Practical Septic shock resuscitation ไ ไชยร ตน เพ มพ ก ล พบ. ภาคว ชาอาย รศาสตร คณะแพทยศาสตร ศ ร ราชพยาบาล ประช มว ชาการ 101 ป อาย รศาสตร ศ ร ราช 6 ก มภาพ นธ 2561
Early recognition Early resuscitation Early goal achievement Early antibiotics Effective source control Optimal organ support Effective after shock care Important steps in sepsis resuscitation
why The story of sepsis Local infection. Local inflammation. Controlled If uncontrolled dissemination.. Generalized inflammation vascular effects.. Perfusion defect. end organ effects shock ischemic effect immune defect coag.defect... MODS death
Basic pathophysiology
The shock cascade Dutton RP. Anesthesiology Clin 25 (2007) 23 34
Strategy 1 Early recognition of sepsis Patient setting Fever, no other symptoms Fever, with symptoms and/ or signs Afebrile, with sepsis signs Shock etc ท าอย างไรจ งจะ ว น จฉ ยได แต ต น Vital signs Early warning scores eg. EWS, MEWS. SOS scores Quick SOFA or SOFA
Former definition of Sepsis ACCP/SCCM consensus conference 1992 Various stages of disease Bacteremia Systemic inflammatory response syndrome Sepsis syndrome Septic shock: early and refractory Systemic Inflammatory Response Syndrome Widespread inflammatory response to variety of severe clinical insults. Recognized by the presence of two or more of the followings: Temp > 38 o C or < 36 o C HR > 90/min RR > 20/min or PaCO2 < 32mmHg WBC > 12,000,000/ cu.mm. Or < 4000/cu.mm.
SOFA score
Influence of Systemic Inflammatory Response syndrome and Sepsis on Outcome of Critically Ill infected Patients Cumulative incidences of death of patients with infection (from date of infection to hospital discharge) according to sepsis stage : blue line for infection, red line for sepsis, green line for severe sepsis, black line for septic shock Septic Shock Severe sepsis sepsis infection Alberti, Brun-Buisson, Goodman, et al.: AJRCCM 2003:168;79 83
Strategy 2 Early resuscitation เป าหมายในการร กษา Mean arterial pressure > 65 mmhg Urine output > 0.5 ml/kg/hr Reversal of tissue hypoxia Fluid replacement Vasopressors if blood pressure (BP) goal is not reached Check and normalize tissue perfusion after BP goal Within 6 hours
Fluid replacement Fluid Bolus Initial fluid loading 30 ml/kg or more Isotonic crystalloids (0.9%NaCl, LRS or other balanced salt solution are recommended) Fluid challenge if BP goal is not reached CVP or other volume responsive tests Used as check point (ie. CVP 8 12 mmhg) Fluid maintenance After the goal is reached
Four Phases Fluid in the bolus Treatment of Shock Salvage Optimization Stabilization De-escalation Aggressive restoration of blood pressures Life saving measures Treat underlying causes Provide adequate oxygen delivery Optimize CO, ScvO2 and lactate Provide organ support Vasopressor weaning Achieve a negative balance Myburgh JA, Mythen MG. N Engl J Med 2013;369:1243 51.
What fluid? Isotonic crystalloids NSS LRS or acetate Balance salt solution Albumin Synthetic colloids others Ann Intern Med 2014; 161(5):347 355
Fluid Challenge When intravascular volume status is uncertain Static (pressure parameters) CVP, PAOP Dynamic (functional) parameters derived from heart lung interaction: PPV, SPV IVC Cardiac output Invasive Thermodilution Less invasive Indicator dilution Pulse contour Impedance PLR EEO Doppler Echo
If the BP target is not reached after adequate fluid เป แนวทางการร กษา าหมายในการร กษา Fluid replacement Mean arterial pressure > 65 Vasopressors if blood mmhg pressure (BP) goal is Urine not reached output > 0.5 ml/kg/hr Reversal Check and of tissue normalize hypoxia tissue perfusion after Within BP goal 6 hours Norepinephrine 0.1 2µg/kg/min First line agent Dopamine If NE contraindicated Arrhythmia, common complication Adrenaline If no response from the above agents
Can vasopressors be given earlier?
Early norepinephrine administration vs. standard treatment during severe sepsis/septic shock resuscitation: a randomized control trial Chairat Permpikul, Surat Tongyoo and Tanuwong Viarasilpa Division of Critical Care, Department of Medicine Siriraj Hospital, Mahidol University Bangkok 10700 THAILAND ESICM 2017, September 26
Outcomes Primary outcome Achieved target MAP + tissue perfusion goal within 6 hours no(%) Secondary outcomes Early Norepinephrine (N = 155) Standard Norepinephrine (N = 155) 118 (76.1) 75 (48.4) Mortality at 28 days no (%) 22 (14.2) 33 (21.3) Hospital mortality no (%) 33 (21.3) 37 (23.9) Time from initial treatment to achieve target MAP and tissue perfusion goal hr:min Outcomes Relative Risk (95% CI) 1.76 (1.42 2.18) 0.77 (0.54 1.08) 0.93 (0.70 1.22) P value <0.001 0.1 0.59 5:52±5:17 7:22±4:35 0.01 ESICM 2017, September 26
Detection and reversal of tissue hypoxia Adequacy of tissue perfusion Urine < 0.5 ml/kg/hr Low ScvO 2 < 70% Lactate > 2 mmol/l, or lactate clearance > 10% If perfusion goal is not reached Check afterload/ intense vasoconstriction Correct anemia Dobutamine, in those with low cardiac output Correct metabolic acidosis
Strategy 3,4 Early goal achievement Early antibiotics Hemodynamic restoration within 6 hours Macrocirculation mocrocirculation Antibiotics within 1 hour
Therapeutic goal achievements and their association with patients' outcomes during severe sepsis and septic shock resuscitation Milestone achievements during guideline implementation and their association with patients mortality were reported. These milestones include: 1. mean arterial > 65 mmhg 2. urine output > 0.5 ml/kg/hour 3. superior vena cava O 2 saturation > 70% or serum lactate clearance > 10%. Permpikul C. et al J Med Assoc Thai 2013
Main results Outcomes/ goal achievement No goal (n = 25) Blood pressure (n = 31) Blood pressure and urine output (n = 75) Blood pressure and urine output and lactate (n = 23) Urine output (n= 21) P value 28 days mortality (%) 44 35.5 16 8.7 23.8 0.008 Hospital mortality (%) 48 41.9 18.7 8.7 28.6 0.003 ICU LOS 48 pts (days) 16.2+13.9 20.1+25.0 5.7+4.7 5.8+5.0 61.5+58.7 <0.001 Hospital LOS (days) 24.5+21.9 31.0+30.0 19.0+16.5 23.5+30.7 28.6+22.1 0.34
The influence of early hemodynamic optimization on biomarker patterns of severe sepsis and septic shock. The temporal patterns of inflammatory mediators were serially examined over the first 72 hrs of hospitalization after early hemodynamic optimization strategies of EGDT trial IL 1 ra TNF α Crit Care Med 2007;35:2016 24
Delayed initiation of antimicrobial therapy increases mortality. Kumar A Crit Care Med 2006;34(6):1589 96;
Strategy 5 Effective source control Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 We recommend that a specific anatomic diagnosis of infection requiring emergent source control should be identified or excluded as rapidly as possible in patients with sepsis or septic shock, and that any required source control intervention should be implmented as soon as medically and logistically practical after the diagnosis is made (BPS). Crit Care Med 2017; 45:486 552
Ease of removal of colonized devices Urinary catheter Increasing risk associated with removal Intravascular catheter Endotracheal tube Peritoneal dialysis catheter Prosthetic joint; orthopedic hardware Vascular graft Prosthetic heart valve Left ventricular assist device
Strategy 6 Optimal organ support Organ failure in sepsis and shock Hemodynamics Respiration Renal Coagulation system GI Metabolic Immune Etc.
Strategy 6 Effective after shock care Patients condition after shock Source controlled?? High risks hemodynamics Adequate/ inadequate volume Continued leakage Myocardial blood supply Organ failure/ recovery Anergy High risk of HAI or reactivation of silent infection
Early recognition Early resuscitation Early goal achievement Early antibiotics Effective source control Optimal organ support Effective after shock care Key success factors in sepsis resuscitation
ขอฝาก Guideline ง ายๆ