Management of Sepsis

Management of Sepsis Luca Bigatello, MD Director, Surgical ICU, Massachusetts General Hospital Associate Professor of Anesthesia, Harvard Medical School

Definitions ,[object Object],[object Object],[object Object],Bone et al ., Crit Care Med ‘92 SCCM/ etc ., Crit Care Med ‘03

Sepsis & Septic Shock ,[object Object],[object Object],[object Object],Hotchkiss & Karl, NEJM ‘03

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],20 Societies- CCM ’08;36:296

Early Antibiotic Therapy ,[object Object],[object Object],Kumar et al ., CCM ’06;34:1589 ,[object Object],[object Object],[object Object],[object Object]

Early Goal-Directed Therapy: RCT ,[object Object],[object Object],[object Object],[object Object],Rivers et al ., NEJM ’01;345:1368 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],Comments Rivers et al ., NEJM ’01;345:1368

Does it Change Practice in the ICU? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rivers et al ., NEJM ’01;345:1368

A Word of Caution on ScvO 2 ,[object Object],[object Object],Chawla et al ., Chest ’04, Dueck et al ., Anesthesiology ’05 Reinhardt et al ., ICM ’04, Scheinman et al ., Circulation ‘69

Steroids in Septic Shock ,[object Object],30 mg/kg MP x 4 doses No diff. in death, prevention or reversal of shock MP: higher death in pts with  ’d Crea., from infection

Relative Adrenal Deficiency in Septic Shock (SS) ,[object Object],[object Object],[object Object],[object Object],[object Object]

76% of pts. were non-responders! ,[object Object],[object Object],[object Object],[object Object],Annane et al ., JAMA ’02;288:862 ,[object Object],[object Object]

Comments ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Annane et al ., JAMA ’02;288:862

[object Object],[object Object],[object Object],CORTICUS, NEJM ’08;358:111

CORTICUS…….. N=251 Steroids N=248 Placebo 28-day Mortality

Stim - test, non-responders (~51%) Stim - test, responders (~47%) P=0.8 P=1.0 28-day Mortality ,[object Object],[object Object]

So, Who Should Get Steroids? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Guidelines, 20 Societies- CCM ’08;36:296

Tight Glucose Control- I > 5 days ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Van den Berghe et al ., NEJM ’01;345:1359

[object Object],[object Object],[object Object],[object Object],[object Object],Van den Berghe et al ., NEJM ’01;345:1359 Langouche et al ., J Clin Invest ’05;115:2277 Angus & Abraham, AJRCCM ’05;172:1358 Comments

Aftermath ,[object Object],[object Object],http://www.ihi.org/IHI/Topics/PatientSafety/ http://www.jointcommission.org/

Tight Glucose Control- II ,[object Object],[object Object],[object Object],[object Object],Van den Berghe et al ., NEJM’06;354:449 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],Tight Glucose Control- III VISEP, NEJM ’08;358:125

Tight Glucose Control- IV, V…. GLUCONTROL, in press……. ,[object Object],[object Object],NICE-SUGAR, ongoing….. ,[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],Insulin Infusion Protocols Wilson et al., Diabetes Care 2007;30:1005

So, Who Should Get…. How Tight …? ,[object Object],[object Object],[object Object],[object Object],[object Object],Guidelines, 20 Societies- CCM ’08;36:296

Vasopressin ,[object Object],[object Object],Landry et al ., Circulation ‘97

Vasopressin Holmes et al ., Int. Care M. ’97 Patel et al ., Anesthesiology ’02 Dunser et al ., Circulation ‘04

Vasopressin- Concerns ,[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],VASST, NEJM ’08;358:877

[object Object],[object Object],So, Who Should Get Vaso.? Guidelines, 20 Societies- CCM ’08;36:296

r-Human Activated Protein C for Severe Sepsis PROWESS, NEJM ‘01 ,[object Object],[object Object]

r-aPC for Severe Sepsis Angus et al ., CCM ‘04 PROWESS, NEJM ‘01 ,[object Object],2% 3.5% bleeding 31% 25% mortality placebo rAPC 1700 pts .

r-aPC for Less- Severe Sepsis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Abraham et al ., NEJM ’05;353:1332

r-aPC in Kids ,[object Object],[object Object],[object Object],Nadel et al., Lancet 2007;369:836-43

So, Who Should Get r-a PC? ,[object Object],[object Object],[object Object],[object Object]

Conclusions ,[object Object],[object Object],[object Object]

Quantifying the Impact ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Management of Sepsis

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Management of Sepsis