SEPTIC SHOCK AND MULTIORGAN FAILURE

DEFINITIONS: 2SEPSIS: SIRS + evidence of infection SEVERE SEPSIS: sepsis + evidence of organ dysfunction SEPTIC SHOCK: sepsis + systolic BP < 90 after adequate volume replacement... A

SEPTIC SHOCK A ND MULTIORGA N FA ILURE

RECOMMENDATIONS FROM THE SURVIVING SEPSIS CAMPAIGN

(Crit Care Med 2008; 36:296-327)

Joe Heit, MSc, MD, FA CP

DEFINITIONS: 2

SEPSIS: SIRS + evidence of infection

SEVERE SEPSIS: sepsis + evidence of

organ dysfunction

SEPTIC SHOCK: sepsis + systolic

BP < 90 after adequate

volume replacement

DEFINITIONS: 3

MULTIORGAN FAILURE (MOF)

Evidence of dysfunction in more than one organ No universally recognized parameters, but the following

markers utilized often.

MA NA GEMENT

(SURVIVING SEPSIS CAMPAIGN GUIDELINES)

• Early goal directed therapy (first 6 hours)

• Diagnosis

• Antibiotics

• Source - identify and control measures

• Supportive strategies

EA RLY GOA L DIRECTED

THERA PY

Low blood pressure = Shock

EGDT: Resuscitation for

EGDT: resuscitation

(within the first 6 hours)

• Fluids can be crystalloids or colloids

– No evidence to prefer either choice

– Generally 1000cc NS or 300-500 cc colloids

• Transfuse to hematocrit of 30%

– Only within the first 6 hours

• Consider dobutamine if inadequate response to the above interventions

DIA GNOSIS

• Appropriate cultures

– Include cultures from any intravascular devices if present for > 48 hours (timed if possible)

– At least 2 blood cultures

• Imaging studies as clinically indicated

A NTIBIOTICS

• First challenge is to get appropriate cultures

• Second challenge is to balance these 2:

1 Initiation of antibiotics that are broad enough and effective

enough (mortality cost if initial antibiotics are not active enough against pathogens)

2 Avoidance of unnecessarily broad and unnecessary numbers of

antibiotics

• Third challenge is to deescalate antibiotics as soon as

appropriate (usually after culture results)

• Fourth challenge is to avoid continuing antibiotics too

long (generally stop after 7-10 days)

SOURCE CONTROL

•4 D’s

–Drainage (chest, abdomen, joints)

–Debridement (devitalized/infected tissue)

–Device Removal (IV, urinary catheters, shunts, any foreign body)

–Definitive control (usually means surgical resection)

•Adequate vascular access

•Administer to goals - CVP, MAP, urine output

•We usually underestimate volume needed

–Remember EGDT recommendations

•FCCS guidelines allow administering fluids until something

good (meeting targets as above) or something bad (hypoxia starts

or worsens or chest exam worsens)

•Auto transfuse by lifting legs an quick, reversible way to give a

‘colloid’ challenge

V A SOPRESSORS

When adequate fluids are not enough.When early transfusion is not enough.Even when dobutamine is not enough

When all else fails,

VASOPRESSORS!

V A SOPRESSORS

•First concern - adequate IV access; the risk and possible

diminished effectiveness of peripheral access for administration makes central access a priority

•Second concern - Know which receptors you’re stimulating

with which drug

–SSC guidelines recommend dopamine or norepinephrine as first line vasopressors for septic shock

–Vasopressin as a second line agent

–Epinephrine as a second line agent

–Neosynephrine as a third line agent

V A SOPRESSORS

•Target MAP 65 mm Hg or greater

•Target should also be improved end organ function and drop

in serum lactate

central line, arterial line

Short answers:

•No proven mortality benefit for steroids in septic shock or MOF (CORTICUS study)

•Mortality cost for high dose steroids in septic shock

•Acceptable to utilize stress dose steroids (150-300 mg/day of hydrocortisone if shock not responsive to all other

interventions

•ACTH stimulation tests should not be used

GLY CEMIC CONTROL

•Recommend Insulin to maintain glucose at < 150mg/dl

Optimal range for control not known

Optimal protocol for glycemic control not established

Only randomized control trial that showed decreased mortality with

tight control was in Cardiovascular surgery patients

Only RCT in a Medical ICU showed no decreased mortality with

tight glycemic control, but there was a morbidity benefit and a lower LOS in the ICU and hospitalization

There was a mortality benefit with tight glycemic control I several

non-randomized trials

GLY CEMIC CONTROL

Cautions with tight glycemic control:

 Increased mortality with hypoglycemic events

 Fingerstick methods of glucose measurement

(point of care testing) may overestimate actual blood glucose levels

GI PROPHY LA X IS

Recommendations are:

 All critically ill patients should receive GI

prophylaxis

 H-2 blockers first line

 Proton pump inhibitors second line

 Sulcrafate less effective than H-2 blockers or PPI

DV T PROPHY LA X IS

Recommendations are:

All patients with severe sepsis receive DVT

prophylaxis

•UFH or LMWH appropriately dosed

Mechanical compression devices used if UFH or

LMWH contraindicated

RENA L REPLA CEMENT

Recommendations are:

No evidence of a mortality benefit when CRRT

compared to HD in this patient population

Some studies suggested that fluid management was

improved with CRRT

RECOMBINA NT HUMA N

A CTIV A TED PROTEIN C

Recommendations are:

Use in patients with MOF and/or APACHE II score >25

• 3 large trials (PROWESS, ADDRESS, ENHANCE)

• A RCT currently underway in Europe of rhAPC v placebo

• Bleeding risk

BLOOD PRODUCT

A DMINISTRA TION

Recommendations are:

Maintain Hgb 7-9 g/dl

•No mortality benefit with higher Hgb (10-12)

•Accumulating evidence of increased morbidity (nosocomial infection) with blood product administration

Erythropoietin not be used in these patients unless anemia

secondary to other causes that have EPO indications (e.g Renal failure)

Use FFP to correct bleeding or if planned procedures with

bleeding risk, NOT solely to correct elevated INR

THESE STEPS Y OU CA N

INSTITUTE …

TOMORROW