Post on 04-Jan-2016
Resuscitating Sepsis – How I do it after CRISTAL?
Djillali AnnaneUniversité de Versailles SQY
Université de Paris SaclayHôpital Raymond Poincaré - APHP
Disclosures No financial conflict of interest All works on this topic were
supported by grants from the French ministry of health
Risks/Benefits Colloids Versus
Risks/Benefits Crystalloids
Theoretical Consideration
Inexpensive Non-allergic Depleted ECF No transmission of
infection No effect on
coagulation Edema Short half life Chlorid acidosis
Prolonged plasma volume expansion
More rapid Less edema Decreased efficacy if
capillary leaks Allergic Infection risk Coagulopathy Kidney problems Cost
Crystalloids Colloids
Goo
dB
ad
Colloids versus Crystalloids to achieve Resuscitation
Goals
SSC 2012 Guidelines Initial Resuscitation
We recommend the protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined as hypotension persisting after initial fluid challenge or lactate ≥ 4 mmol/L). This protocol should be initiated as soon as hypoperfusion is recognized and should not be delayed pending ICU admission.
SSC 2012 Guidelines Initial Resuscitation
• During the first 6 hours of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as a part of a treatment protocol Grade 1C –CVP 8–12 mm Hg–MAP ≥ 65 mm Hg–Urine output ≥ 0.5 mL/kg/hour–Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively
Resuscitation Goals
7
9
11
13
Cen
tral
Ven
ous
Pre
ssur
e m
mH
g
Basal Day1 Day2 Day3 Day4
AlbuminSaline
Finfer et al, NEJM 2004
<0.001<0.001<0.001 <0.001
Resuscitation Goals
Brunkhorst et al, NEJM 2008
Hours
Resuscitation Goals
Mybrugh et al, NEJM 2012
Resuscitation Goals
G. Martin, Crit Care Med 2002; 30: 2175KA Powers, Crit Care Med 2003; 31: 2355
SSC 2012 Guidelines Initial Resuscitation
• We suggest, in patients with elevated lactate levels as a marker of tissue hypoperfusion, targeting resuscitation to normalize lactate as rapidly as possible
Grade 2C
0
2
4
6
8ColloidCrystalloid
Time
Art
eria
l lac
tate
s (m
mol
/L)
Arterial lactate
*
*
**
15
20
25
30ColloidCrystalloid
Time
Art
eria
l Bic
arbo
nate
(mm
ol/L
)Bicarbonate
*
METAANALYSIS OF STARCH VS OTHER FLUIDS
Mortality
Rochwerg et al, Ann Intern med 2014
Mortality
Rochwerg et al, Ann Intern med 2014
Mortality
Rochwerg et al, Ann Intern med 2014
RENAL ADVERSE EVENTS
RIFLE: risk or worse
RIFLE: injury or worse
RIFLE: failure
Use of RRT
CHEST
In PracticeDesign VISEP
N=5376ES
N=798CHEST
N=6651CRISTALN=2857
Setting
18 academic tertiary
hospitals in Germany
26 university & non-university
hospitals in Denmark, Norway,
Finland, Iceland
32 hospitals in
Australia and New Zeland
57 academic and non academic hospitals, in
France, Belgium, Canada, Algeria,
Tunisia ,UK
Subjects
Septic shock Septic shock All All
Control RL RA NS NS (86%), RL (18%)
Exp HES HES HES HES (69%), Gelatins (35%)
Primary outcome
Composite: 28-day
deaths + SOFA
Composite: 90-day deaths
+ dialysis
90-day deaths 28-day deaths
Blinding Double blind Double blind Double
blind Open
In PracticeOUTCOMES VISEP
N=5376ES
N=798CHEST
N=6651CRISTALN=2857
28-day deaths NO dif NO dif NO dif NO dif
90-day deaths NO dif Crys > Col
P=0.04NO dif Col > Crys
P=0.03
RIFLE risk ?Col> Crys 0.72 [0.52,
0.99]
Col> Crys0.94 [0.90,
0.98]?
RIFLE injury ? NO DifCol>Crys0.91 [0.85,
0.97]?
RIFLE failure ? NO Dif NO Dif ?
RRTCrys > Col1.66 [1.22,
2.25]
Crys > Col1.35 [1.01,
1.80]
NO Dif1.21 [1.00,
1.45]
NO Dif0.88 [0.72,
1.08]
Role of Fluid Balance
Penglin et al, 2013 Sino-french Crit Care Conference
Role of Fluid Balance
Penglin et al, 2013 Sino-french Crit Care Conference
In Practice
Sepsis Initial ResuscitationFirst 24 hours
Low risk of AKI
Crystalloids RL>NS
<3000 mL
Starches <1000mL
If more fluid neededAlbumin
Moderate to high risk of AKI
Crystalloids RL
If more fluid neededAlbumin
Thank you
2nd Paris International Conference, June 7 & 8 2012