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Septic shock A decade of Intensive Care Research
The beginning of wisdom is the definition of terms. - Socrates
Sepsis re-defined
Sepsis 2 - >2 SIRS Criteria and suspicion of infection Temp >38 C (100.4 F) or <36 C (96.8 F) HR >90 beats per minute RR >20 breaths per minute or PaCO 2 <32 mm Hg WCC >12 or < 4 or >10% immature [band] forms
Sepsis 3 - >2 qsofa and suspicion of infection Hypotension (SBP 100 mmhg), Altered mentation (Glasgow coma scale<15). Tachypnoea ( 22 breaths per min),
Is it septic shock? Septic Shock now defined as Sepsis and despite adequate volume resuscitation both of: Persistent hypotension requiring vasopressors to maintain MAP >65 mmhg, Lactate 2
Early Goal Directed Therapy
EGDT
Case Mrs DB, 48 yo Presented to CMH from home, BIBA, hypoglycaemic and shocked with reduced level of consciousness. Found obtunded by daughter 3-4 day Hx of cough, SOB and fevers. Retrieval call at night: Presumptive dx Pneumonia SBP initially 60 mmhg, tachycardiac Hypoxaemic BSL 1.9 GCS 9 Febrile
BP 60/40 - What fluid to resuscitate with? Pollev.com/jhhicu012 Username jhhicu012 Password jhhicupoll
Choice of Colloids around the world
SAFE Trial
SAFE Trial Overall no significant difference in death (i.e. <3%) at 28 days between those that got saline vs albumin for resus fluids
6S - Starches
That was Europe, what about Australia?
CHEST Trial
Starches In high volumes increase mortality In lower volumes increase renal failure and need for dialysis
Background cholecystectomy hysterectomy SBO from adhesions abnormal LFTs with tests c/w primary biliary cirrhosis (not radiologically confirmed) anaemia diet-controlled DM depression incl. deliberate self harm OA herniated lumbar disc fibromyalgia chronic pain smoker minimal EtOH approx 70 kg, BMI 25 poor functional status, mostly housebound
Initial management? Management at CMH Glucose for initial hypoglycaemia Fluid resuscitated 3L Intubated with ketamine and sux Broad-spectrum Abx Peripheral norad CVC and arterial line Hydrocortisone 200 mg 100 ml 8.4% sodium bicarbonate 2 units PRC in progress Urine output >100 ml/hr on 0.15 mcg/kg/min norad No ICU beds at CMH
Advice: Ventilate harder to bring pco2 down Maintenance with normal bicarbonate Potassium acetate centrally Thiamine Titrate noradrenaline to MAP>65 We ll come and pick her up shortly
Initial biochemistry
Initial haematology
Should we transfuse her? Hb 77 Hct 0.246 Shocked, on norad
TRICC
TRICC Trial Results 30-day mortality (Restrictive vs Liberal) 18.7% vs. 23.3% (P=0.11) Less cardiac events in ICU in the restrictive group (13.2% vs 21%) Avg of 20% of pts had pre-existing cardiac disease and were included in study Patients with underlying cardiac disease did no worse with restrictive approach
TRISS Trial
TRISS Results No statistically significant difference in mortality or cardiac ischaemia Halved the number of transfusions
Back to case Becoming oliguric
Gas on arrival JHH ICU
Should we dialyse her?
AKI and Renal Replacement Therapy Unified definition and classification (RIFLE, AKIN, KDIGO) When to start? What mode of RRT? How much? What dose?
Early vs. late? AKIKI NEJM 2016 ELAIN JAMA 2016
Earlier initiation of RRT may produce benefit by avoiding hypervolemia, elimination of toxins, establishing acid-base homeostasis, and preventing other complications attributable to AKI. However, early initiation of RRT may unnecessarily expose some patients to potential harm because some patients will spontaneously recover renal function. - Zarbock et al.
Intermittent vs. continuous? BEST Kidney Study 2007, Swedish SWING study 2007, Collaborative Group for treatment of AKI in ICU by Mehta in 2001. Systematic review in 2013. All suggesting worse long-term outcome with IHD vs CRRT (e.g. dialysis dependence).
Back to Mrs DB. We did not start RRT. R10: Flu B, Picornavirus. Urine Pneumococcal antigen positive
Profound hypoxia Prone ventilation (PROSEVA Trial) Paralysis infusion (ACURSYS Trial) Inhaled prostacyclin Ventilate harder to bring pco2 down Not for HFOV (Oscar/Oscillate Trials) Unfortunately VV ECMO not available as in use, and controversial use in sepsis.
Magic bullets?
Steroids in (severe) pneumonia?
HYPRESS trial and the Sep-Net Critical Care Trials Group in Germany. JAMA 2016.
We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day (weak recommendation, low quality of evidence). SSC 2016
Activated Protein C (Xigris)
Blood purification (high-volume filtration and/or haemoadsorption)
Polyclonal IVIg The reduction in deaths observed with polyclonal IgM-enriched preparations as add-on therapy for sepsis needs to be confirmed in large studies that use high quality methods. Cochrane We suggest against the use of IV immunoglobulins in patients with sepsis or septic shock (weak recommendation, low quality of evidence). SSC
If no magic bullet exists, is there anything else that can improve long-term outcome?
Glucose control
Nutrition
Mrs DB End-of life discussions due to persistent multi-organ failure, failure to wake despite off sedation, and increase haemodynamic instability.