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F*Ckin’ Process
trial
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Our first 15,000
Severe Sepsis Patients
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The old days…
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60
Hospitals
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Recognition
Treatment
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0%
10%
20%
30%
40%
50%
Jan-‐11 Feb-‐11 Mar-‐11 Apr-‐11 May-‐11 Jun-‐11 Jul-‐11 Aug-‐11 Sep-‐11 Oct-‐11 Nov-‐11 Dec-‐11 Jan-‐12 Feb-‐12 Mar-‐12 Apr-‐12 May-‐12 Jun-‐12 Jul-‐12 Aug-‐12 Sep-‐12
* N = 9,133
January 2011 41%
September2012 19%
January 2012 27%
22% ARR of In-Patient Mortality
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How’d We Do It?
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We really didn’t do
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Ok there was some of
stuff…
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Administrative Buy-In
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Recognition
Treatment
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Recognition
Treatment
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They’re Not Looking!
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Occult or Cryptogenic
Severe Sepsis
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Triage Screen
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Lactate
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Lactate or
Persistent Hypotension
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Turnaround <
30 Minutes
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Panic Value if
≥ 4
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Why are more lactates a good
thing?
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How do Severe Sepsis Patients Die?
Time
Stability
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Denominator Shift
Crit Care 2010;14:R77
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Pneumonia 14% Severe Sepsis 40%
Pre-Lactate Screen
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Pneumonia 8% Severe Sepsis 30%
Post-Lactate Screen
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What did they do after they found them?
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Recognition
Treatment
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Treat the Source Perfuse the Tissues
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Early Abx Source Control
Don’t box ‘em with the tube A Wee bit of Fluid
Pressors
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Early Antibiotics
Kumar et al. & Gaieski et al.
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Individual Hospital Empiric
Guidelines
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Immediate Availability
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Source Control
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“He’s too sick to intervene”
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Arterial Oxygen Saturation
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How not to kill septic patients
while intubating
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Responsiveness
Volume?
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Empirically Gave 2-3
Liters
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SWEAR ON YOUR
PATIENT’S LIFE
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2nd Lactate?
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Recognition
Treatment
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0%
10%
20%
30%
40%
50%
Jan-‐11 Feb-‐11 Mar-‐11 Apr-‐11 May-‐11 Jun-‐11 Jul-‐11 Aug-‐11 Sep-‐11 Oct-‐11 Nov-‐11 Dec-‐11 Jan-‐12 Feb-‐12 Mar-‐12 Apr-‐12 May-‐12 Jun-‐12 Jul-‐12 Aug-‐12 Sep-‐12
* N = 9,133
January 2011 41%
September2012 19%
January 2012 27%
22% ARR of In-Patient Mortality
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ARISE ProCESS ProMISe
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Gain from Sepsis Interventions
Easy Crap
Mental Masturbation
95%
5%
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5%
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FOAMcc
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Fluids Vasopressors
Endpoints
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Hemodynamics
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Plumber’s
Approach
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Hemodynamic Resuscitation
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EGDT
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Fluids
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Debate
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Give everyone two liters of…
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Balanced Crystalloid
Ann Surg. 2012 May;255(5):821-9 JAMA. 2012 Oct 17;308(15):1566-72)
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HIP
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Give 1 (or max 2)
liter(s) more
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Tense the Tank
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Critical Care 2007, 11(Suppl 2):P37 Crit Care Med 2011;39(4):689-94 Critical Care 2010, 14:R142 Crit Care Med. 2012;40(12):3146-3153 Crit Care Med. 2013 Jan;41(1):143-50
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Peripheral Pressor
Administration Crit Care Med. 2013 Sep;41(9):2108-15
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First 24 hrs: Think you Need
Additional Fluid?
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Volume Loading by SV
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After First 24 hrs:
Better have a think about it
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Microcirculatory Resuscitation?
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Glycocalyx
?
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Goals
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MAP > 65 CI > 2.2 (2.5)
Microcirc Goals?
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ScvO2
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2nd Lactate?
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Lack of Prognostic Value of Lactate Clearance in a Center with a Severe
Sepsis Protocol
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199 patients received aggressive monitored severe sepsis care.
39 patients expired during their hospital course
(18% mortality)
The mean arrival lactate was 4.8 (± 3.0) in the survivors compared to 7.3 (± 4.4) in those patients
who died (p<0.0001).
Lactates ≥4 were significantly associated with increased mortality (p<0.05).
However, the patients who achieved lactate
clearance did not have significantly improved survival when compared to those patients in
whom clearance was not achieved (p=.60).
In addition, patients with rebound in lactate ≥4, after initial clearance, showed a 10-fold increase
in mortality (p<.05).
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If you are already doing the good stuff, clearance doesn’t
matter--unless they rebound…
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May not be applicable to places without a team that wants to care about these
patients
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emcrit.org/smacc
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The old days…
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Gain from Sepsis Interventions
Easy Crap
Mental Masturbation
95%
5%
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5%
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Stop Sepsis Deaths
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You don’t need to do a whole lot of
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You just need to give a
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