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    Sepsis Update 2019

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    Yeshwanth Umapathi
    Sepsis is a serious condition that affects over 1 million people in the US each year, resulting in high costs and mortality rates as high as 50%. New definitions and guidelines have been established to help improve early recognition and treatment. Early administration of antibiotics and IV fluids, source control, and vasopressor support when needed can help reduce organ dysfunction and death from sepsis. Ongoing research continues to evaluate resuscitation strategies and potential adjunctive therapies to improve sepsis outcomes.

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    Sepsis Update 2019

    Uploaded by

    Yeshwanth Umapathi
    128 views44 pages
    Sepsis is a serious condition that affects over 1 million people in the US each year, resulting in high costs and mortality rates as high as 50%. New definitions and guidelines have been established to help improve early recognition and treatment. Early administration of antibiotics and IV fluids, source control, and vasopressor support when needed can help reduce organ dysfunction and death from sepsis. Ongoing research continues to evaluate resuscitation strategies and potential adjunctive therapies to improve sepsis outcomes.

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    Sepsis is a serious condition that affects over 1 million people in the US each year, resulting in high costs and mortality rates as high as 50%. New definitions and guidelines have been established to help improve early recognition and treatment. Early administration of antibiotics and IV fluids, source control, and vasopressor support when needed can help reduce organ dysfunction and death from sepsis. Ongoing research continues to evaluate resuscitation strategies and potential adjunctive therapies to improve sepsis outcomes.

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    © All Rights Reserved
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    Download as pdf or txt
    128 views44 pages

    Sepsis Update 2019

    Uploaded by

    Yeshwanth Umapathi
    Sepsis is a serious condition that affects over 1 million people in the US each year, resulting in high costs and mortality rates as high as 50%. New definitions and guidelines have been established to help improve early recognition and treatment. Early administration of antibiotics and IV fluids, source control, and vasopressor support when needed can help reduce organ dysfunction and death from sepsis. Ongoing research continues to evaluate resuscitation strategies and potential adjunctive therapies to improve sepsis outcomes.

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    of 44

    Sepsis Update 2019

    Daniel Arellano, MSN, RN, CCRN, CEN, ACNP-BC


    University of Texas MD Anderson Cancer Center
    Department of Critical Care
    Houston, Texas
    The Facts

     Sepsis is diagnosed in over one million patients


    each year in the United States
     Sepsis treatment resulted in an estimated $27
    billion or 5.2 percent of the total cost for all
    hospitalizations
     Most expensive condition treated in the year
    2011/12/13/14/15/16/17/18
     Mortality rate of 28-50%

    -National Center for Health Statistics Data Brief No. 62 June 2011
    -Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med.
    2001;29:1303-10.
    CDC 2016
    “Except on few occasions,
    the patient appears to die from
    the body's response to infection
    rather than from it.”

    Sir William Osler – 1904


    The Evolution of Modern Medicine
    Arellano, Daniel L., and Sandra K. Hanneman. "Vasopressor weaning in patients with septic shock." Critical care nursing clinics of North America26.3
    (2014): 413-425.
    OLD Terminology:

    Sepsis: Systemic manifestations of infection

    Severe sepsis: Sepsis with organ dysfunction,


    hypoperfusion, or hypotension

    Septic shock: Sepsis with arterial hypotension,


    despite fluid resuscitation, with organ
    dysfunction
    Identifying Acute Organ Dysfunction as a
    Marker of Severe Sepsis
    Altered Tachycardia
    Consciousness Hypotension
    Confusion Altered CVP
    Psychosis Altered PAOP

    Tachypnea
    PaO2 <70 mm Hg Oliguria
    SaO2 <90% Anuria
    PaO2/FiO2 300  Creatinine

    Jaundice
     Platelets
     Enzymes
     PT/APTT
     Albumin
     Protein C
     PT  D-dimer

    Balk RA. Crit Care Clin 2000;16:337-52.


    Bone, et al. 1992
    Definition Changes in 2016
    • A task force of 19 leaders in the field of sepsis was convened by SCCM
    and the European Society of Intensive Care Medicine (ESICM)

    • Sepsis
    • A life-threatening organ dysfunction caused by a dysregulated host response to
    infection

    • The new diagnostic tool for sepsis : quickSOFA (qSOFA), 2 of 3


    indicators below:
    • An alteration in mental status
    • A decrease in systolic blood pressure of less than 100 mm Hg
    • A respiration rate greater than 22 breaths/min

    Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock
    (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
    Definition Changes in 2016

    • Septic Shock:
    • A subset of sepsis in which underlying circulatory and
    cellular/metabolic abnormalities are profound enough to
    substantially increase mortality.
    • Persisting hypotension requiring vasopressors to maintain MAP
    ≥65 mm Hg
    • Blood lactate >2 mmol/L despite adequate volume resuscitation

    Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock
    (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
    HAT “Magic HAT predicts”
    2018 Sepsis Treatment Guidelines
    Screening
    • Routine screening of potentially infected seriously ill patients for severe
    sepsis to allow earlier implementation of therapy (grade 1C)
    • Hospital based performance improvement efforts in severe sepsis

    • Role of the Sepsis Team


    Goals
    • First 6 hrs of resuscitation:
    – a) Central venous pressure 8–12 mm Hg
    – b) Mean arterial pressure (MAP) ≥ 65 mmHg????) Urine output ≥ ?0.5 mL/kg/hr d)
    Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%,
    respectively (grade 1C)
    • In patients with elevated lactate levels targeting resuscitation to normalize
    lactate
    Antibiotics

    • Administration of effective intravenous


    antimicrobials within the first hour of
    recognition of septic shock
    • Antimicrobial regimen should be reassessed
    daily for potential de-escalation (grade 1B)
    • Empiric combination therapy should not be
    administered for more than 3–5 days. (grade
    2B)
    • Duration of therapy typically 7–10 days (grade
    2C)
    • Antiviral therapy initiated as early as possible
    in patients with severe sepsis or septic shock of
    viral origin (grade 2C)
    Source control

    • When source control in a severely septic patient is required, the effective


    intervention associated with the least physiologic insult should be used (eg.
    percutaneous rather than surgical drainage of an abscess)

    • If intravascular access devices are a possible source of severe sepsis or septic


    shock, they should be removed promptly after other vascular access has
    been established
    Resuscitation
    • Crystalloids as the initial fluid of choice in the resuscitation of severe
    sepsis and septic shock (grade 1B)
    • Avoid Hetastarch or Hespan compounds (grade 1B)
    • Albumin in the fluid resuscitation of severe sepsis and septic shock
    when patients require substantial amounts of crystalloids (grade 2C)
    • Initial fluid challenge in patients with sepsis induced tissue
    hypoperfusion with suspicion of hypovolemia to achieve a minimum of
    30 mL/kg of crystalloids. More rapid administration and greater
    amounts of fluid may be needed in some patients (grade 1C)
    • Fluid challenge technique be applied where in fluid administration is
    continued as long as there is hemodynamic improvement
    Vasopressors

    • Vasopressor therapy initially


    to target a mean arterial
    pressure (MAP) of 65 mm Hg

    • Norepinephrine as the first


    choice vasopressor (grade 1B)

    • All patients requiring


    vasopressors have an arterial
    catheter placed as soon as
    practical if resources are
    available

    Arellano, Daniel L., and Sandra K. Hanneman. "Vasopressor weaning in patients with septic shock." Critical care nursing clinics of North America26.3
    (2014): 413-425.
    Catecholamine Sparing
    Strategies
    Vasopressors

    • First isolated ~ 1900


    • Catecholamines
    • Norepinephrine
    • Epinephrine
    • Dopamine
    • Non-catecholamines
    • Phenylephrine
    • Vasopressin/terlipressin
    • Angiotensin II (AT2)
    Adverse Effects of Catecholamines

    • Arrhythmias
    • Ischemia
    • Increased myocardial O2 demand
    • Hyperglycemia
    • Decreased cardiac output
    • Inflammation
    • Immunosuppression
    • Increased mortality??
    Corticosteroids
    • Indicated with persistent hemodynamic instability
    • Hydrocortisone 50mg IV every 6 hours. OR Hydrocortisone 100mg IV
    every 8 hours
    • DO NOT use the ACTH stimulation test (grade 2B)
    • In treated patients hydrocortisone, taper when vasopressors are no longer
    required
    • Corticosteroids not be administered for the treatment of sepsis in the
    absence of shock
    • Multiple studies have shown decreased time on vasopressors. No
    mortality benefit
    • Complications associated with steroids
    Vasopressin

    • VASST Trial
    • Evaluated vasopressin (AVP) versus norepinephrine (NE) effect on 28
    day mortality in septic shock
    • Multicenter, randomized, double-blind; N = 778
    • Stratified by baseline NE dose
    • No difference in primary outcome (35.4% vs. 39.3%) 28- day Mortality
    • Secondary outcomes: No difference in 90 day mortality, any organ
    dysfunction subgroup, or LOS
    • No difference in adverse effects

    • Conclusions▫ AVP significantly decreased NE doses at day 4 (p < 0.001)▫ AVP


    MAY improve mortality in patients with less severeshock
    ATHOS-3

    • Phase III trial evaluating AT2 for severe vasodilatory shock


    • Randomized, double-blind, multicenter, placebo controlled; May 2015-
    January 2017
    • N = 321
    • Purpose: to determine effectiveness of AT2 for vasodilatory shock resistant to
    high-dose vasopressors
    • Primary Outcome: MAP response 3 hours after start of infusion
    Angiotensin II

    • Good
     Effective vasopressor
     Catecholamine-sparing
     May provide benefit in certain populations
    • Bad
     Very limited published data in septic shock
     Concerning ADEs
    • Ugly
     $1800 per vial
    The resuscitation challenge
    Protocolized Care for Australasian Resuscitation The Protocolised
    Early Septic Shock in Sepsis Evaluation Management in
    (ProCESS) – 31 ED’s (ARISE) – 51 ED’s in Sepsis (ProMISe)
    in US Australia, New Zealand, Trial – 56 ED’s in the
    Finland, Hong Kong, UK
    Ireland
    ProMise, ProCess and ARISE Trials
    • Key points
    – Fluid administration similar in both control and experimental groups
    – Vasopressor use similar in both groups
    – Antibiotics administered similarly in both groups
    – Lactates obtained in both groups
    – Mortality rates (<20%) is not as common outside centers with well designed
    sepsis recognition/management programs
    • Problems – Antibiotics and fluids given in both control and experimental
    groups within 3 hours
    Take away Points

    • IF Patients are
    • identified early
    • Receive antibiotics EARLY
    • receive IVF EARLY
    • THEN ScvO2 and CVP monitoring does not seem to add a benefit
    • BUT EGDT with ScvO2 not really tested since resuscitation had
    already occurred
    Types of Fluids

    • Is normal saline normal?


    • Lactated Ringers vs normal
    saline – are they comparable?
    Setting Goals
    • Discuss goals of care and prognosis with patients
    and families (grade 1B)
    –Sepsis has a high mortality rate.
    Families should understand and
    recognize that determining what the
    patient’s wishes are may help dictate
    the aggressiveness of therapy
    • Incorporate goals of care into treatment and
    end-of-life care planning, utilizing palliative care
    principles where appropriate (grade 1B)
    • Address goals of care as early as feasible, but no
    later than within 72 hours of ICU admission
    (grade 2C)
    Questions?

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