R. Phillip Dellinger, MD, MCCM, FCCP Acting Chair & Chief of Department of Medicine Head, Division...
-
Upload
kayli-lowen -
Category
Documents
-
view
213 -
download
1
Transcript of R. Phillip Dellinger, MD, MCCM, FCCP Acting Chair & Chief of Department of Medicine Head, Division...
R. Phillip Dellinger, MD, MCCM, FCCPActing Chair & Chief of Department of MedicineHead, Division of Critical Care MedicineCooper University Hospital Camden, New Jersey
Professor of Medicine Cooper Medical School of Rowan University
What’s new with the 2012 guidelines and
associated changes in the database
R. Phillip Dellinger MD, MCCMChrista A. Schorr RN, MSN, FCCM
Cooper Medical School Rowan UniversityCooper University Hospital
Camden, NJ
Potential Conflicts of Interest
• Neither has direct or indirect potential financial conflict of interest as to any material presented in this presentation
• As to potential intellectual conflict of interest both hold leadership positions in Surviving Sepsis Campaign
R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung,
Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus,
Clifford S. Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup.
Crit Care Med 2013; 41:580-637 Intensive Care Medicine 2013; ..
Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012
Currently Funded with a Gordon and Betty Moore Foundation Grant
No direct or indirect industry support for guidelines revision
Grading Quality of EvidenceGRADE System
• A- high quality
• B- intermediate
• C- low
• D- very low
– Case series or expert opinion
• Upgrade capability
• Ungraded (UG) recommendation
Grading Strength of RecommendationGRADE System
• 1- strong recommendation – We recommend
• 2- weak recommendation – We suggest
Early Screening and a Performance Improvement Program
Antibiotic Therapy
• We recommend that intravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (1C).(Best Practice versus Stand of Care)
Resuscitation of Sepsis Induced Tissue Hypoperfusion
• Recommend MAP 65 mm Hg
FLUID THERAPY
Fluid therapy
1. We recommend crystalloids be used in the initial fluid resuscitation of severe sepsis (Grade 1B).
Fluid therapy
1. We suggest the use of albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (Grade 2C).
Fluid challenge
Initial fluid challenge in sepsis-induced tissue hypoperfusion (hypotension or elevated
lactate) A minimum of 30ml/kg of crystalloids
(a portion of this may be albumin equivalent). (1B)
Vasopressors
Vasopressors
1. We recommend norepinephrine as the first choice vasopressor (Grade 1 B).
Vasopressors
2. We suggest epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain blood pressure (Grade 2B).
Vasopressors
3. Vasopressin .03 units/min can be added to norepinephrine with the intent of raising MAP to target or decreasing or decreasing norepinephrine dosage.
(UG)
Phenylephrine
Pure vasopressor and in general not recommended
Sepsis Induced Tissue Hypoperfusion(Recommend Quantitative
Resuscitation) Requirement for vasopressors after fluid
challenge
or
Lactate ≥ 4 mg/dL
Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion
Recommend Insertion central venous catheter• Central venous pressure: 8–12 mm Hg
• Higher with altered ventricular compliance or increased intrathoracic pressure
Grade 1C
Arterial Systolic Pressure Variation
Parry-Jones, et al. Int J Respir Crit Care Med 2003;2:67
Part
At
Effect on Stroke Volume
Effect on Stroke Volume
Effect on Cardiac Filling
Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion
Recommend Insertion central venous catheter• ScvO2 saturation (SVC) 70%Grade 1C
Lactate Clearance
In patients with elevated lactate levels as amarker of tissue hypoperfusion we suggesttargeting resuscitation to normalize lactate asrapidly as possible (grade 2C).