medical Director of Critical Care Bellevue Hospital COI Disclosures No financial interests to disclose Learning Objectives Review the evolution
Goal-directed resuscitation in sepsis; a case-based approach
Goal-directed resuscitation in sepsis; a case-based approach Jorge A Guzman, MD, FCCM Head, Section Critical Care Medicine Respiratory Institute Cleveland Clinic Foundation The challenges to managing septic
Updates On Sepsis Updates based on 2016 updates on sepsis from The International Surviving Sepsis Campaign
Updates On Sepsis Updates based on 2016 updates on sepsis from The International Surviving Sepsis Campaign Dr. Joseph K Erbe, DO Medical Director Hospitalist Division of Medicine Objectives 1. Review the
Staging Sepsis for the Emergency Department: Physician
Staging Sepsis for the Emergency Department: Physician Sepsis Continuum 1 Sepsis Continuum SIRS = 2 or more clinical criteria, resulting in Systemic Inflammatory Response Syndrome Sepsis = SIRS + proven/suspected
Dr. F Javier Belda Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia (Spain) Pulsion MAB
State of the Art Hemodynamic Monitoring III CO, preload, lung water and ScvO2 The winning combination! Dr. F Javier Belda Dept. Anesthesiology and Critical Care Hospital Clinico Universitario Valencia
Swan Ganz catheter: Does it still have a role? Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium
Swan Ganz catheter: Does it still have a role? Daniel De Backer Department of Intensive Care Erasme University Hospital Brussels, Belgium How can cardiac output be measured? Thermodilution Arterial waveform
Sepsis overview. Dr. Tsang Hin Hung MBBS FHKCP FRCP
Sepsis overview Dr. Tsang Hin Hung MBBS FHKCP FRCP Epidemiology Sepsis, severe sepsis, septic shock Pathophysiology of sepsis Recent researches and advances From bench to bedside Sepsis bundle Severe sepsis
Ralph Palumbo, MD, FCCP
Ralph Palumbo, MD, FCCP Septic shock is the leading cause of mortality in patients admitted to the ICU In the United States alone there are over 750,000 cases of severe sepsis and septic shock annually
SEPSIS: Seeing Through the. W. Graham Carlos MD, MSCR, ATSF, FACP
SEPSIS: Seeing Through the W. Graham Carlos MD, MSCR, ATSF, FACP Objectives Forget everything you have known about sepsis Learn new things Objectives Define sepsis Explain why Early Goal Directed Therapy
Diagnosis and Management of Sepsis and Septic Shock. Martin D. Black MD Concord Pulmonary Medicine Concord, New Hampshire
Diagnosis and Management of Sepsis and Septic Shock Martin D. Black MD Concord Pulmonary Medicine Concord, New Hampshire Financial: none Disclosures Objectives: Identify physiologic principles of septic
Sepsis Care and the New Core Measures. Daniel S. Hagg, MD January 15, 2016
Sepsis Care and the New Core Measures Daniel S. Hagg, MD January 15, 2016 Outline What is sepsis? A brief history of sepsis care How should we take care of septic patients now? Core measures What strategies
Surviving Sepsis Campaign Guidelines 2012 & Update for David E. Tannehill, DO Critical Care Medicine Mercy Hospital St.
Surviving Sepsis Campaign Guidelines 2012 & Update for 2015 David E. Tannehill, DO Critical Care Medicine Mercy Hospital St. Louis Be appropriately aggressive the longer one delays aggressive metabolic
Update in Sepsis. Conflicts of Interest: None. Bill Janssen, M.D.
Update in Sepsis Bill Janssen, M.D. Associate Professor of Medicine National Jewish Health University of Colorado Denver Conflicts of Interest: None A 62 year-old female presents to the ED with fever,
No conflicts of interest to disclose
No conflicts of interest to disclose Introduction Epidemiology Surviving sepsis guidelines 2012 Updates Resuscitation protocols Map Goals Transfusion Sepsis-3 Bundle Management Questions Sepsis is a systemic,
Sepsis care and the new core measures
Sepsis care and the new core measures Daniel S. Hagg, MD January 15, 2016 Outline What is sepsis? A brief history of sepsis care How should we take care of septic patients now? Core measures What strategies
R2R: Severe sepsis/septic shock. Surat Tongyoo Critical care medicine Siriraj Hospital
R2R: Severe sepsis/septic shock Surat Tongyoo Critical care medicine Siriraj Hospital Diagnostic criteria ACCP/SCCM consensus conference 1991 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference
Tailored Volume Resuscitation in the Critically Ill is Achievable. Objectives. Clinical Case 2/16/2018
Tailored Volume Resuscitation in the Critically Ill is Achievable Heath E Latham, MD Associate Professor Fellowship Program Director Pulmonary and Critical Care Objectives Describe the goal of resuscitation
towards early goal directed therapy
Paediatric Septic Shock- towards early goal directed therapy Elliot Long Paediatric Acute Care 2011 Conference Outline Emergency Department Rivers Protocol (EGDT) ACCM Sepsis Protocol Evidence Barriers
Managing Patients with Sepsis
Managing Patients with Sepsis Diagnosis; Initial Resuscitation; ARRT Initiation Prof. Achim Jörres, M.D. Dept. of Nephrology and Medical Intensive Care Charité University Hospital Campus Virchow Klinikum
Sepsis and septic shock Practical hemodynamic consequences. Intensive Care Training Program Radboud University Medical Centre Nijmegen
Sepsis and septic shock Practical hemodynamic consequences Intensive Care Training Program Radboud University Medical Centre Nijmegen Septic cardiomyopathy Present in > 50% and often masked by low vascular
Sepsis: Identification and Management in an Acute Care Setting
Sepsis: Identification and Management in an Acute Care Setting Dr. Barbara M. Mills DNP Director Rapid Response Team/ Code Resuscitation Stony Brook University Medical Center SEPSIS LECTURE NPA 2018 OBJECTIVES
Sepsis Story At Intermountain Healthcare Intensive Medicine Clinical Program
Sepsis Story At Intermountain Healthcare 2004-2012 Intensive Medicine Clinical Program The International Surviving Sepsis Campaign Was Organized In 2002 During The ESICM International Meeting In Barcelona,
Dilemmas in Septic Shock
Dilemmas in Septic Shock William Janssen, M.D. Assistant Professor of Medicine National Jewish Health University of Colorado Denver Health Sciences Center A 62 year-old female presents to the ED with fever,
Case year old female nursing home resident with a hx CAD, PUD, recent hip fracture Transferred to ED with decreased mental status BP in ED 80/50
Case 1 65 year old female nursing home resident with a hx CAD, PUD, recent hip fracture Transferred to ED with decreased mental status BP in ED 80/50 Case 1 65 year old female nursing home resident with
IV fluid administration in sepsis. Dr David Inwald Consultant in PICU St Mary s Hospital, London CATS, London
IV fluid administration in sepsis Dr David Inwald Consultant in PICU St Mary s Hospital, London CATS, London The talk What is septic shock? What are the recommendations? What is the evidence? Do we follow
Fluid responsiveness and extravascular lung water
Fluid responsiveness and extravascular lung water Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France Conflicts of interest Member of the Medical Advisory Board of Maquet/Pulsion
Sepsis Update: Focus on Early Recognition and Intervention. Disclosures
Sepsis Update: Focus on Early Recognition and Intervention Jessie Roske, MD October 2017 Disclosures I have no actual or potential conflict of interest in relation to this program/presentation. I will
Objectives. Epidemiology of Sepsis. Review Guidelines for Resuscitation. Tx: EGDT, timing/choice of abx, activated
Update on Surviving Sepsis 2008 Objectives Epidemiology of Sepsis Definition of Sepsis and Septic Shock Review Guidelines for Resuscitation Dx: Lactate, t cultures, SVO2 Tx: EGDT, timing/choice of abx,
SEPSIS SYNDROME
INTRODUCTION Sepsis has been defined as a life threatening condition that arises when the body s response to an infection injures its own tissues and organs. Sepsis may lead to shock, multiple organ failure
Sepsis and septic shock
Sepsis and septic shock Practical hemodynamic consequences Intensive Care Training Program Radboud University Medical Centre Nijmegen Septic cardiomyopathy Present in > 50% and often masked by low vascular
AnnMarie Papa, DNP,RN,CEN,NE-BC,FAEN, FAAN Clinical Director, Emergency, Medical & Observation Nursing Hospital of the University of Pennsylvania
AnnMarie Papa, DNP,RN,CEN,NE-BC,FAEN, FAAN Clinical Director, Emergency, Medical & Observation Nursing Hospital of the University of Pennsylvania Who Am I? Except on few occasions, the patient appears
Advancements in Sepsis
Objectives Advancements in Sepsis Brian Gilbert, PharmD PGY-1 Pharmacy Resident Jackson Memorial Hospital 3/13/2016 www.fshp.org Pharmacist objectives Review recent updates in resuscitation strategies
Management of Severe Sepsis:
Management of Severe Sepsis: Update from the Surviving Sepsis Campaign Barbara Birriel, MSN, ACNP-BC, FCCM The Pennsylvania State University NONE Disclosures Review evidence-based international sepsis
Troubleshooting Audio
Welcome! Audio for this event is available via ReadyTalk Internet Streaming. No telephone line is required. Computer speakers or headphones are necessary to listen to streaming audio. Limited dial-in lines
Modern fluid therapy. Anders Perner. Dept of Intensive Care, Rigshospitalet, University of Copenhagen
Modern fluid therapy Anders Perner Dept of Intensive Care, Rigshospitalet, University of Copenhagen Scandinavian Critical Care Trials Group www.ssai.info/research/scctg Intensive Care Medicine www.icmjournal.esicm.org
Shock and hemodynamic monitorization. Nilüfer Yalındağ Öztürk Marmara University Pendik Research and Training Hospital
Shock and hemodynamic monitorization Nilüfer Yalındağ Öztürk Marmara University Pendik Research and Training Hospital Shock Leading cause of morbidity and mortality Worldwide: dehydration and hypovolemic
A Critical Review of Early Goal Directed Therapy and Government Endorsement
A Critical Review of Early Goal Directed Therapy and Government Endorsement Charles Natanson M.D. Critical Care Medicine Department Clinical Center National Institutes of Health Clinical Center None Conflicts
Septic Shock. Rontgene M. Solante, MD, FPCP,FPSMID
Septic Shock Rontgene M. Solante, MD, FPCP,FPSMID Learning Objectives Identify situations wherein high or low BP are hemodynamically significant Recognize complications arising from BP emergencies Manage
Core Measures SEPSIS UPDATES
Patricia Walker, RN-BC, BSN Evidence Based Practice Manager Quality Management Services UCLA Health System, Ronald Reagan Medical Center Core Measures SEPSIS UPDATES Severe Sepsis and Septic Shock Based
Sepsis: Getting to ZERO Probable or Impossible?
Sepsis: Getting to ZERO Probable or Impossible? Carol A Rauen, RN-BC, MS, CCRN, PCCN, CEN Independent Clinical Nurse Specialist & Education Consultant. Burn Trauma ICU, Sentara Norfolk General, VA Sepsis
DESIGNER RESUSCITATION: TITRATING TO TISSUE NEEDS
DESIGNER RESUSCITATION: TITRATING TO TISSUE NEEDS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical School of Rowan University Chief of Medicine Cooper University Hospital
What works in sepsis. Topics. EGDT: Severe Sepsis/ Shock. Sepsis
What works in sepsis Eric Schmidt, MD Denver Health Medical Center University of Colorado School of Medicine Topics Understanding and implemen@ng early goal directed therapy (EGDT) Ac@vated Protein C should
John Park, MD Assistant Professor of Medicine
John Park, MD Assistant Professor of Medicine Faculty photo will be placed here park.john@mayo.edu 2015 MFMER 3543652-1 Sepsis Out with the Old, In with the New Mayo School of Continuous Professional Development
Sepsis Combine experience and Evidence. Eran Segal, MD Director General ICU, Sheba Medical Center, Israel
Sepsis Combine experience and Evidence Eran Segal, MD Director General ICU, Sheba Medical Center, Israel The Science of Sepsis A complex and diverse clinical entity Outcome is affected by: Infecting organism
Looking for sepsis. Sepsis: Update. Prevalence of High Profile Dzs. Screening and risk stratification. Mortality of High Profile Diseases
Sepsis: Update Prevalence of High Profile Dzs Edward A. Panacek, MD, MPH Professor and Chair, Emergency Medicine USA Medical Center, Mobile, AL NDAFP Conference Big Sky. 2016 Syllabus Angus Crit Care Med
EFFECT OF EARLY VASOPRESSIN VS NOREPINEPHRINE ON KIDNEY FAILURE IN PATIENTS WITH SEPTIC SHOCK. Alexandria Rydz
EFFECT OF EARLY VASOPRESSIN VS NOREPINEPHRINE ON KIDNEY FAILURE IN PATIENTS WITH SEPTIC SHOCK Alexandria Rydz BACKGROUND- SEPSIS Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated
Septic AKI in ICU patients
Septic AKI in ICU patients Prof. Achim Jörres, M.D. Dept. of Nephrology and Medical Intensive Care Charité University Hospital Campus Virchow Klinikum Berlin, Germany achim.joerres@charite.de Agenda Epidemiology
Nurse Driven Fluid Optimization Using Dynamic Assessments
Nurse Driven Fluid Optimization Using Dynamic Assessments 2016 1 WHAT WE BELIEVE We believe that clinicians make vital fluid and drug decisions every day with limited and inconclusive information Cheetah
Goal-directed vs Flow-guidedresponsive
Goal-directed vs Flow-guidedresponsive therapy S Magder Department of Critical Care, McGill University Health Centre Flow-directed vs goal directed strategy for management of hemodynamics S Magder Curr
Endpoints of Resuscitation for Circulatory Shock: When Enough is Enough?
Endpoints of Resuscitation for Circulatory Shock: When Enough is Enough? Emanuel P. Rivers, MD, MPH, IOM Vice Chairman and Research Director Departments of Emergency Medicine and Surgery Henry Ford Hospital
The Hemodynamic Puzzle
The Hemodynamic Puzzle SVV NIRS O 2 ER Lactate Energy Metabolism (Oxygen Consumption) (Ml/min/m 2 ) Oxygen Debt: To Pay or Not to Pay? Full Recovery Possible Delayed Repayment of O 2 Debt Oxygen Deficit
4/5/2018. Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY. I have no financial disclosures
Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY I have no financial disclosures 1 Objectives Why do we care about sepsis Understanding the core measures by Centers for Medicare
Bedside assessment of fluid status
Bedside assessment of fluid status 2nd AKI Academy October 18 th 2014 David Treacher Guy s & St Thomas NHS Trust Assessing the circulation - the 3 key questions v Is my patient adequately filled? v What
Purist? or Pragmatist? Assessment & Management of ICU Volume Status
Assessment & Management of ICU Volume Status 9 th Annual Rocky Mountain Hospital Medicine Symposium Denver, Colorado Paula Dennen, MD Assistant Professor of Medicine Nephrology and Critical Care Medicine
Methodological co-investigators
Protocolised Management In Sepsis: A multicentre randomised controlled trial of the clinical and cost-effectiveness of early, goal-directed, protocolised resuscitation for emerging septic shock Methodological
Initial Resuscitation of Sepsis & Septic Shock
Initial Resuscitation of Sepsis & Septic Shock Dr. Fatema Ahmed MD (Critical Care Medicine) FCPS (Medicine) Associate professor Dept. of Critical Care Medicine BIRDEM General Hospital Is Sepsis a known
Surviving Sepsis Campaign. Guidelines for Management of Severe Sepsis/Septic Shock. An Overview
Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock An Overview Mechanical Ventilation of Sepsis-Induced ALI/ARDS ARDSnet Mechanical Ventilation Protocol Results: Mortality
Year in Review 2014: Critical Care Medicine
Disclosures Year in Review 2014: Critical Care Medicine I receive laboratory support from CytoVale Diagnostics for research on early sepsis diagnostics Eric J. Seeley, M.D., F.C.C.P. Assistant Professor
Steps to Success in Sepsis ASHNHA Quality Webinar. Maryanne Whitney, RN, CNS, MSN Improvement Advisor, Cynosure Health
1 Steps to Success in Sepsis ASHNHA Quality Webinar Maryanne Whitney, RN, CNS, MSN Improvement Advisor, Cynosure Health Goals for Today State the Problem: Create Awareness & Will Unravel the mysteries
Sepsis and Hemodynamic Support in September 15, 2017 Carleen Risaliti
Sepsis and Hemodynamic Support in 2017 September 15, 2017 Carleen Risaliti Objectives Review fluid resuscitation guidelines in septic shock Discuss volume assessment v. fluid responsiveness Evaluate pros
Where did it all begin?
EXPLORE Healthcare Summit Sepsis: Can We Finally Just Relax on the SOFA? Mark Keuchel, D.O. Background: 1. Sepsis is a wide-spectrum disease process that remains poorly understood 2. Early-goal directed
Surviving Sepsis Campaign
Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock An Overview By professor Ahmad Alaysh BMC-MICU 1 Surviving Sepsis A global program to Reduce mortality rates in severe
Hell or High Lactate. Charles Bruen, MD. resusreview.com/regionsmar17
Hell or High Lactate Charles Bruen, MD resusreview.com/regionsmar17 No Disclosures No Off-label Use 3 Positive troponin? Inpatient or Observation? Lactate elevated? Goals What causes lactate production?