Professional Documents
Culture Documents
Surat Tongyoo
Critical care medicine
Siriraj Hospital
Overview
Definition
Diagnostic criteria
Clinical impact
Treatment
Hemodynamic management
Fluid resuscitation
Vasopressors & Inotropes
Tissue perfusion evaluation
Source control
Organs and metabolic support
Overview
Surviving Sepsis Campaign: International
Guidelines for Management of Sepsis and
Septic shock: 2016
Department of Medicine, Siriraj Hospital
experience
Diagnostic criteria
SCCM/ESICM/ACCP/ATS/SIS International
Sepsis Definitions Conference 2001
Sepsis (n = 1,063)
20%
Infection, no SIR (n = 584)
0% Days in hospital
0 20 40 60 80
JAMA. 2016;315(8):775-787
Definition
Sepsis
Life-threatening organ dysfunction caused by a dysregulated
host response to infection.
Sepsis is a life-threatening condition that arises when the bodys
response to an infection injures its own tissues and organs.
Organ dysfunction can be identified as an acute change in
total SOFA score 2 points consequent to the infection.
The baseline SOFA score can be assumed to be zero in patients not
known to have preexisting organ dysfunction.
A SOFA score 2 reflects an overall mortality risk of
approximately 10% in a general hospital population with
suspected infection.
JAMA. 2016;315(8):801-810.
SOFA score
JAMA. 2016;315(8):801-810.
How to make diagnosis of
sepsis/septic shock?
Sepsis
Fever or hypothermia
Documented or suspected infection
Organ dysfunction
Tachypnea, hypoxemia
Hypotension
Low platelet, elevated creatinine or bilirubin
Alteration of consciousness
SOFA score 2 or more
Definition
Septic shock
Adult patients with septic shock can be identified
using the clinical criteria of
1. Clinical of sepsis
2. Hypotension requiring vasopressor therapy to maintain
mean BP 65 mmHg or greater
3. Having a serum lactate level greater than 2 mmol/L
after adequate fluid resuscitation.
Hospital mortality > 40%
JAMA. 2016;315(8):801-810.
Baseline serum lactate and Hospital
mortality
JAMA. 2016;315(8):801-810.
Incidence of severe sepsis:
Age dependence
High incidence
2-5% of hospitalization patient
Incidence increasing in elderly
High mortality
30-60%
High cost
USA = 663,000 Thai baht/case
Siriraj = 240,000 Thai baht/case
Problems
Incidence of severe sepsis and septic shock in
Siriraj hospital
Outcome of previously use treatment strategy
What is/are the prognostic determining
factors?
How can we improve our patients outcome?
Clinical significance
During 6 months period
Feb July 2550
Mortality rate
Severe sepsis = 34.3%
Septic shock = 52.6%
Septic shock management
Hemodynamic management
Fluid therapy
Vasopressors & inotrope
Hemodynamic target
Get rid of source of infection
Appropriate antibiotic
Appropriate drainage
Organs support
Metabolic supports
Ventilator support
Adjunctive therapies
Inclusion criteria
2-4 criteria for SIRS
Systolic BP <90 mmHg after 20-
30 ml/Kg crystalloid in 30 min
Blood lactate > 4 mmol/L
Achieve goal in 6 hours
CVP 8-12 mmHg
MAP 65-90 mmHg
ScvO2 > 70%
Result
28d mortality 49.2 vs 33.3%,
OR 0.58(0.39-0.87), P=0.01
60d mortality 56.9 vs 44.3%,
OR 0.67(0.46-0.96), P=0.03
Sudden cardiac death
21 vs 10.3%, P=0.02
Siriraj septic shock
guideline
.. 2545
ICU
septic shock
% %
The first study
Overall mortality 59%
Guideline oriented 65.4%
Better outcome in guideline
used group
Achieve goal in 6 hrs
86.8 vs 44.4%, P<0.001
Hospital mortality
41.2 vs 69.4%, P=0.008
Factors predicted outcome
Lower APACHE II score
1st hr volume > 800mL
Achieve goal in 6 hrs
Correlation of 1sthr volume and survival rate
Percent
P=0.012
Volume 1sthr
Survival of septic shock:
Impact of rapid volume resuscitation
Intervention
EGDT: ScvO2 goal
ScvO2 > 70
EGDT: Lactate clearance
Lactate decrease > 10% in 2-6hrs
JAMA. 2010;303(8):739-746
Lactate and shock management
Good correlation of
serum lactate from
capillary, venous and
arterial blood
A lactate = V lactate
C lactate = A lactate + 1
The 3rd study
Low ScvO2
associated with high
serum lactate
Are current
mmHg
hemodynamic goals
good enough?
Prospective study
60-65
Septic shock survival rate:
According to urine output at 6 hours
Initial lactate level and outcome
Goals achievement and
septic shock outcome
Hemodynamic management
What is(are) our targets? What do we have?
Macrocirculation Intravenous fluid
CVP target? Crystalloid
Blood pressure Colloid
Mean arterial pressure>65 mmHg Albumin, starch, gelatin
Microcirculation Vasopressors
Urine output > 0.5 mL/kg/d Norepinephrine, Dopamine,
ScvO2 > 70 Adrenaline
Lactate < 2 mmol/L Inotrope
Lactate clearance > 10% Dopamine, milrinone,
levosimendan
Invasive monitoring in ICU
Fluid management
Mean BP = 74 mmHg
43% Surgical patients
19% Severe sepsis
17% Trauma patients
Randomized to
Saline vs 4% albumin
NEJM 2004
Outcome
28 d mortality
32% vs 31.8%, P=0.94
Subgroup
Included No septic shock (660)
32.7% vs 37%, P=0.25
1st
1818 d severe sepsis
Septic shock (1121)
SOFA score 8
49.9% vs 43.6%, P=0.03
Mean BP 74 mmHg
Lactate 2.4 mmol/L
Intervention
Crystalloid alone
20% albumin + crystalloid
To keep serum albumin >3 g/dL
NEJM 2012
Results
6%HES vs RLS
Dead at day 90 51% vs 43%
OR 1.17 (1.011.36) P=0.03
Bleeding 10% vs 6%
OR 1.52 (0.942.48) P=0.09
798 severe sepsis patients
RRT 22% vs 16%
OR 1.35 (1.011.80) P=0.04
Randomized to
6HES (Tetraspan) vs RLS
30% Surgical patients
55% Lung infection
33% Abdominal infection
NEJM 2012
Results
Mortality rate
Colloid vs Crystalloid OR (95%CI)
28 d 25.4% vs 27.0% 0.96 (0.88-1.04) P=0.26
2857 shock pts (SBP 92 mmHg) 90 d 30.7% vs 34.2% 0.92 (0.86-0.99) P=0.03
ICU 25.1% vs 28.1% 0.92 (0.85-1.00) P=0.06
54% Septic shock Hospital 30.1% vs 32.6% 0.94 (0.87-1.02) P=0.07
40% Hypovolemic shock
6% Trauma
Random to received
Crystalloid
Colloid
645 Hydroxyethyl starches
281 Gelatin
80 Albumin
JAMA 2013
Fluid management
Current recommendation