Bohomolets septic shock
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Transcript of Bohomolets septic shock
Septic Shock
Absolute hypovolemia Relative hypovolemia Distributive shock :areas
of VD/VC Cardiac dysfunction Impaired O2 extraction
History of Septic Shock60’s hypotension vasopressors
normalize BP70’s Inadequate flow
measure CO + inotrope80’s Inadequate DO2
DO2/VO2 + inotrope90’s Regional circulations + dopexamine
phi, lactate + dopexamine00’s Microcirculation failure + vasodilators
« open » capillary beds
CCM , 2008 , 36 , 296-327
Initial Resuscitation
MAP 65 mmHg CVP 8-12 mmHg UF 0.5 ml.kg-1.hr-1
ScvO2 70% SvO2 65%
BE SURETHE PATIENT
IS ADEQUATLYFLUID-
RESCUCITATED
Fluid challenge
French Consensus Conference 2005
10 mmHg or 9%5 mmHg12-13 %9-10%
< 5 mmHg
SAPdownPPSVV
CVP
thresholdParameterRespiratory variation under MV
5-6 %
00
2020
4040
6060
8080
100100
00 2020 4040 6060 8080 100100100100-- SpecificitySpecificity(%)
Sens
itivi
tySe
nsiti
vity
(%)
(%)
PPPP
SPVSPV
RAPRAP
PAOPPAOP
AmAm J J RespirRespir CritCrit Care Care MedMed 2000; 162:1342000; 162:134--88
Passive Leg Rising Predicts Response to Fluid Loading
Rapid fluid loading :300 ml, > 20 min.
Boulain, Chest 2002, 121, 1245
Fluid challenge
500 ml (7 ml/kg)(either colloid or crystalloid
20 – 30 min
Fluid Challenge and Severe Sepsis
Cristalloids Colloids
Schierhout BMJ 1998, 316, 961Wilkes Ann Int Med 2001, 135, 149Choi CCM 1999, 27, 200Sibbald www.uptodate.com 2003, 1/03
SafeStudy
NEJM 2004 , 350 , 2247-2256
Safe Study
NEJM 2004 , 350 , 2247-2256
HEA or Gelatine for Severe Sepsis ?Schortgen et al Lancet 2001 , 357 , 911
Patients without Acute Renal Failure
Gelatine
HES
HEA or Gelatine for Severe Sepsis ?Schortgen et coll Lancet 2001 , 357 , 911
Survivors
P=0.09
Subgroup Analysis
(</= 22mL/Kg/day)
(> 22mL/Kg/day)
P<0.001
Hydroxyethyl Starch
HES 200,000/0.66% solution (60g/l)Na+ 154 mmol/l12 - 24h
HES 200,000/0.56% solution (60g/l)Na+ 154 mmol/l4 - 8h
33 ml / kg / 24h
ChestChest 1993, 103:18261993, 103:1826--3131
32 patients 32 patients randomizedrandomized : dopamine: dopamine ((UntilUntil 25 25 µµg/kg/min)g/kg/min) or or norepinorepi ( ( UntilUntil 5 5 µµg/kg/min)g/kg/min)
Objectif : PAM > 80 Objectif : PAM > 80 mmHgmmHg 6 h6 h
NorepiNorepi (n=16) (n=16) Dopa (n=16) Dopa (n=16)
successsuccess (n=5)(n=5)10 to 25 10 to 25 µµg/kg/ming/kg/min
ééchec (n=11)chec (n=11)25 25 µµg/kg/ming/kg/min
successsuccess (n=15)(n=15)1.51.5±±1.2 1.2 µµg/kg/ming/kg/min
failurefailure (n=1)(n=1)5 5 µµg/kg/ming/kg/min
10 10 successsuccess withwith Dopa + Dopa + NorepiNorepi (25 (25 µµg/kg/min +1.7g/kg/min +1.7±±1.8 1.8 µµg/kg/min)g/kg/min)
increaseincrease in urine outputin urine outputdecreasedecrease in lactatein lactate
increaseincrease in urine outputin urine outputdecreasedecrease in lactatein lactate
increaseincrease in urine output in urine output andand decreasedecrease in lactatein lactate
Dopamine or Norepinephrine ?
69%P < 0.001
93%
7 % p < O. 001
Success FailuresDopamine
Success FailuresNorepinephrrine
31%
C. Martin et al Chest 1993, 103, 1826
Dopamine or Norepinephrine ?Hyperdynamic septic shock
Dopamine(2.5-25 g /kg/min)
16 patientssuccess : 5/16 (31%)
failure : 11/16success : 0/1
Norepinephrine(0.5-5.0 g/kg/min)
16 patientssuccess : 15/16 -93%)
failure : 1/16success : 10/11
C. Martin et al Chest 1993, 103, 1826
p<0.001
110 patientsMAP < 70 mmHg with 20 g/kg/min
Resistance to Dopamine
Levy et al CCM 2005, 33.
40%
Dopa S
60%
P < 0.001
Dopa R
Resistance to Dopamine
Levy et al CCM 2005, 33.
Septic Shock :Norepinephrine
Martin C et al Crit Care Med2000 , 28 , 2758 .
0102030405060708090
100
0 5 10 15 20 25 30 35 40 45 50
Other vasopressors
Norepinephrine
Days
% Survival
p<0.0001
CATS Study(Epinephrine / norepi-dobu)
Epinephrinen = 161
Norepi-dobu(n = 169)
Hospital survival47.8%
Hospital survival51.5%
p = 0.51
D. Annane et al Lancet 2007,370,676-684
D. Annane et al Lancet 2007,370,676-684
MAP :65-75-85
mmHg ???
20 40 60 80 100 Renal Artery Pressure (mmH g)
Renal Blood Flow(% baseline)
150
100
50
0
Renal Autoregulationin Disease
Control3 weeks
1 week
20 40 60 80 100 Renal Artery Pressure (mmH g)
Renal Blood Flow(% baseline)
150
100
50
0
Renal Autoregulationin Disease
Control3 weeks
1 week
20 40 60 80 100 Renal Artery Pressure (mmH g)
Renal Blood Flow(% baseline)
150
100
50
0
Renal Autoregulationin Disease
Control3 weeks
1 week
20 40 60 80 100 Renal Artery Pressure (mmH g)
Renal Blood Flow(% baseline)
150
100
50
0
Renal Autoregulationin Disease
Control3 weeks
1 week
65 85
Increasing MAP ?UF
Creatinine
Cr ClA Bourgoin et alCCM 2005,33,780-786
8565
MAP :65 mmHg
Septic shock. Inotropic Therapy
. Dobutamine is the first choice for patients with low CO
< 2.5 l/min/m2after fluid resuscitationafter an adequate MAP (Level E)
. Dobutamine may cause hypotensionand /or tachycardia in some patients: especially those with low filling
pressureTask Force of the SCCM. Crit. Care Med 2004,32,1928-1948
Initial Resuscitation
MAP 65 mmHg CVP 8-12 mmHg UF 0.5 ml.kg-1.hr-1
ScvO2 70% SvO2 65%
Early « Goal-directed therapy »
Rivers et coll N Eng J Med 2001, 345, 1368-1377
3499 ml4981 ml
P < 0,001
18.5%
64.1% p < 0,001
contrôles GDTExpansion volémique
contrôles
contrôles GDT
GDT
Transfusion (% patients)
0.8%p < 0,001
13.7%
Dobutamine (% patient)
Early « Goal-directed Therapy »
Hospital mortality
46.5%30.5% (p = 0.009)
Controls GDT
Rivers et al NEJM, 2001, 345, 1368-1377
Rescue Therapy
1-AR AC AC
arrestin
endosome
P P P
clathrin
Receptorinternalization Receptor
dephosphorylation
Receptordegradation
Receptorresensitization
Gs protein
VASOPRESSIN
• Regulation of plasmaticosmolarity and volemia
• Heterogeneousvasoconstriction
Liard et al. Am J Physiol 1982
• Vasodilation in somecirculatory beds
Walker. Am J Physiol 1986
AVP
Norepinephrine > 15 mcg/min
Norepinephrine 5-14 mcg/min
Only asrescue therapy
Terlipressin?
Albanese , Martin Shock 2004,22,314-319
MAPmmHg
SVRI dyn.sec.cm-5.m-2
NE + dopa TER NE + dopa TER
TERNE + dopa
15 patients with catecholamine - resistantseptic shock: NE ( 2.2 mcg/kg/min ) dopamine ( 25 mcg/kg/min )
Terlipressin 1 or 2 bolus of 1 mgCI l/min/m2
84+/- 64.7+/-1.3
1147+/-134
55+/- 5
654+/-108
5.3+/-1.2
P< 0.01
Terlipressin?
UFml/min
Cr CL ml/min/ 1.74 m2
NE + dopa TER
TERNE + dopa
67+/- 33
49+/-37
11+/-15
17+/-44
P<0,01
P<0.01
15 patients with catecholamine - resistantseptic shock: NE ( 2.2 mcg/kg/min ) dopamine ( 25 mcg/kg/min )
Terlipressin 1 or 2 bolus of 1 mg
Albanese , Martin Shock 2004,22,314-319
Dynamic Aspect
1st hour blood gas lactate cultures ATB peripheral IV vasopressor fluid
2nd hourMAP 65 mmHg arterial line CVC SvO2 CVP > 5 mmHg
6th hour
ScvO2 > 70%SvO2 > 65 % plateau pressure
< 30 mmHg
Dynamic Aspect
1st hour
blood gas lactate cultures ATB peripheral IV vasopressor fluid
2nd hour
MAP 65 mmHg arterial line CVC SvO2 CVP > 5 mmHg
6th hour
ScvO2 > 70%SvO2 > 65 % plateau pressure
< 30 mmHg