sepsis care in 2015
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Sepsis Care in 2015
Salim R. Rezaie, MDUTHSCSA, San Antonio, TX
Twitter: @srrezaie
Email: srrezaie@gmail.com
No
Financial
Disclosures
Objectives
BP
Target
Hb
Transfusion
Threshold
SIRS
Screening
CVP
MAP
ScvO2
<8 mmHg
<65mmHg
<70%
IVF
Pressors
PRBCs
Surviving Sepsis Campaign
MAP ≥65 mmHg
Level 1C Rec
LeDoux D et al.
Crit Care Med 2000
Bourgoin A et al.
Crit Care Med 2005
10 Patients
28 Patients
MAP
65mmHg
75mmHg
85mmHg
Lactate
Renal Fxn
UOP
Dunser MW et al.
Crit Care Med 2009274 Patients
MAP
<75mmHg
Increased
Renal
Replacement
Therapy
MAP
<60mmHg
Increased
Mortality 3x
Does a Higher MAP Decrease
Renal Failure in Sepsis?
29 Centers in France
with 776 Patients
Low Target
Group
MAP
65 – 70 mmHg
High Target
Group
MAP
80 – 85 mmHg
Difference
NO
Difference
28 or 90 Day
Mortality
28 Day Survival
w/o Organ Support
More
Atrial
Fibrillation
Longer
Pressor
Duration &
Dose
3L IVF in 24h
then
Pressors
Mortality = 34 – 36.6%
Don’t Chase
MAP ≥65mmHg
Bottom Line
Give Fluids
Early
CVP
MAP
ScvO2
<8 mmHg
<65mmHg
<70%
IVF
Pressors
PRBCs
Surviving Sepsis Campaign
Maintain Hct ≥30%
Hb ≤7g/dL
Level 1B Rec
Liberal Transfusion Harms
Hebert PC et al.
NEJM 1999838 Patients
Liberal Transfusion Benefits
Vincent JL et al.
Anesthesiology 20081,040 Patients
Park DW et al.
Crit Care Med 2012407 Patients
Does a Liberal Transfusion Strategy
Improve Mortality in Sepsis?
32 Centers in Europe
with 998 Patients
Transfusion
Requirements
In
Septic Shock
(TRISS)
Liberal
Transfusion
Hb ≤9g/dL
Restrictive
Transfusion
Hb ≤7g/dL
50% Less
Transfusions
36% No
Transfusions
No 90 Day Mortality Difference
Acute
Myocardial
Infarction
Excluded
Chatterjee S et al.
JAMA Intern Med 2013
+
Increased All-Cause Mortality
18.2% vs 10.2%
Bottom Line
Use A
Restrictive
Transfusion
Strategy
Infection SIRS
Sepsis
Severe
Sepsis
Septic
Shock
Pancreatitis
Burns
Trauma
Other
Severe Sepsis
Infection Organ
Dysfunction>2 SIRS
Criteria
1992
How Good is SIRS at Screening for
Severe Sepsis?
172 ICUs in Australia
& New Zealand
With 109,663 Patients
SIRS + SIRS -
87.9% 12.1%
Will Miss
1 in 8
Severe Sepsis
SIRS Criteria Screening
13% Incremental
Increase
Bottom Line
≥2 SIRS Criteria
Lacks Sensitivity
& Specificity for
Sepsis
ProCESS
ARISE
ProMISe
ProCESS ARISE ProMISe
Country
Patients
Primary
Outcome
1351 12601600
60d
Mortality
90d
Mortality
90d
Mortality
Before Randomization…
A B CThen Followed for 1st 6 Hours
The ProCESS Trial
Trust the ProCESS
21% 18.2% 18.9%
EGDT Usual
IVF
Pressors
CVC
PRBC
4.9L 3.5L
27.4% 30.3%
Mandatory Mandatory
64.1% 18.5%
Rivers Study 1999
ProCESS
EGDT Protocol Usual
IVF
Pressors
CVC
PRBC
5.0L 5.5L 4.4L
54% 52% 44%
93% 56% 57%
14.4% 8.3% 7.5%
Flexibility in Management
Feasibility in the Community
Mostly
University EDs
The ARISE Trial
18.6% 18.8%
ARISE
EGDT Pragmatic
IVF
Pressors
CVC
PRBC
1.96L 1.71L
66.6% 57.8%
90% 61.9%
13.6% 7.0%
ARISE
A-Lines 91% 76%
Community/Rural
Intravenous Fluids
3 – 4.5 L
in
1st 6 Hours
2001 Rivers Study Mortality
47 31% (NNT = 6)
Sepsis Trilogy Mortality
18.2 – 29.5%
The ProMISe Trial
29.5% 29.2%
ProMISe
EGDT Usual
IVF
Pressors
CVC
PRBC
2.23L 2.02L
53.3% 46.6%
92.1% 50.9%
8.8% 3.8%
ProMISE
A-Lines 74.2% 62.2%
Nail in the Coffin for EGDT?
>10 Years
Later…
EGDT Usual Care
The Gap
Sepsis Care 2015
CVP
ScvO2
Surviving Sepsis Campaign
Updates 6 Hour Bundle
Surviving Sepsis Campaign
1. Check Lactic Acid
2. Send Blood Cultures
3. Give Antibiotics
4. 30mL/kg IVF (if low BP/High Lactate)
Within 3 Hours…..
Surviving Sepsis Campaign
1. Vasopressors if MAP <65mmHg
2. Re-assess Volume Status & Tissue Perfusion
3. Re-Check Lactic Acid (Unless Initially Normal)
Within 6 Hours…..
CVP ScvO2 Cardiac US Passive Leg Raise
MAP ≥65 mmHg
Give Fluids
Early
Restrictive
Transfusion
Hb ≤7g/dL
SIRS Criteria
Poor SensitivityAnd
Finally…
Miss 1 in 8
EARLY
Recognition IVF Antibiotics
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