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 Camden NJ USA
Potential Conflicts of Interest No potential financial conflict of interest as to any material presented in this presentation Leadership position in Surviving Sepsis Campaign
Definitions of Designer designer 1 a person who devises and executes designs, as for works of art, clothes, machines, etc. 2 designed by and bearing the label or signature of a well-known fashion designer 3 having an appearance of fashionable trendiness 4 designed (or produced) to perform a specific function or combat a specific problem
Designer Jeans
Designer Jewelry
Designer Drugs
Designer Resuscitation of Septic Shock
Protocolized Care Protocolized Quantitative Resuscitation
Emergency Management of the Critically Ill Patient Airway Breathing Circulation Disability Endpoints of Resuscitation
Resuscitation of severe sepsis Reverse hypotension Maintain adequate mean arterial pressure Maintain adequate urine output Prevent, slow or reverse organ dysfunction Potential conflicting goals Cardiovascular versus pulmonary Normalize superior vena cava oxygen saturation Decrease and/or normalize elevated serum lactate
Sepsis Induced Tissue Hypoperfusion Requirement for vasopressors after fluid challenge Lactate elevation
The Problem Dellinger RP. Cardiovascular management of septic shock. Crit Care Med 2003;31:946-955.
Step 1 (1) Fill the tank
Fluid therapy Crystalloids always Colloids often Hetastarch no
Fluid therapy Initial fluid challenge in sepsis-induced tissue hypoperfusion (hypotension or elevated lactate) with suspicion of hypovolemia to be a minimum of 30ml/kg of crystalloids(a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid, may be needed in some patients ( 1B) Surviving Sepsis Campaign 2013
Resuscitation of Sepsis Induced Tissue Hypoperfusion Recommend MAP 65 mm Hg Recommend urine output 0.5 ml/kg/hr Grade 1C
During Septic Shock End Diastole 10 Days Post Shock End Systole
Choice of vasopressors First line norepinephrine If norepinephrine fails to achieve MAP target Epinephrine Low dose vasopressin Special circumstances Phenylephrine Dopamine
(1) When do you know when the tank is full?
Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion Recommend Insertion central venous catheter Recommended goals : Central venous pressure: 8 12 mm Hg Higher with altered ventricular compliance or increased intrathoracic pressure Grade 1C Surviving Sepsis Campaign 2013
Limitation of pressure measurement to predict fluid responsiveness
Starling Principle relates to volume
Effect on Cardiac Filling
Fluid therapy Technique using incremental fluid boluses wherein fluid administration continued as long as hemodynamic improvement based on dynamic variables (e.g. delta pulse pressure, stroke volume variation ) (1C).
Arterial Systolic Pressure Variation Parry-Jones, et al. Int J Respir Crit Care Med 2003;2:67
Expected Result of Volume Expansion
The Ultimate Fluid Resuscitation Target, Flow Itself?
Efffect on Stroke Volume
Arterial Line and Pulse Contour Analysis P art A LIDCO, PICCO, FLOTRAC t
PA Catheter for Quantitative Resuscitation Pulmonary artery occlusion pressure 12-14 with fluids Cardiac index 3.0 with dobutamine Mean arterial pressure 65 mm Hg with norepinephrine
Limit for Raising Left Ventricular End Diastolic Pressure (LVEDP) Pulse oximetry
Caveats Venous blood gases Intermittent or continuous Intermittent from central line in superior vena cava Peripherally inserted central catheter (PICC) line PICC line transduction of central venous pressure (CVP)
Hospital Mortality and Length of Stay Jones, A. E. et al. JAMA 2010;303:739-746.
Am J Respir Crit Care Med. 2010 Sep 15;182(6):752-61.
Lactate Clearance In patients with elevated lactate levels as a marker of tissue hypoperfusion we suggest targeting resuscitation to normalize lactate as rapidly as possible (grade 2C). Surviving Sepsis Campaign 2013
Old and New Areas of Investigation Venous-arterial CO2 gap (Weil) Venous-arterial Carbon Dioxide Difference/Arterial-Venous Oxygen Difference Ratio* *Monet et al. Crit Care Med 2013; 41:1412 1420
Thank You