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