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SEPSIS Y
   TRAUMA
GUILLERMO ORTIZ RUIZ M.D.
Unidad de Cuidado Intensivo
 HOSPITAL SANTA CLARA
SEPSIS Y TRAUMA
• ASOCIACIÓN ENTRE SEPSIS Y
  TRAUMA
• DIAGNÓSTICO DE SEPSIS EN EL
  PACIENTE CON TRAUMA.
• TERAPIAS ACTUALES EN SEPSIS.
• ABORDAJE FUTURO DEL PACIENTE
  SÉPTICO
Sepsis y Trauma
Sepsis y Trauma
• 199 UNIDADES,24 PAISES
• DURACION:DOS SEMANAS
• 3147 PACIENTES-1177 CON SEPSIS
• MORTALIDAD EN UCI 27% CON
  SEPSIS VS 14% SIN SEPSIS

• MORTALIDAD HOSPITALARIA 36%
  CON SEPSIS VS 17% SIN SEPSIS
Sepsis y Trauma
Sepsis y Trauma
Bacterial Translocation across Microvilli
     and How It Spreads into the
              Bloodstream
Sepsis y Trauma
Sepsis y Trauma
Sepsis y Trauma
• POLIMORFISMO DE IL-6
Sepsis y Trauma
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Sepsis y Trauma
Hypermetabolic Response to
           Stress—Cause




Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
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LIST OF THERAPIES CURRENTLY AVALAIBLE
FOR EVENTUALLY TREATING SEVERE SEPSIS
2/4 SIRS,
                                                    PAS<90

                           Terapia                                 Terapia “temprana”
                                                  263 Pacientes   dirigida por objetivos
                           estándar

                                                                        PVC >8-12
                                                 Golden hour          PAM >65 mm Hg
                                                                       GU >0.5 mlK/h
                                                                        SvO2 > 70%
                           PVC >8-12
                         PAM >65 mm Hg
                         GU >0.5 ML/K/H
                                                      6h                 SaO2 >93%
                                                                          Hcto >30%
                                                                       Indice cardíaco
                                                                             VO2




                                            Reducción de
% Mortalidad a 28 dias




                                                            15.9%       NNT : 6
                                            Riesgo absoluto



                                  49.2

                                          33.3
Sepsis y Trauma
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Sepsis y Trauma
Colloids versus crystalloids for fluid resuscitation
             in critically ill patients
        Alderson P, Schierhout G, Roberts I, Bunn F



     The Cochrane Library, Issue 1, 2003. Oxford
Sepsis y Trauma
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Sepsis y Trauma
Feb 2, 2000
    Tratamiento intensivo con insulina, glucosa entre 80mg/dl y 110 mg/dl




    Tratamiento convencional con insulina, glucosa entre 180mg/dl y 200 mg/dl solo si glucosa >215mg/dl

    1548 ptes                     8.0%



                                                                RRA 3.4% = NNT 29
            % Mortalidad




                                                  4.6%
                                 85/783


                                                 55/765        Reducción de la Mortalidad general 34%
                                                               •DOM
                                                               •Foco séptico probado
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Sitios de infección
Jul 1998




       96h                  28d   90d                                     2.5a
1690 ptes                         30.8%


                                                      RRA 6.1% = NNT 16
             % Mortalidad




                                            24.7%


                                  259/840


                                            210/850
Sepsis y Trauma
N     (APC)   Placebo
 GRAL                                            1690        24.7   30.8
3-19                                                  433    15.1   12.1
20-25                                                 440    22.5   25.7
26-29                                                 366    23.5   35.8
30-53                                                 451    38.1   49.0

        0.5    0.6 0.7 0.8 0.9 1   1.25      1.67 2
              Riesgo relativo de muerte ( CI 95% )
Sepsis y Trauma
Is Drotrecogin Alfa
(Activated) Safe and
Effective For Surgical
       Patients?
Determination of the Surgical
              Cohort       Non-surgical
 PROWESS                   1690            1158
                                                  1216 (72%)
Selection Cohort       532 (31.5%)         58

Surgical Cohort        474 (28.0%)



       Xigris 228 (48.1)          Placebo 246 (51.9%)
Primary Source of Infection
              by Surgical Status
                                Surgical                    Non-surgical
                                   N=468                         N=1,117

                                    n (%)                            n (%)
Lung                            95 (20.3)                         790 (67.5)            p<0.001


Intra-abdominal               295 (63.0)                            68 (5.8)            p<0.001


Urinary                         23 (4.9)                         179 (15.3)             p<0.001




    Note: Source of infection determined by the PROWESS Surgical Evaluation Committee

                                                                              .
DrotAA was Associated with Increased Survival in
     Both Surgical and Non-surgical Patients
                               Surgical Patients                                Non-surgical Patients
               100                                                  100
                                            DrotAA, n=1230                                 rhAPC, n = 1995
                                            Placebo, n = 274                               Placebo, n = 566
                    95                                               95
Survival Rate (%)




                    90                                               90

                    85                                               85

                    80                                               80

                    75                                               75

                    70                                               70

                         0      7      14         21           28          0       7      14       21         28
                                     Days                                                Days

                             28-day mortality                                     28-day mortality
                             Surgical patients                                  Non-surgical patients
                                                                          Placebo = 30.9% vs. DrotAA = 24.4%
  Placebo = 30.7% vs. DrotAA = 26.3%
Prevention of infection in multiple trauma patients by high-
            dose intravenous immunoglobulins
                         [Feature Articles]

Douzinas, Emmanuel E. MD; Pitaridis, Marinos T. MD; Louris, George
MD; Andrianakis, Ilias MD; Katsouyanni, Klea DrMedSc; Karmpaliotis,
  Dimitrios MD; Economidou, Joanna MD; Sfyras, Dimitrios MD;
                      Roussos, Charis MD, PhD


      Volume 28(1)        January 2000        pp 8-15
• MORTALIDAD

• DÍAS EN CUIDADOS INTENSIVOS

• DÍAS EN VENTILACIÓN MECÁNICA
Sepsis y Trauma
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CONCLUSIONES
• ASOCIACIÓN TRAUMA Y SEPSIS-
  ANÁLISIS TEMPORAL DEL SIRS.
• DIFICULTAD DIANÓSTICA DE LA
  INFECCIÓN EN TRAUMA.
• VENTAJAS DE LA IMPLEMENTACIÓN
  DE TERAPIAS ACTUALES.
• FUTURO-ESTRATIFICACION DE LA
  INFECCIÓN.
Sepsis y Trauma

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Sepsis y Trauma

  • 1. SEPSIS Y TRAUMA GUILLERMO ORTIZ RUIZ M.D. Unidad de Cuidado Intensivo HOSPITAL SANTA CLARA
  • 2. SEPSIS Y TRAUMA • ASOCIACIÓN ENTRE SEPSIS Y TRAUMA • DIAGNÓSTICO DE SEPSIS EN EL PACIENTE CON TRAUMA. • TERAPIAS ACTUALES EN SEPSIS. • ABORDAJE FUTURO DEL PACIENTE SÉPTICO
  • 5. • 199 UNIDADES,24 PAISES • DURACION:DOS SEMANAS • 3147 PACIENTES-1177 CON SEPSIS
  • 6. • MORTALIDAD EN UCI 27% CON SEPSIS VS 14% SIN SEPSIS • MORTALIDAD HOSPITALARIA 36% CON SEPSIS VS 17% SIN SEPSIS
  • 9. Bacterial Translocation across Microvilli and How It Spreads into the Bloodstream
  • 20. Hypermetabolic Response to Stress—Cause Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
  • 33. LIST OF THERAPIES CURRENTLY AVALAIBLE FOR EVENTUALLY TREATING SEVERE SEPSIS
  • 34. 2/4 SIRS, PAS<90 Terapia Terapia “temprana” 263 Pacientes dirigida por objetivos estándar PVC >8-12 Golden hour PAM >65 mm Hg GU >0.5 mlK/h SvO2 > 70% PVC >8-12 PAM >65 mm Hg GU >0.5 ML/K/H 6h SaO2 >93% Hcto >30% Indice cardíaco VO2 Reducción de % Mortalidad a 28 dias 15.9% NNT : 6 Riesgo absoluto 49.2 33.3
  • 38. Colloids versus crystalloids for fluid resuscitation in critically ill patients Alderson P, Schierhout G, Roberts I, Bunn F The Cochrane Library, Issue 1, 2003. Oxford
  • 43. Feb 2, 2000 Tratamiento intensivo con insulina, glucosa entre 80mg/dl y 110 mg/dl Tratamiento convencional con insulina, glucosa entre 180mg/dl y 200 mg/dl solo si glucosa >215mg/dl 1548 ptes 8.0% RRA 3.4% = NNT 29 % Mortalidad 4.6% 85/783 55/765 Reducción de la Mortalidad general 34% •DOM •Foco séptico probado
  • 64. Jul 1998 96h 28d 90d 2.5a 1690 ptes 30.8% RRA 6.1% = NNT 16 % Mortalidad 24.7% 259/840 210/850
  • 66. N (APC) Placebo GRAL 1690 24.7 30.8 3-19 433 15.1 12.1 20-25 440 22.5 25.7 26-29 366 23.5 35.8 30-53 451 38.1 49.0 0.5 0.6 0.7 0.8 0.9 1 1.25 1.67 2 Riesgo relativo de muerte ( CI 95% )
  • 68. Is Drotrecogin Alfa (Activated) Safe and Effective For Surgical Patients?
  • 69. Determination of the Surgical Cohort Non-surgical PROWESS 1690 1158 1216 (72%) Selection Cohort 532 (31.5%) 58 Surgical Cohort 474 (28.0%) Xigris 228 (48.1) Placebo 246 (51.9%)
  • 70. Primary Source of Infection by Surgical Status Surgical Non-surgical N=468 N=1,117 n (%) n (%) Lung 95 (20.3) 790 (67.5) p<0.001 Intra-abdominal 295 (63.0) 68 (5.8) p<0.001 Urinary 23 (4.9) 179 (15.3) p<0.001 Note: Source of infection determined by the PROWESS Surgical Evaluation Committee .
  • 71. DrotAA was Associated with Increased Survival in Both Surgical and Non-surgical Patients Surgical Patients Non-surgical Patients 100 100 DrotAA, n=1230 rhAPC, n = 1995 Placebo, n = 274 Placebo, n = 566 95 95 Survival Rate (%) 90 90 85 85 80 80 75 75 70 70 0 7 14 21 28 0 7 14 21 28 Days Days 28-day mortality 28-day mortality Surgical patients Non-surgical patients Placebo = 30.9% vs. DrotAA = 24.4% Placebo = 30.7% vs. DrotAA = 26.3%
  • 72. Prevention of infection in multiple trauma patients by high- dose intravenous immunoglobulins [Feature Articles] Douzinas, Emmanuel E. MD; Pitaridis, Marinos T. MD; Louris, George MD; Andrianakis, Ilias MD; Katsouyanni, Klea DrMedSc; Karmpaliotis, Dimitrios MD; Economidou, Joanna MD; Sfyras, Dimitrios MD; Roussos, Charis MD, PhD Volume 28(1) January 2000 pp 8-15
  • 73. • MORTALIDAD • DÍAS EN CUIDADOS INTENSIVOS • DÍAS EN VENTILACIÓN MECÁNICA
  • 91. CONCLUSIONES • ASOCIACIÓN TRAUMA Y SEPSIS- ANÁLISIS TEMPORAL DEL SIRS. • DIFICULTAD DIANÓSTICA DE LA INFECCIÓN EN TRAUMA. • VENTAJAS DE LA IMPLEMENTACIÓN DE TERAPIAS ACTUALES. • FUTURO-ESTRATIFICACION DE LA INFECCIÓN.