SEPSIS & SEPTIC SHOCK 10.15. 2009 Jaime Palomino, MD Pulmonary & Critical Care Medicine Tulane...
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Transcript of SEPSIS & SEPTIC SHOCK 10.15. 2009 Jaime Palomino, MD Pulmonary & Critical Care Medicine Tulane...
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SEPSIS & SEPTIC SEPSIS & SEPTIC SHOCKSHOCK 10.15. 10.15. 2009 2009
Jaime Palomino, MDJaime Palomino, MDPulmonary & Critical Care MedicinePulmonary & Critical Care Medicine
Tulane University Health Sciences CenterTulane University Health Sciences CenterNew Orleans, LouisianaNew Orleans, Louisiana
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EpidemiologyEpidemiology
Sepsis yearly incidence Sepsis yearly incidence 50 – 95 cases / 50 – 95 cases / 100,000100,000
Increasing by 9% each yearIncreasing by 9% each year 2% hospital admissions2% hospital admissions 9% sepsis 9% sepsis severe sepsis severe sepsis 3% severe sepsis 3% severe sepsis septic shock septic shock
10% of ICU admissions10% of ICU admissions
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Annane D et al. Lancet 2005;365:63-78
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Russell J. NEJM 2006;355:1699-713
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Russell J. NEJM 2006;355:1699-713
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Russell J. NEJM 2006;355:1699-713
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Septic Shock – TreatmentSeptic Shock – Treatment
Initial Resuscitation Initial Resuscitation
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Rivers E et al. NEJM 2001;345:1368-1377
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Rivers E et al. NEJM 2001;345:1368-1377
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Septic Shock – TreatmentSeptic Shock – Treatment
What are the recommended vasopressors What are the recommended vasopressors in septic shock patients?in septic shock patients? MAP MAP ≥ 65 mmHg≥ 65 mmHg Norepinephrine and Dopamine Norepinephrine and Dopamine initial initial
vasopressors of choicevasopressors of choice Epinephrine Epinephrine first alternative when BP is first alternative when BP is
poorly responsive to Norepinephrine or poorly responsive to Norepinephrine or DopamineDopamine
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Annane D et al. Lancet 2007;370:676-84
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Septic Shock – TreatmentSeptic Shock – Treatment
VasopressorsVasopressors VasopressinVasopressin
• May be subsequently added to Norepinephrine May be subsequently added to Norepinephrine (Dose: 0.03units/min) with anticipation of an effect (Dose: 0.03units/min) with anticipation of an effect equivalent to Norepinephrine alone.equivalent to Norepinephrine alone.
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Russell J et al. NEJM 2008;358:877-887
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Russell J et al. NEJM 2008;358:877-887
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Russell J et al. NEJM 2008;358:877-887
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Povoa P et al. CCM 2009;37:410-416
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Septic Shock – TreatmentSeptic Shock – Treatment
VasopressorsVasopressors Comparison of Dopamine and Norepinephrine as the Comparison of Dopamine and Norepinephrine as the
First Vasopressor Agent in the Management of ShockFirst Vasopressor Agent in the Management of Shock De Backer D. NCT00314704De Backer D. NCT00314704 Primary Outcome Measures: 28 day survivalPrimary Outcome Measures: 28 day survival Estimated Enrollment: 1600 Estimated Enrollment: 1600 Study Start Date: December 2003 Study Start Date: December 2003 Estimated Study Completion Date: December 2010Estimated Study Completion Date: December 2010
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Septic Shock – TreatmentSeptic Shock – Treatment
SteroidsSteroids
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Sprung et al. NEJM 2008;358:111-24
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Sprung et al. NEJM 2008;358:111-24
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Sprung et al. NEJM 2008;358:111-24
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Sprung et al. NEJM 2008;358:111-24
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Sprung et al. NEJM 2008;358:111-24
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Relative Adrenal Insufficiency DiagnosisRelative Adrenal Insufficiency Diagnosis
Thomas Z et al. Ann Pharmacother 2007;41:1456-65
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Dellinger R et al. Crit Care Med 2008; 36:296-327
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Annane et al. JAMA 2009;301:2362-2375
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Annane et al. JAMA 2009;301:2362-2375
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Annane et al. JAMA 2009;301:2362-2375
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Annane et al. JAMA 2009;301:2362-2375
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Septic Shock – TreatmentSeptic Shock – Treatment
Glucose ControlGlucose Control
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Van Den Berghe G et al. NEJM 2001;345:1359-1367
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Van Den Berghe G et al. NEJM 2001;345:1359-1367
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Van Den Berghe G et al. NEJM 2006;354:449-461
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Van Den Berghe G et al. NEJM 2006;354:449-461
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Brunkhorst FM et al. NEJM 2008;358:125-139
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Brunkhorst FM et al. NEJM 2008;358:125-139
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NEJM 2009;360:1283-97
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NEJM 2009;360:1283-97
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NEJM 2009;360:1283-97
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NEJM 2009;360:1283-97
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NEJM 2009;360:1283-97
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NEJM 2009;360:1283-97
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Septic Shock– TreatmentSeptic Shock– Treatment
Activated Protein CActivated Protein C
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Bernard GR et al. NEJM 2001;344:699-709
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Bernard GR et al. NEJM 2001;344:699-709
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Abraham E et al. NEJM 2005;353:1332-1341
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Abraham E et al. NEJM 2005;353:1332-1341
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Abraham E et al. NEJM 2005;353:1332-1341
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Dellinger R et al. Crit Care Med 2008; 36:296-327
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Early Versus Delayed Enteral Feeding and Omega-3 Fatty Early Versus Delayed Enteral Feeding and Omega-3 Fatty Acid/Antioxidant Supplementation for Treating People With Acid/Antioxidant Supplementation for Treating People With Acute Lung Injury or Acute Respiratory Distress SyndromeAcute Lung Injury or Acute Respiratory Distress Syndrome
(The EDEN-Omega Study) (The EDEN-Omega Study)
This study has been terminated. This study has been terminated. ( The Omega arm of this study was ( The Omega arm of this study was
stopped for futility. The EDEN arm stopped for futility. The EDEN arm continues to recruit patients as a separate continues to recruit patients as a separate independent study. )independent study. )
http://clinicaltrials.gov/ct2/show/study/NCT00609180
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Early Versus Delayed Enteral Feeding and Omega-3 Fatty Early Versus Delayed Enteral Feeding and Omega-3 Fatty Acid/Antioxidant Supplementation for Treating People With Acid/Antioxidant Supplementation for Treating People With Acute Lung Injury or Acute Respiratory Distress SyndromeAcute Lung Injury or Acute Respiratory Distress Syndrome
(The EDEN-Omega Study) (The EDEN-Omega Study)
Interim analysis:Interim analysis: Mortality @ day 60:Mortality @ day 60:
• 26.6% Omega-3 Vs 16.3% Control26.6% Omega-3 Vs 16.3% Control Ventilator-Free days (within 28 days): Ventilator-Free days (within 28 days):
• 14.6 days Omega-3 Vs 17.4 days Control14.6 days Omega-3 Vs 17.4 days Control ICU-Free days (within 28 days):ICU-Free days (within 28 days):
• 13.9 days Omega-3 Vs 16.8 days Control13.9 days Omega-3 Vs 16.8 days Control
Chest Physician. August 2009. Elsevier.
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Septic Shock – DiagnosisSeptic Shock – Diagnosis
Serum MarkersSerum Markers
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Annane D et al. Lancet 2005;365:63-78
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Nobre V et al. AJRCCM 2008;177:498-505
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Tang B et al. AJRCCM 2007;176:676-684
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Wurfel M et al. AJRCCM 2008;178:710-720
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Cinel I et al. CCM 2009;37:291-304
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Russell J. NEJM 2006;355:1699-713
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Septic Shock – TreatmentSeptic Shock – Treatment
Last but not less important…Last but not less important… Sedation protocolSedation protocol
• Sedation GoalSedation Goal• Daily awakening trialsDaily awakening trials• Avoid NMBAs as much as possibleAvoid NMBAs as much as possible
DVT prophylaxisDVT prophylaxis Stress Ulcer (GI) prophylaxisStress Ulcer (GI) prophylaxis Consideration for Limitation of SupportConsideration for Limitation of Support
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