actep2014: sepsis management has anything change
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Sepsis management: Has anything changed? - อ.นพ.กลวิชย์ ครองตระกูลTRANSCRIPT
Sepsis Management: Has anything changed ?
นพ.กลวิชย์ ตรองตระกูล หน่วยเวชบำบัดวิกฤต
ภาควิชาเวชศาสตร์ฉุกเฉิน คณะแพทยศาสตร์วชิรพยาบาล มหาวิทยาลัยนวมินทราธิราช
ACTEP @ เขาใหญ่, ๒๘ พฤศจิกายน ๒๕๕๗, ๐๘:๓๐-๐๙:๐๕ น.
1
Introductions• Pathophysiology of sepsis, severe sepsis and
septic shock
• What is new in septic shock resuscitation?
• Protocolized in resuscitation
• EGDT, CVP, MAP target, ScvO2, and blood transfusion threshold
• Type of fluid resuscitation
• Chloride base, HES, and albumin
2
Pathophysiology of Sepsis
Angus DC, et al. New Engl J Med 2013;369:840-51.
3
• T ≤ 36, ≥ 38 °C • HR ≥ 90 • RR ≥ 20, or PaCO2 < 32 mmHg • WBC ≥ 12,000 or ≤ 4,000 or >
10% immature WBC
Presence of organ dysfunction
Shock despite adequate fluid resuscitation
SIRS with presume/confirm infections
Sepsis with ≥ 1 sign of organ failure
(renal, respiratory, sepsis induce
hypotension, confusion)
MODs
Sepsis: Disease of continuum
Septic ShockSevere SepsisSepsisSIRS
Infection
Angus DC, et al. New Engl J Med 2013;369:840-51.
Relative hypovolemia
Peripheral vasodilatation
Myocardial suppression
Fluid Vasopressor
Inotrope
4
Oxygen Delivery
Cardiac Output (CO)
Heart
Lung
Vascular
RBC Oxy
gen
deliv
ery
Tissue
Oxygen in atm
X
Oxygen Content (CaO2)
Preload
Contractility
Afterload
Heart rate
Hemoglobin
Oxygen
Fluid
Vasopressor
Inotrope
FiO2
RBC txf
}
BP = CO x SVROxygen Consumption
5
การกู้ชีพเบื้องต้น (initial resuscitation) ในช่วง 6 ชั่วโมงแรกของภาวะภาวะติดเชื้อในกระแสโลหิตแบบรุนแรง (severe sepsis) และภาวะช็อกจากการติดเชื้อในกระแสโลหิต (septic shock) จากข้อแนะนำของ SSC 2012
1. ผู้ป่วยที่มีภาวะติดเชื้อในกระแสโลหิตที่ทำให้ความดันโลหิตต่ำ (sepsis-induced hypotension) หรือ แลกเตทในเลือดมากกว่าหรือเท่ากับ 4 มิลลิโมลต่อลิตร ควรได้รับ การกู้ชีพตามข้อกำหนดซึ่งวัดเป็นเชิงปริมาณได้ (protocolized, quantitative resuscitation) ได้แก่ ก) Central venous pressure 8 - 12 มิลลิเมตรปรอท ข) Mean arterial pressure (MAP) มากกว่าหรือเท่ากับ 65 มิลลิเมตรปรอท ค) ปัสสาวะออกมากกว่าหรือเท่ากับ 0.5 มิลลิลิตรต่อกิโลกรัมต่อชั่วโมง ง) Central venous oxygen saturation (ScvO2) หรือ mixed venous oxygen saturation (SvO2) มากกว่าร้อยละ 70 หรือ 65 ตามลำดับ (grade 1C)
2. ในผู้ป่วยที่มีระดับแลกเตทในเลือดสูง ควรให้การกู้ชีพจนค่าแลกเตทเข้าสู่ค่าปกติ (grade 2C)
6
Protocolized resuscitation
What is new ?
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Early Goal Directed Therapy Rivers, NEJM 2001
- 263 SS&SSh pts at ED in US randomised to EGDT vs standard therapy - Primary outcome: In hospital mortality
Fluid
Vasopressor
RBC
Inotrope
fluid 500 ml q 30 min crystalloid to achieve CVP 8-12 mmHgVasopressor if MAP <=65, vasodilator if MAP > 90DBT 25 mcg/kg/min, increased by 2.5 q 30 min until ScvO2 > 70 or max 20, decrease or stop if HR > 120 or MAP < 65
8
Increasing in Oxygen Demand
Normal condition
Increase demand co2
o2 o2
o2o2
o2 o2
o2co2
Oxygen delivery SaO2 = 100%
Venous Oxygen SvO2 = 75%
co
o2 o2
o2o2
o2 o2
co2
Oxygen delivery SaO2 = 100%
Venous Oxygen SvO2 = 50%
co
co2
9
Outcome
Early Goal-Direct Therapy in The Treatment of Severe Sepsis and Septic Shock (EGDT)
EGDT collaborative group, New Engl J Med 2001,345:1368-77.
- 263 SS&SSh pts at ED in US randomised to EGDT vs standard therapy - Primary outcome: In hospital mortality
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CVP is only 56% in predicting fluid responsiveness
Marik PE et al. Chest 2008;134:172-8.Osman et al. Crit Care Med 2007;35(1)
11
Limitation of EGDT
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Pace of Goal directed study
EGDT by Rivers
US 263
SS/SSh
EGDT 6 hr vs
usual Rx
In Hos MR
2001 2014 2014 2015
ProCESS
US 1351 SS/SSh
EGDT 6 hr vs
standard usual
Rx
60-MR
ARISE
ANZICs 1600
SS/SSh
EGDT 6 hr vs
usual Rx
90-MR
ProMISe
UK 1260
SS/SSh
EGDT 6 hr vs
usual Rx
90-MR
13
A Randomized Trial of Protocol-Based Care for Early Septic Shock (ProCESS study)
1341 patients, of whom 439 were randomly assigned to protocol-based EGDT,
446 to protocol-based standard therapy, and 456 to usual care
ProCESS Study. N Engl J Med 2014;370:1683-93.
Protocol-based standard therapy
No central line
SBP ≥ 100 mmHg
SI (HR/SBP) ≤ 0.8
HB ≥ 7.5 gm/dL
CVP ≥ 8-12 mmHg
MAP ≥ 65 mmHg
SCVO2 ≥ 70 mmHg
Hct ≥ 30 %
Early goal directed therapy
vs vs Usual Care
Usual care therapy
14
SI = HR/SBP
*Time Sensitive target
Time allowed7
Corrective action
Fluid bolus (500-1000 ml) 20 minutes 3rd IV or
central line
Initial fluid bolus (2L) 1 hour 3rd IV or
central line
SBP ≥ 100 mmHg 1 hour Vasopressors
-Fluid overload by clinical Dx: JVD, rales, drop in SpO2 -Definition of hypoperfusion: MAP < 65 despite SBP > 100, arterial lactate 4, mottled skin, oliguria and altered sensorium
15
A Randomized Trial of Protocol-Based Care for Early Septic Shock (ProCESS study)
ProCESS Study. N Engl J Med 2014;370:1683-93.
16
Goal-Directed Resuscitation for Patients with Early Septic Shock (ARISE trial)
• 1,600 enrolled pts, 796 were assigned to EGDT and 804 to usual care • Conducted at 51 enters (mostly in Australia or New Zealand, 3#care and not 3# care centre)
ARISE trial. N Engl J Med 2014;371:1496-506.
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Goal-Directed Resuscitation for Patients with Early Septic Shock (ARISE trial)
ARISE trial. N Engl J Med 2014;371:1496-506.
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Outcome of 3 protocolized studies
EGDT ProCESS ARISE ProMISe
Location US US ANZICs UK
Publications 2001 2014 2014 ~2015
Population 263 1351 1600 1260
Fluid before randomisatio
n
20-30 mL/kg 20 > 30 mL/kg 1000 ml 1000 ml
Hos MR 30.5 vs 46.5, p = 0.009
- - 90-day MR
28 day MR 33.3 vs 49.2, p = 0.01
- 14.8 vs 15.9, p = 0.53 (3°)
n/a
60 day MR 44.3 vs 56.9, p = 0.03
21.0 vs 18.0 vs & 18.9, p = 0.83
- n/a
90 day MR - 31.9 vs 30.8 vs 33.7, p =0.06
18.6 vs 18.8, p = 0.90 (1°)
n/a
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Baseline characteristic EGDT ProCESS ARISE
Location US US ANZICs
Age 67.1±17.4 vs 64.4±17.1
60±16.4 vs 62±16.0
62.7±16.4 vs 63.1±16.5
APACHE II 21.4±6.9 vs 20.4±7.4
20.8±8.1 vs 20.7±7.5
15.4±6.5 vs 15.8±6.5
Lactate 7.7±4.7 vs 6.9±4.5 4.8±3.1 vs 4.9±3.1 4.4±3.3 (6.7±3.3) vs 4.2±2.8 (6.6±2.8)
SBP 106±36 vs 109±34
100.2±28.1 vs 99.9±29.5
78.8±9.3 vs 79.6±8.4
Septic shock 54.7% vs 51.3% 55.6% vs 53.3 70% vs 69.8%
ScvO2 48.6±11.2 vs 49.2±13.3 71.±13 vs n/a 75.9±8.4 vs n/a
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High versus Low Blood-Pressure Target in Patients with Septic Shock (SEPSISPAM)
Outcome Low target (N=388)
High target (N=388)
P value
Death at day 28-no.(%) 132 (34.0) 142 (36.6) 0.57
Death at day 90-no.(%) 164 (42.3) 170 (43.8) 0.74
Doubling S cr 161 (41.5) 150 (38.5) 0.32
No HTN 71/215 (33.0) 85/221 (38.5) 0.32
HTN 90/173 (52.0) 65/167 (38.9) 0.02
RRT day 1- 7 139 (35.8) 130 (33.5) 0.50
No HTN 66/215 (30.7) 77/221 (34.8) 0.36
HTN 73/173 (42.2) 53/167 (31.7) 0.046
SEPSISPAM. N Engl J Med 2014; 370:1583-93.
P=0.57 at 28 days P=0.74 at 90 days
776 pts with SSh in France
Target: High 80-85 mmHg vs Low
65-70 mmHg x for 5 day/wean off
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Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock (TRISS study)
TRISS study. N Engl J Med 2014; 371:1381-91.
998 pts with SSh assigned to receive Leukoreduced PRC for different Hb threshold
in ICU ( 7 vs 9 g/dL)
Exclusion: ischemic heart disease, severe hypoxia, life-threatening bleeding, ischemia developed in the ICU, and ECMO
Primary outcome: death by 90 days
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Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock (TRISS study)
TRISS study. N Engl J Med 2014; 371:1381-91.
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Which vasopressors? Which inotropes?
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Comparison of Dopamine and Norepinephrine in the Treatment of Shock
• Which one agent is superior to the other? • Multicenter RCT in 1679 patients (MAP<70 or SBP<100)
• 858 were assigned to dopamine (20 mcg/kg/min) • 821 were assigned to norepinephrine (0.19 mcg/kg/min)
Mortality Rates
Backer DD. N Engl J Med 2010;362:779-89.
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Comparison of Dopamine and Norepinephrine in the Treatment of Shock
Backer DD. N Engl J Med 2010;362:779-89.
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“Fluid Strategy in Sepsis”
1. Early resuscitation 2. Maintenance fluid
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Fluid resuscitation why?
• Relative hypovolemia
• Arterial and venous dilatation and leakage of plasma to extravascular space
• Low SVR, increase CO2 production, tachycardia, and elevated oxygen concentration in PA = hyper-dynamic shock syndrome
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“Type of fluid using
in Sepsis”
Colloid vs Crystalloid
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Starling’s Law
Qf = net fluid filtration between compartment Kf = Capillary filtration coefficient Pcap = Capillary hydrostatic pressure
Pif = Interstitial hydrostatic pressure ơ = reflection coefficient ¶cap = Colloid osmotic pressure ¶if = Interstitial oncotic pressure
Qf = Kf [(Pcap - Pif) - ơ (¶cap-¶if)]
In Sepsis
• ↑ Pcap, ↓¶ cap = ↑ edema formation
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Resuscitation fluid. New Engl J Med 2013,369:1243-51.
A) Normal endothelial
glycocalyx (EG) layer
B) Damaged EG in sepsis etc.
C) Transvascular exchange
by Starling’s Law
c
Qf = Kf [(Pc - Pi) - ơ (¶c-¶i)]
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Basic fluid therapy
Intracellular 40% of BW
Extra cellular20% of BW
Intra vascu
lar5 % of
BW
Interstitial15 % of
BW
BP,HR,UOP,CVP
Thirst
skin tugor, mucosa
Osmotic (oncotic) and hydrostatic pressure
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33
Stages of volume status
Volu
me
stat
us
Time
Resu
scita
tion
Opt
imiz
atio
n
Stab
iliza
tion
Dees
cala
tion
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Ideal of fluid resuscitation• Predictable and sustained increase in intravascular
volume
• Chemical composition as close as possible to ECF
• Metabolized and completely excreted without accumulation in tissue
• Does not produce adverse metabolic or systemic effects
• Cost-effective in terms of improving outcomes
Resuscitation fluid. New Engl J Med 2013,369:1243-51.
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Normal saline: toxic to kidney? Chloride solutions may cause renal failure
• Chloride rich fluid (0.9% NSS, 4% gelatine, 4% albumin) vs Chloride restrictive fluids (chloride poor 20% albumin, Hartmann solution, Plasma-lyte 148)
• Serum Creatinine was higher in chloride rich fluid than chloride restriction
• 22.6 (17.5-27.7) vs 14.8 (9.8-19.9) umol/L; p=0.03
• Severity stage of AKI and RRT was lower in chloride restriction group than chloride rich fluid
JAMA 2012;308:1566-72.
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Abnormal saline !!
Renal replacement therapy in ICUAKI stage 2-3 by KDIGO definition
JAMA 2012;308:1566-72.
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Chloride and Kidney
KI 2014, doi:10.1038/ki.2014.105
38
Intensive Insulin therapy and Pentastarch Resuscitation in Severe Sepsis (VISEP study)
VISEP study, NJEM 2008,385:125-39.
-537 pts with SS in Germany, 18 ICU (Stopped early due to safety reason) -10% HES 200/0.5 vs Ringer lactate solution in pts with SS&SSh -Primary outcome: Death 28 days, Secondary outcome: AKI
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Intensive Insulin therapy and Pentastarch Resuscitation in Severe Sepsis (VISEP study)
VISEP study, NJEM 2008,385:125-39.
Outcome HES (N=262)
RLS (N=275) P value
Death at 28 days - no./total (%) 70/262 (26.7) 66/274 (24.1) 0.48
Death at 90 days - no./total (%) 107/261 (41.0) 93/274 (33.9) 0.09
Acute renal failure - no./total (%) 91/261(34.9) 62/272 (22.8) 0.002
RRT - no./total (%) 81/261 (31.0) 51/272 (18.8) 0.001
RBC transfusion - no./total (%) 199/262 (76.0) 189/275(68.7) 0.06
No. of RBC transfusion (unit) 6 (4-12) 4 (2-8) < 0.001
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Hydroxyethyl Starch 130/0.42 versus Ringer’s Acetate in Severe Sepsis (6S trials)
-798 pts with severe sepsis in Denmark Norway Finland and Iceland, 26 ICUs -6% HES 130/0.4 vs Ringer’s acetate throughout their illness -Primary outcome: Dead or need for dialysis at 90 days after randomization
6S trials, NJEM 2012.
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Hydroxyethyl Starch 130/0.42 versus Ringer’s Acetate in Severe Sepsis (6S trials)
6S trials, NJEM 2012.
Outcome HES (N=398)
RA (N=400)
Relative risk (95%CI)
P value
Dead or dependent on dialysis at day 90 - no. (%)
202 (51) 173 (43) 1.17 (1.01-1.36)
0.03
Dead at day 90 - no. (%) 201 (51) 172 (43) 1.17 (1.01-1.36)
0.03
Dependent on dialysis at day 90 - no.(%)
1 (0.25) 1 (0.25) - 1.00
Use RRT - no. (%) 87 (22) 65 (16) 1.35 (1.01-1.80)
0.004
Doubling creatinine level - no. (%)
148 (41) 127 (35) 1.18 (0.98-1.43)
0.08
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Hydroxyethyl Starch or Saline for Fluid Resuscitation in Intensive Care (CHEST trials)
CHEST Trail, NJEM 2012,367:1901-11.
-7000 pts admitted to ICU in Australia & New Zealand -6% HES 130/0.4 vs 0.9% NaCl for fluid resuscitation until D/C -Primary outcome: Death, secondary outcome: AKI-I & F and RRT
43
Hydroxyethyl Starch or Saline for Fluid Resuscitation in Intensive Care (CHEST trials)
CHEST Trail, NJEM 2012,367:1901-11.
Outcome HES Saline RR (95%CI) P value
Death at day 90 - no.total no. (%)
597/3315 (18.0) 566/3336 (17.0) 1.06 (0.96-1.18) 0.26
Renal outcome
RIFLE-R 1788/3309 (54.0) 1912/3335 (57.3) 0.94 (0.90-0.98) 0.007
RIFLE-I 1130/3265 (34.6) 1253/3300 (38.0) 0.91 (0.85-0.97) 0.005
RIFLE-F 336/3243 (10.4) 301/3263 (9.2) 1.12 (0.97-1.3) 0.12
Use RRT 235/3352 (7.0) 196/3375 (5.8) 1.21 (1.00-1.45) 0.04
-7000 pts admitted to ICU in Australia & New Zealand -6% HES 130/0.4 vs 0.9% NaCl for fluid resuscitation until D/C -Primary outcome: Death, secondary outcome: AKI-I & F and RRT
44
HES increased AKI in Sepsis/septic shock
Trial VISEP study 6S Trial CHEST Trial CRYSTMAS study
Intervention 10%HES 200/0.5 vs RLS
6%HES 130/0.42 vs RA
6%HES 130/0.4 vs 0.9%NSS
0.6%HES130/0.4 vs 0.9%NSS
Population 537 pts with Severe sepsis
798 pts with Severe sepsis in ICUs
7000 pts within ICU (fluid ressus)
196 pts with Severe sepsis
Outcome Death at 28 days Death or ESKD at 90 days Death within 90 days Volume and time to
reach HDS
Results81/261 (31%) vs 51/272 (18%),
p 0.001
201/398 (51%) vs 172/400 (43%),
p = 0.03
Death Not significant, RRT 235/3352 (7%) vs
196/3375 (5.8%), p = 0.04
Less HES volume was used to reach HDS vs
NSS AKI 24.5% vs 20%,
p = 0.454
Conclusion HES was harmful, increased risk of AKI
HES increased risk of death and RRT HES increased RRT Less volume to reach
HDS by HES vs NSS
Journal NEJM2008;358:125-39. NEJM2012;367:124-34. NEJM2012;367:1901-11. Crit Care2012;16:R94.
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A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit (SAFE study)
: There were 726 deaths in the albumin group as compared with 729 deaths in the saline group at 28 days
SAFE study. N Engl J Med 2004;350:2247-56.
Outcome Albumin Saline RR (95%CI)
P value
Status at 28 days - no./total (%)
Dead 726/3473 (20.9)
729/3460 (21.1)
0.99 (0.91-1.09) 0.87
Alive in ICU
111/3473 (3.2)
87/3460 (2.5)
1.27 (0.96-1.68) 0.09
Alive in hosital
793/3473 (22.8)
848/3460 (24.5)
0.93 (0.86-1.01) 0.10
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A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit (SAFE study)
: There were 726 deaths in the albumin group as compared with 729 deaths in the saline group at 28 days
SAFE study. N Engl J Med 2004;350:2247-56.
47
Albumin Replacement in Patients with Severe Sepsis or Septic Shock (ALBIOS study)
ALBIOS study. N Engl J Med 2014;370:1412-21.
1121 patients with septic shock showed significantly lower mortality at 90 days in the albumin group than in the crystalloid group.
In albumin group • Greater proportion reached the targeted
MAP within 6 hours • During the first 7 days, higher MAP,
whereas lower HR and net fluid balance
-1818 pts with SS admitted to 100 ICU in Italy -20% Albumin and crystalloid vs crystalloid alone (keep Alb>3g/dL until D/C) -Primary outcome: Death from any cause at 28 days
48
Saline or Albumin for Fluid Resuscitation in Patients with Traumatic Brain Injury (SAFE TBI)
SAFE TBI study. N Engl J Med 2007;357:874-84.
-460 pts with traumatic brain injury (Hx of HI, CT +ve, GCS ≤ 13) -4% Albumin and crystalloid vs crystalloid alone (keep Alb>3g/dL until D/C) -Outcome: Death from any cause at 28 days and 2 years
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Fluid summaryTable 1
Benefits Risks
Saline Less expensiveHypercholemic metabolic
acidosis
Albumin Colloids of choiceExpensive
Increase mortality in TBI
Gelatins Less expensive Hypersensitivity
Hydroxyethyl strach Less expensiveAcute kidney injury
Coagulopathy
Balance salt solution ?? ???
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Fluid therapy of Severe Sepsis
Hemodynamic support and adjunctive therapy,Surviving Sepsis Campaign 2012
1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).
2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B)
3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients required substantial amounts of crystalloids (grade 2C)
4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid may be needed in some patients (grade1C)
51
Amount of fluid comparison from 3 studies
Total fluid EGDT ProCESS ARISE
Pre hosp n/a2,254±1,472 vs
2,083±1,4052,515±1,244 vs 2,591±1,331
0-6 hr 4,981±2,984 vs 3,349±2,438
2,805±1,957 vs
2,279±1,8811,964±1,415 vs 1,713±1,401
6-72 hr 8,625±5,162 vs 10,602±6,216
4,458±3,878 vs
4,354±3,8824,274±3,071 vs 4,382±3,136
0 - 72 hr 13,443±6,390 vs 13,358±7,729
7,253±4,605 vs
6,633±4,560n/a vs n/a
52
Maintenance fluid
53
Comparison of Two Fluid Management Strategies in Acute Lung Injury (ARDS Clinical Trails Network)
Data from 1000 patients with ALI with seven days fluid protocol
Fluid accumulation in 7 days 6992±502 ml vs -136±491ml
(P<0.001)
ARDS Clinical Trial Network. New Engl J Med 2006;354:2564-75.
CONCLUSIONSNo significant difference in 60-day mortality. However CONSERVATIVE strategy of fluid improved lung function and shortened duration of mechanical ventilation and ICU without increasing non-pulmonary organ failure.
54
Acute inflammatory insult
Ebb phase
Organ dysfunction
Established Acute lung injury
Coexisting condition
Identify and treatment
Flow phase
Recovery
Impaired fluid mobilization
Rivers EP. N Engl J Med 2006;354:2598-600.
Goal in resuscitation in first 6 hr Diuretic
UltrafiltrationHemofiltration
Measure Fluid
responsiveness
Conservative fluid Mx
Fluid management in ALICerda J et al. Blood Purif 2010:29:331-8.
55
ยังต้องทำ EGDT ตาม protocol ของ Rivers ใน SS/SSh หรือไม่ ?
56
JAMA 2010;303:739-46.
Lactate clearance vs central venous oxygen saturation as Goals of Early Sepsis Therapy
ScvO2 > 70% vs lactate clearance at least 10% within 6 hr
% D
eath
0
10
20
30
ScvO2 Lactate
17
23
Observed difference between mortality rates did not reach
the predefined -10% threshold
57
-Surviving Sepsis Campaign 2012-
“Conservative fluid management and keep adequate tissue perfusion”
“Initial protocolized, quantitative fluid resuscitation during the first 6 hours”
58
Key concepts in shock resuscitation
• Early recognition of sepsis syndrome
• Control source of infection
• Appropriate antibiotic and timing of antimicrobial administration
• Early resuscitation with intravenous fluids and vasoactive drugs
59
Effective antimicrobial initiation and survival association
each hour of delay in initiation of effective antimicrobial was associated with mean decrease in survival of 7.6%
60
Sepsis supportive therapyFluid restriction
Nutritional support DVT prophylaxis
Source of Infectious control
De-escalate antibiotic
Glucose control
Restricted blood transfusion
Stress ulcer prophylaxisMechanical ventilation support
Sedation, analgesia, NMBA Renal replacement therapy
61
Conclusion• Continuous ScvO2 monitoring
• +/- Central venous pressure
• Target in mean arterial pressure over 65 mmHg, and keep higher in chronic hypertension
• Hb less than 7 g/dL is the trigger threshold
• Noradrenaline is the vasopressor of choice
• Crystalloid is the fluid of choice
• Early effective antibiotic (within 1 hour)
62
SI = HR/SBP
*Time Sensitive target
Time allowed7
Corrective action
Fluid bolus (500-1000 ml) 20 minutes 3rd IV or
central line
Initial fluid bolus (2L) 1 hour 3rd IV or
central line
SBP ≥ 100 mmHg 1 hour Vasopressors
-Fluid overload by clinical Dx: JVD, rales, drop in SpO2 -Definition of hypoperfusion: MAP < 65 despite SBP > 100, arterial lactate 4, mottled skin, oliguria and altered sensorium
63