The New Paradigm: Goal-Directed Therapy for Severe Sepsis and Septic Shock Jamie Cowan April 25, 2006 Emergency Medicine Clerkship

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The New ParadigmGoal-Directed Therapy for
Severe Sepsis and Septic ShockJamie
CowanApril 25, 2006Emergency Medicine Clerkship
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Patient Scenario

• 45 yo male
• CC Not feeling well
• Known alcoholic w/cirrhosis
• Temp 96.2
• BP 100/65
• HR 100
• RR 18

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SIRS System Inflammatory Response Syndrome

• Criteria 2 or more of the following
• Temp gt 38C or lt 36 C
• HR gt 90
• RR gt 20
• PaCO2 lt 32
• WBC gt 12,000 or lt 4,000
• Bands gt 10

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Patient History and Exam

• Patient looks ill
• Known alcoholic with acute/chronic pancreatitis
• Says he had an operation to remove dead pancreas
  7 days ago
• Started feeling bad 2 days ago, felt much worse
  last night, developed N/V/D
• Complains of severe abdominal and back pain

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Labs

• Na 141
• K 4.2
• Cl 100
• Cr 1.8
• Glucose 191
• WBC 13 with 15 bands
• Lactate 4.1

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Definition Sepsis

• Sepsis
• SIRS probable site of infection
• Severe Sepsis
• Organ Dysfunction (Oliguria, INR, Cr)
• Hypotension
• Hypoperfusion
• Delta MS
• Lactate
• Septic Shock
• Sepsis induced Hypotension with perfusion
  abnormalities despite fluid resuscitation
• Multiple Organ System Failure (MOSF or MODS)
• Shock, ARDS, ARF, DIC, Liver Failure,
  Hyperglycemia

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Sepsis Epidemiology

• Estimated 750,000 severe sepsis cases in USA per
  year
• 387,000 initially present to ED
• Mortality rate ranges from 23-46
• 500 deaths per day
• Estimated annual cost is 16.7 billion
• Global estimates range from 51-206 cases per
  100,000

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Early Goal-Directed Therapy in the Treatment of
Severe Sepsis and Septic ShockNEJM, Nov 2001
Rivers EP et al.
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• Please see the following tables and figures from
  this article
• Figure 2
• Table 2
• Table 3
• Table 4
• Pubmed link
• Rivers et al. Early goal-directed therapy in the
  treatment of severe sepsis and septic shock. N
  Engl J Med. 2001 Nov 8345(19)1368-77. PMID
  11794169

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Key points from article

• Goal-oriented therapy for sepsis
• Balancing oxygen therapy and demand by managing
  preload, afterload, and contractility
• Primary focus of ICU management
• Study examined role of goal-oriented therapy in
  ED setting and effects on mortality and organ
  dysfunction
• Goal directed therapy in the ED setting was
  associated with
• Decreased in-hospital mortality than standard
  therapy (72 hour comparison)
• Less severe organ dysfunction (APACHE II scores)

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Key points

• Fluid resuscitation
• Monitor MAP, CVP
• Tx Crystalloid/colloid, vasopressors,
  ionotropes
• Estimate total body ischemia
• Monitor lactate and SvO2
• Tx PRBC transfusions