Sepsis
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Transcript of Sepsis
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Jay Green, PGY-3Dr. Jason LordOctober 2, 2008
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Dr. Jason LordDr. Dan HowesDr. Trevor LanghanDr. Aric Storck
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CaseDefinitionsKeys to sepsis managementRecognition!Early abxEGDTetcPut together the pocket cue card version
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Severe sepsis/septic shock mortality 20-50%Incidence increasing10th most common cause of death in the US2-10% of hospital admissions
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Non-infectious causes of SIRSTissue damageSurgery, trauma, DVT, MI, PE, pancreatitis, etcMetabolic Thyroid storm, adrenal insufficiencyMalignancyTumor lysis syndrome, lymphomaCNSSAHIatrogenicTransfusion rx, anesthetics, NMS, etc
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72F generalized abdo pain x 3d, weak x 1dPMHRA, HTN, goutHR 109, bp 85/45, T 38.9, RR 20, SpO2 94%CVS unremarkableResp scattered cracklesAbdo tender LLQ/RLQ/suprapubic, +BSCNS AAOx3, screening exam N
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SIRST38HR>90RR>20WBC12 or >10% bands
Sepsis Management
- Two of:HR > 90RR > 30T > 38 or < 36WBC > 12 or
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Lactic Acidosis Oliguria Altered mental statusMortality 16%SEPSISSEPSIS + Organ DysfunctionSEVERE SEPSIS
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Severe Sepsis +/- hypotension despite adequate fluid resuscitationMortality 46%SEVERE SEPSISSEPTIC SHOCK
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Mortality: 46%SEVERE SEPSISSEPTIC SHOCKSEPSISSIRSMortality: 10%Mortality: 16%
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72F generalized abdo pain x 3d, weak x 1dHR 109, bp 85/45, T 38.9, RR 20, SpO2 94%You think shes septic?Urosepsis?
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SIRST38HR>90RR>20WBC12 or >10% bands
Sepsis Management 1. Recognition
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#1 priority in sepsis?
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Kumar et al. Crit Care Med 2006;34(6):1589
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SurvivalSeries 2Series 3
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After hypotension onsetEach hour delay = 7.6% increase mortality (first 6hrs)9.9% increase in the first hour
Mortality increases 9%/hour in hospitalized pts for every hour of delay
Kumar et al. Crit Care Med 2006;34(6):1589 Garnacho-Monero et al. Crit Care 2006;10(4):R111
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Kumar et al. Crit Care Med 2006;34(6):1589
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Column2SourcesSeries 2Series 3
Lung37%2.42
Abdo29%4.42
GU11%1.83
Skin7%2.85
CNS1%
Joint1%
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Chest LevoAzithro + ceftriaxoneAbdoPip/tazo or AGF or ceftriaxone/FlagylGUGent or cefriaxoneSkinAncef +/- vancoHeadCeftriazone + vanco + dex
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Get them in fast!!STAT, communication, check backCultures prior to abx if possibleBlood, urine, csfRemove the source if possibleFoley, cvcAbscess, necrotizing fasciitisMRSA coverage?Nursing home, other hospital, homeless, etc
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AntibioticsStart within first hour of recognitionCultures before Abx if possibleSource controlExclude surgical sources within 6hCrit Care Med 2008;36(1):296
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SIRST38HR>90RR>20WBC12 or >10% bands
Sepsis Management 1. Recognition 2. ABX!
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72F abdo pain & weaknessHR 109, bp 85/45, T 38.9, RR 20, SpO2 94%C/S 13.4
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Does this patient have SIRS?Sepsis?Severe sepsis?Septic shock?
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Investigations?Initial management priorities?
CBC, lytes, BUN, Cr, culturesCXR
ABCs O2, IV x 2, monitor applied ABX Fluids How much?20-30cc/kg over 30minAnything else?-Lactate!
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Persistent hTN despite 2.5L NS over first 90minLabs returningU/A +nit, +leuksWBC 20.4 (3 bands), lytes/Cr N, lactate 5.2Why is lactate important?
What does she have?What evidence is there to guide you now?
You cant act earlyif you dont know theclock is ticking!
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Mortality: 46%SEVERE SEPSISSEPTIC SHOCKSEPSISSIRSMortality: 10%Mortality: 16%EGDT Mortality: 30%EGDT
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Prospective RCTStandard therapy vs EGDT protocol (= 4mmol/LExclusion criteriaMany
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Followed pts for 60dPrimary outcomeIn hospital mortalityICU staff blinded to group
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Results
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46% vs 30% in hospital mortality in septic shockARR = 16%NNT = 6
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Hinshaw & Cox. The Fundamental Mechanisms in Shock. Plenum Press, New York. 1972.
HypovolemicDistributiveCardiogenic Obstructive
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HypovolemicDistributiveCardiogenic
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HypovolemicDistributiveCardiogenic
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You ordered NSHypovolemic
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Why are patients in hypovolemic shock?Venodilation3rd spacingLosses (vomiting, diaphoresis)Recent poor PO intake
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Meta-analysisSAFE trialCochrane review
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Meta-analysis19 RCTs, N = 1315Trauma, surgery, burn, sepsis (1)
BMJ 1998;316:961
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DBRCT, N=6997, pts admitted to ICU4% albumin vs NSVolume titrated to clinical statusPrimary outcome28d mortality18% had sepsis (predefined subgroup)NEJM 2004;350:2247
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Cochrane Systematic Reviews, 2005. 19 Trials reported data on mortalityN= 7576 RR from these trials was 1.02 (0.93, 1.11).
No evidence of meaningful benefit to colloids vs crystalloids
Normal SalineCheap, availableUSE IT FIRST
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Colloid or crystalloidGoalCVP >=8 (>=12 in ventilated patients)Fluid challenge technique>=1L crystalloid (300-500mL colloid) over 30minAs long as hemodynamic improvementReduce rate when CVP increases without hemodynamic improvementCrit Care Med 2008;36(1):296
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How fast?1000mL crystalloid q30minHow much volume?DependsGoal: CVP 8-12Rivers study: avg 5L in first 6h
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SIRST38HR>90RR>20WBC12 or >10% bandsEGDTCVP 8-12 Crystalloid (1L q30min)
Sepsis Management 1. Recognition (lactate, u/o) 2. ABX 3. EGDT (NNT=6)
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BP 80/50 despite 2.5L NSYouve addressed the hypovolemic shockWhat is her MAP?What next?
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Distributive
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Tank is full (CVP goal reached)Need to increase vascular toneWhich vasoactive agent would you like to use?Starting dose?
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Alpha adrenergic receptors:vascular walls - peripheral vasoconstrictionBeta adrenergic receptorsBeta 1: myocardium - increase inotropy (force of contraction) and chronotropy (heart rate)Beta 2: vascular walls - peripheral vasodilatation lungs - bronchodilationDopamine receptorsrenal and splanchnic arteries - vasodilatation and inc blood flow
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DopaminePrecursor of epi/norepiRelease of norepi from presynaptic terminalsDosingDopaminergic 10ug/kg/minvasoconstrictionNorepinephrineAlpha >> beta agonistVasoconstriction, little inotropy/chronotropyDosingStart at 0.1 ug/kg/minDouble every five minutes to effectMaximum ~ 2ug/kg/min
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Theoretical advantages to norepinephrineDirect acting, works in catecholamine depleted patientsLess dysrhythmiasMartin et al, Chest 1993;103:1826DBRCT, N=32Hemodynamic endpoints achieved with NE>dopCochrane Review (Mullner, 2004)NE vs dopamine3 studies, N=62RR mortality 0.88 (0.57-1.36)
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Should we use vasopressin in sepsis?
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RCT NE-resistant septic shock N=48.All pts NE>0.5 mcg/kg/minVasopressin 4U/hr + NE vs NE aloneCross-over permitted at 24hrsEndpoints: primarily HD
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Either NE or dopamine as 1st lineDont use epi, phenyl or vasopressin as 1st lineUse epi next if poorly responsive to NE/dopButDose of 0.03U/min can be added to NE
Crit Care Med 2008;36(1):296
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DBPRCT, N=778InclusionSeptic shock on >=5ug/min NEVasopressin 0.01-0.03U/min vs NE 5-15ug/minCould use other pressors at MD discretionPrimary endpoint28d mortalityMean time from study inclusion to drug = 12hr
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We tend to add to NE/dopamine, not use alone
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Likely decreases HR, increases MAP, decreases NE requirements in septic shockNo convincing mortality benefitReasonable to try in septic shock that is refractory to NE/dopamineMax/increasing dose vasopressor and doing poorly0.04U/min
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SIRST38HR>90RR>20WBC12 or >10% bandsEGDTCVP 8-12 Crystalloid (1L q30min)MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/min
Sepsis Management 1. Recognition (lactate, u/o) 2. ABX 3. EGDT (NNT=6)
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BP 90/60 on 2ug/kg/min LevophedNext steps in EGDT?
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Cardiogenic
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ScvO2Measured where?SVC or RADifferent than mixed venous O2?PACaseHb 83, hct 0.26ScvO2 = 68%What does this mean?How do we increase her ScvO2?
- EGDT recommends if ScvO2
- Multicenter RCT of 838 ICU pts with Hb
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ResultsNo difference in 30 or 60 day mortalityLower in-hospital mortality in restrictive group22.2% vs 28.1% (p=0.005)No difference in mortality in sepsis sub-groupLess sick pts (APACHE II score 100 g/L
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EGDTHypovolemic patientsActual measurement of suboptimal O2 deliveryED study
TRICCEuvolemic pts enrolled within 72 hours of ICU admitOnly 6% sepsis, only 27% had any infectionSurviving Sepsis CampaignRecommends EGDTTRICC once hypoperfusion has resolved
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If after pRBC her ScvO2 < 70%You want to start dobutamineMechanism?Beta-agonist (Beta1>Beta2)Inotropy/chronotropy, vasodilationBP effect??Dose?2-20ug/kg/min
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After fluid resus, hypotensive septic patients may have low, normal or high cardiac outputIf CO not measured (eg. in the ED)Combined vasopressor/inotrope recommended1st line inotrope = dobutamineCrit Care Med 2008;36(1):296
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SIRST38HR>90RR>20WBC12 or >10% bandsEGDTCVP 8-12 Crystalloid (1L q30min)MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/minScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/min
Sepsis Management 1. Recognition (lactate, u/o) 2. ABX 3. EGDT (NNT=6)
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Pt has had ABX, NS, pRBC, and is now on Levophed, dobutamineRepeat ScvO2 = 67%Pt is becoming more alteredWhat now?
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What would be your choice of induction agent?
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Predictable dosing and effectFast onset, short duration of actionMinimal respiratory depressionRelative hemodynamic stabilityMinimal histamine releaseStimulates alpha receptors
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Absalom 1999, Malerba 2005, Vinclair 2007Single dose inhibits cortisol synthesis for 24-48hMohammed 2006, Ray 2007, Riche 2007Studies designed for etomidate vs no etomidateNo increase in mortalityCORTICUS (2008)>28d mort with one dose (OR 1.53 (1.06-2.26)) Etomidate non-randomized, post-hoc analysisBottom lineAvoid in sepsis
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What is it?Non-cardiogenic pulmonary edemaInflammatory lung injuryWhat do you see clinically?Bilateral infiltrates on CXRPaO2/FiO2 < 200Vent settings?
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RCT, N=861Pts with ARDS (27% septic)GroupsControl: 12cc/kg, plateau pressures < 50cm H2OIntervention: 6cc/kg, plateau pressures < 30cm H2OPrimary outcomesIn hospital mortalityVentilator-free days in first 28 days
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Trial stopped earlyLow TV betterARR 8% (2.4%-15.3%)NNT = 11
- Target TV 6cc/kgPlateau pressure
- SIRST38HR>90RR>20WBC12 or >10% bandsEGDTCVP 8-12 Crystalloid (1L q30min)MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/minScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/minARDSNetTV 6cc/kgPEEPPplateau
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CaseYour pt is now intubated, ARDS vent settings, has had NS, ABX, pRBC, Levophed & dobIsnt there anything else you can do doctor?Steroids?Insulin?APC?
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Early studies show no benefitVeterans administration. Effect of high-dose glucocorticoid therapy on mortality in patients wit clinical signs of systemic sepsis. N Eng J Med. 1987; 317: 659-65Bone et al. A controlled clinical trial of high dose methylprednisolone in the treatment of severe sepsis and septic shock. N Eng j Med. 1987; 317: 653-58Potential increased mortality at higher dosesCronin et al. Corticosteroid treatment for sepsis: A critical appraisal and meta-analysis of the literature. Crit Care Med. 1995; 23: 1430-39
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DBPRCT, N=499, 52 ICUs, 9 countriesHydrocortisone 50mg q6h x 5d vs placeboPrimary outcome28d mortality in corticotropin non-respondersSecondary outcomes28d mortality in corticotropin responders1y mortality rateOthers
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ConclusionsNo mortality benefit with steroids in vasopressor responsive septic shockFaster reversal of shockBut no difference in proportion of patients achieving reversal of shock
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Suggest steroids in vasopressor-unresponsive patientsMax/increasing vasopressor dose and doing poorlyHydrocortisone 50mg q6hNo role for ACTH stim testHydrocortisone > dexamethasoneCan use replacement steroids if pt hx warrantsHydrocortisone 100mg q8hCrit Care Med 2008;36(1):296
- SIRST38HR>90RR>20WBC12 or >10% bandsEGDTCVP 8-12 Crystalloid (1L q30min)MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/minScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/minARDSNetTV 6cc/kgPEEPPplateau
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Most recent labsNa = 141K = 3.3Cl = 109HCO3 = 21Cr = 178BUN = 11Glu = 18.1Any other therapy to add to the mix?
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RCT N=1548, not blindedMostly surgical patients
Randomized toIntensive insulin tx (IIT)IV insulin to BG 4.4-6.1mmol/LConventional insulin tx (CIT)IV insulin to BG 10-11.1mmol/L
Primary outcomeAll-cause ICU mortality
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Bacteremic patientsNo difference in mortality29.5% vs 12.5% (NS)
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CriticismsGeneralizabilityMostly post-surgical patientsDoes this apply to septic or other medically sick patients?Single center trialNot blindedHyperglycemia MAY BE badHypoglycemia IS bad
- In ICU IV insulin to target
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VISEP trialMulticenter, RCT, 2x2 design, N=488InterventionsIIT vs CITHydroxyethyl starch vs Ringers lactatePts had severe sepsis or septic shock
- Conventional therapy (BG 10.0-11.1mmol/L)Intensive therapy (BG 4.4-6.1mmol/L)Primary outcomes28d mortalityMorbidity (SOFA score)Stopped earlyHypoglycemia in IIT group (12.1 vs 2.1%, P
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Glucontrol studyMulticenter PRCT, N=1,011IIT vs CIT (same definitions)Primary outcomeICU mortalityStopped for safety and protocol violations
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Intensive Insulin TherapyConventional Insulin TherapyP valueICU Mortality16.7%15.2%NSHypoglycemia9.8%2.7%
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BG target > 10mmol/L probably no longer acceptableSafest range below this level unresolved
Bottom lineNo need in ED unless BG markedly highBolus of insulin R preferrable to infusionAim for BG ~ 10mmol/LLikely only important in the ICU setting
- SIRST38HR>90RR>20WBC12 or >10% bandsEGDTCVP 8-12 Crystalloid (1L q30min)MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/minScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/minARDSNetTV 6cc/kgPEEPPplateau
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APC rationale:The acute inflammatory response in sepsis is integrally related to endothelial activation and procoagulant state
rhAPC is an endogenous anti-coagulant and potent anti-inflammatory agent
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DBPRCTInclusion:Severe sepsis or septic shockAll had 1 (most had 2) organs downExclusion:Many criteriaPrimary outcome:Mortality at 28d
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ARR = 6.1, NNT = 16
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Post hoc analysis of PROWESSDhainaut et al. Drotrecogin alfa (activated) in the treatment of severe sepsis patients with multiple-organ dysfunction: data from the PROWESS trial. Int Care Med 2003; 29: 894 - 903
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Concerns with PROWESSNot powered for subgroups analysisFDA 2001 report contains additional information regarding the participants and interventions that were not publishedThe trial contains 2 subtly different protocolsInitial protocol = 720 participantsAmended protocol = 970 participants 3 changes:Addition of exclusion criteria for pts with septic shockOther altered placebo from NS to 0.1% albuminSponsor introduced a change to the manufactured drug during amendment
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DBPRCT, N=2613InclusionSevere sepsis and low risk of deathAPC vs placebo (NS)Stopped at 2nd interim analysisLow likelihood of efficacy and expected high risk bleeding
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DBPRCT, N=477 kidsOutcomes/ResultsTime to organ dysfunction resolutionNo difference (6% vs 6%)28d mortalityNo difference (17.2% APC vs 17.5% placebo)Serious bleedingNo differenceCNS bleeding (4.6% APC vs 2.1% placebo, NS)
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APC forAdults with sepsis-induced organ dysfunction and high risk of death or multiple organ failureAPACHE II scores calculated using 24h of ICU dataNo current role for APC in the EDCrit Care Med 2008;36(1):296
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N=4911
RR (CI)P value28d Mortality0.92 (0.72-1.18)0.5028d MortalityAPACHE < 251.04 (0.89-1.21)0.7028d MortalityAPACHE > 250.90 (0.54-1.49)0.68Serious Bleeding1.48 (1.07-2.06)0.02
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Unless additional RCTs provide evidence of a treatment effect, policy-makers, clinicians and academics should not promote the use of APC
More comingPROWESS-SHOCKEXTENDRESPOND
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Not for those at low risk of deathNot for kidsNot for use by ED physicians
Maybe for those with > 2 organs downMaybe for those at high risk of deathMaybe, if the ICU decides to use it
- SIRST38HR>90RR>20WBC12 or >10% bandsEGDTCVP 8-12 Crystalloid (1L q30min)MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/minScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/minARDSNetTV 6cc/kgPEEPPplateau
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Your job as an emergency physicianRecognition!Early antibiotics!EGDT!ARDS ventilator settings
Good to know, but MUCH less important to usSteroidsInsulinAPC
- SIRST38HR>90RR>20WBC12 or >10% bandsEGDTCVP 8-12 Crystalloid (1L q30min)MAP > 65 NE 0.1-2ug/kg/min OR dopamine 5-20ug/kg/minScvO2 > 70% pRBC (hct>0.30) dob 2-20ug/kg/minARDSNetTV 6cc/kgPEEPPplateau
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*Adequate fluid resusc = 20-30mL/kg fluid over 30 minutes*Adequate fluid resusc = 20-30mL fluid over 30 minutesArtificial, as you would have someone start a line and start giving fluids before this pt gets abx*Vanco, septra, doxy for MRSA (clinda too, but have inducible resistance)*At least sepsismay be worse*Dont forget lactate!*Lactate allows for timely recognition of septic shock**Adequate fluid resusc = 20-30mL fluid over 30 minutesAge 70%*More early fluids (same after 72h), more early rbc, more early inotropes*So youre giving fluidscrystalloid or colloid?**How does it work? Stimulates V1a receptors in peripheral SM cellsBlock NO productionWorks during acidosisStudies have shown in pts with septic shock low levels of vaso
*Demonstrates that addition of vasopressin causes an increase in MAP and decrease in HR and decreased NE requirements
No mortality benefit to vasopressin*No change in adverse events including arrhythmias*Prospectively defined subgroup of less severe septic shock pts showed benefit to vasopressin*Last drug added, not titrated (background infusion), complications due to vasoC*Low ScvO2 means as the pump begins to fail it cant deliver O2 to the tissues as well, so tissues extract more O2 leaving the ScvO2 lower*Probably not for ED useACS aim for hct > 0.30 or Hb > 100*Pretreatment noInduction ketamine, avoid etomidate or meds causing hTNParalytic - *Transiently inhibits 11-B-hydroxylase (enzyme in the final step of cortisol synthesis)Presume that ketamine is safer (not studied)-causes NE release and is myocardial depressant so maybe bad choice in this patientMaybe small dose fentanyl + lido to pharynx*Leaky lung capillaries 2* to PMN activation causing endothelial damageNot truly pulmonary edema as lungs filled with inflammatory exudate rather than watery edema*Diffuse disease, Normal cap wedge, Fi02:pa02