1 / 17

Early Goal Therapy in Severe Sepsis & Septic Shock

Early Goal Therapy in Severe Sepsis & Septic Shock. Nabil Abouchala, MD, FCCP, FACP Consultant, Pulmonary and Critical Care Medicine King Faisal Hospital & Research Center Riyadh, Saudi Arabia. Sepsis: Defining a Disease Continuum. Infection/ Trauma. Sepsis. Severe Sepsis. SIRS.

aelan
Télécharger la présentation

Early Goal Therapy in Severe Sepsis & Septic Shock

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Early Goal Therapy in Severe Sepsis & Septic Shock Nabil Abouchala, MD, FCCP, FACP Consultant, Pulmonary and Critical Care Medicine King Faisal Hospital & Research Center Riyadh, Saudi Arabia 1

  2. Sepsis: Defining a Disease Continuum Infection/Trauma Sepsis Severe Sepsis SIRS SIRS with a presumed or confirmed infectious process A clinical response arising from a nonspecific insult, including  2 of the following: • Temperature 38oC or 36oC • HR 90 beats/min • Respirations 20/min • WBC count 12,000/mm3or 4,000/mm3 or >10% immature neutrophils SIRS = Systemic Inflammatory Response Syndrome Adapted from: Bone RC, et al. Chest 1992;101:1644 Opal SM, et al. Crit Care Med 2000;28:S81 2

  3. Shock Sepsis: Defining a Disease Continuum Infection/Trauma Sepsis Severe Sepsis SIRS • Sepsis with 1 sign of organ failure • Cardiovascular (refractory hypotension) • Renal • Respiratory • Hepatic • Hematologic • CNS • Metabolic acidosis 3 Bone et al. Chest 1992;101:1644; Wheeler and Bernard. N Engl J Med 1999;340:207

  4. Sepsis 400,000 7-17% Severe Sepsis 300,000 20-53% Septic Shock 53-63% Mortality Increases in Septic Shock Patients Incidence Mortality 4 Balk, R.A. Crit Care Clin 2000;337:52

  5. Sepsis Bundle • A. Initial Resuscitation Resuscitation Bundle Serum Lactate Measured Blood Culture Obtained Prior to Antibiotic Administration Broad-Spectrum Antibiotics Administered within 1 Hour of ED Admission Fluid Resuscitation (30 ML/Kg) for Hypotension or Lactate >4mmol/L Vasopressors for Ongoing Hypotension Maintain Adequate Central Venous Pressure (CVP ≥ 8) Maintain Adequate Central Venous Oxygen Saturation (ScvO2 ≥ 70%) Re-measure Serum Lactate

  6. Early Goal-directed Therapy in the Treatment of Severe Sepsis and Septic Shock To Examine whether Early Goal Directed Therapy (EGDT) before admission to the ICU is superior to standard hemodynamic therapy in patients with sever sepsis and septic shock #Citing articles 2469 N Engl J Med, 2001;345:1368-77

  7. Protocol for Early Goal-Directed Therapy Central venous and arterial catheterization Crystalloid Colloid CVP 8 -12 mm Hg Vasoactive agents MAP ³65 and £90 mm Hg Transf. of RBC until Hct³30% Inotropic agents ScvO2 ³70% Goals achieved Hospital admission N Engl J Med, 2001;345:1368-77

  8. Venous Oxygen Saturation Alternative of using mixed venous oxyhemoglobin saturation from pulmonary artery catheter instead of central venous O2 saturation from CVP catheter

  9. ◦ If venous O2 saturation target not achieved: (2C) • Consider further fluid • Tansfuse packed red blood cells if required to hematocrit of ≥30% and/or • Dobutamine infusion max 20 µg.kg−1 .min−1 Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

  10. Treatment Administered N Engl J Med, 2001;345:1368-77

  11. 10-20% Sudden Death! MOrtality

  12. NNT to prevent 1 event (death) = 6 - 8 Standard therapy 60 EGDT 50 40 Mortality (%) 30 20 10 0 In-hospital mortality (all patients) 28-day mortality 60-day mortality The Importance of Early Goal-DirectedTherapy for Sepsis-induced Hypoperfusion Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.

  13. Results 37 Observational studies showing improved outcomes with early quantitative resuscitation between 2001 and 2011 • Mortality • EGT : 30.5 % • Standard: 46.5 % • Absolute Risk Reduction • NNT = 16% 7 Multicenter trial of 314 patients with severe sepsis in eight Chinese centers (2010). This trial reported a 17.7% absolute reduction N Engl J Med, 2001;345:1368-77

  14. Sepsis induced vasodilatation Lower amount of fluid required to fill the tank NE

  15. Vasoconstriction

  16. Crit Care Med 2007; 35:1736–1740 Early NE + Fluids Late NE + Fluids Fluids NE LPS

More Related