Management of severe sepsis and septic shock in adults

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Management of severe sepsis and septic shock in
adults
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September 2008
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• Early initiation of supportive care to correct
  physiologic abnormalities, such as hypoxemia and
  hypotension.
• Distinguishing sepsis from systemic inflammatory
  response syndrome (SIRS)
• if an infection exists, it must be identified and
  treated as soon as possible. This may require a
  surgical procedure (eg, drainage), as well as
  appropriate antibiotics.

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Noninfectious mimics of sepsis

• Acute myocardial infarction
• Acute pulmonary embolus
• Acute pancreatitis
• Fat emboli syndrome
• Acute adrenal insufficiency
• Acute gastrointestinal hemorrhage
• Overzealous diuresis
• Transfusion reactions
• Adverse drug reactions
• Procedure-related transient bacteremia
• Amniotic fluid embolism

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Early Management

• Stabilize respiration
• Restoring perfusion to the peripheral tissues

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Stabilize respiration

• Supplemental oxygen
• pulse oximetry
• Intubation and mechanical ventilation
• encephalopathy and a depressed level of
  consciousness frequently complicate sepsis.
• Etomidate should be avoided in septic patients
• Etomidate can cause adrenal insufficiency via
  inhibition of glucocorticoid synthesis, increased
  mortality
• Chest radiographs and arterial blood analysis
• acute lung injury (ALI) or acute respiratory
  distress syndrome (ARDS)

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Assess Perfusion

• Common signs cool, vasoconstricted skin due to
  redirection of blood flow to core organs
• restlessness, oliguria or anuria, and lactic
  acidosis
• warm, flushed skin may be present in the early
  phases of sepsis
• These findings may be modified by preexisting
  disease or medications.
• elderly, diabetic, and patients taking
  beta-blockers not exhibit an appropriate
  tachycardia as blood pressure falls
• Patients with chronic hypertension critical
  hypoperfusion at a higher blood pressure than
  healthy patients

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Restore Perfusion

• early restoration of perfusion to limit multiple
  organ dysfunction, reduce mortality
• Early goal-directed therapy (within the first six
  hours of presentation)
• ScvO2 or SvO2gt70 percent.
• central venous pressure 8 to 12 mmHg
• mean arterial pressure (MAP)gt65 mmHg
• urine outputgt0.5 mL/kg per hour

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Early goal-directed therapy in the treatment of
severe sepsis and septic shock. N Engl J Med
2001 Nov 8345(19)1368-77.

• These goals derive from a clinical trial in which
  263 patients with severe sepsis or septic shock
  were randomly assigned to therapy targeting a
  ScvO2 70 percent, or conventional therapy that
  did not target a ScvO2.
• Both groups initiated therapy within six hours of
  presentation and targeted the same CVP, MAP, and
  urine output. Mortality was lower in the group
  that targeted a ScvO2 70 percent (31 versus 47
  percent).

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Protocol for early goal-directed therapy
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Intravenous Fluids

• Volume status, tissue perfusion, blood pressure,
  and the presence or absence of pulmonary edema
  must be assessed before and after each bolus.
• Intravenous fluid challenges can be repeated
  until blood pressure is acceptable, tissue
  perfusion is acceptable, pulmonary edema ensues,
  or fluid fails to augment perfusion.
• Crystalloid versus colloid Clinical trials have
  failed to consistently demonstrate a difference
  between colloid and crystalloid in the treatment
  of septic shock
• In our clinical practice, we generally use
  crystalloid because of the higher cost of colloid.

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Vasopressors

• vasopressors hypotensive despite adequate fluid
  resuscitation or cardiogenic pulmonary edema
• no definitive evidence of the superiority of one
  vasopressor
• norepinephrine, dopamine reasonable
  first-choice among vasopressors
• Phenylephrine, a pure alpha-adrenergic agonist,
  may be useful when tachycardia or arrhythmias
  preclude the use of agents with beta-adrenergic
  activity

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Control of The Septic Focus

• history and physical examination may yield clues
  to the source of sepsis
• Gram stain of material from sites of possible
  infection may give early clues to the etiology of
  infection while cultures are incubating.
• As examples, urine should be routinely Gram
  stained and cultured, sputum should be examined
  in a patient with a productive cough, and an
  intra-abdominal collection in a postoperative
  patient should be percutaneously sampled under
  radiologic guidance.

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Evaluation of Common sources of sepsis
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Additional Therapies

• Recombinant human activated protein C
• Glucocorticoids
• Nutrition
• Intensive insulin therapy

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Summary Recommendation

• Initial management securing the airway and
  correcting hypoxemia.
• Intubation and mechanical ventilation may be
  required
• early restoration of perfusion to limit multiple
  organ dysfunction, reduce mortality. Tissue
  perfusion should be promptly restored using
  intravenous fluids, vasopressors, red blood cell
  transfusions, and inotropes
• central (or mixed) venous oxygen saturation 70
  percent within six hours of presentation (Grade
  1B).
• a central venous pressure 8 to 12 mmHg, mean
  arterial pressure (MAP) 65 mmHg, and urine
  output 0.5 mL per kg per hour.

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Thank You