Professional Documents
Culture Documents
Evolving Concepts
University of Toronto
Sepsis
Pepsis
Hippocrates 460 370 BC
Consequences
Public health
Immunization Sterilization
Antibiotics
+ LPS
- Michalek, J.Infect.Dis. 141:55, 1980
+ LPS
HeJ Marrow Live
Passive immunization
Bruce Beutler
Consequences
New diseases
New therapeutic targets Response is the disease Not unique to infection
Infection
Sepsis
SIRS
<8
CVP
>8
Fluids
<65
Pressors
Transfusion, Inotropes
> 65
ScvO2
> 70
Goals achieved
60
Mortality (%)
50
40
30 20 10 0
Hospital Mortality 28 Day Mortality 60 Day Mortality
(95% CI)
10
Impact of Source Control in 1170 Patients with Sepsis 28 Day Mortality Adequate Inadequate
31.4% (303/964) 42.7% (88/206)
p.
0.003
Despite conventional treatment, 25 - 30% of septic patients die of a process characterized by persistent inflammation and non-resolving
organ dysfunction.
Lipopolysaccharide (LPS)
TLR4
Endotoxin
CD14
IRAK TRAF2
MyD88
NFkB
TLR4
Endotoxin
CD14
IRAK TRAF2
MyD88
NFkB
Toll-like Receptors
TLR2 TLR3 TLR4 TLR5 TLR6 TLR7 TLR8 TLR9 Lipoteichoic acid, bacterial lipoprotein, Injured tissue Double-stranded RNA Endotoxin, elastase, heparan, HSP60, oxidized phospholipids Flagellin Mycoplasma lipopeptide Imiquod, viral DNA Viral DNA, single-strand RNA Bacterial DNA
* *
PMN/Mouse (X 106)
10 8
6
4 2 0 Baseline
C3H/HeN C3H HeJ
0 Day 1 Day 7
4 Hours
Receptors
LPS challenge in
human volunteers
causes altered
expression of 3714
distinct genes.
J5, HA-1A, E5
rBPI21 Polymyxin B dextran HDL, taurolidine Alkaline phosphatase Lipid emulsion Extracorporeal removal
TLR4
Endotoxin
CD14
IRAK TRAF2
MyD88
NFkB
TLR4
Endotoxin
CD14
IRAK TRAF2
MyD88
NFkB
Anti-TNF Antibodies
8 Studies; 6500 patients
TLR4
Endotoxin
CD14
IRAK TRAF2
MyD88
NFkB
0.03 0.03 NS
Percent Surviving
60
Placebo
40
20
p<0.001 Wilcoxon
L-NMMA
14
21
28
Day of Study
- Lopez, Crit Care Med 32:21, 2004
TLR4
Endotoxin
CD14
IRAK TRAF2
MyD88
NFkB
0.4
0.3 0.2 0.1 0.0
10
20
30
40
50
60
70
80
90
703 701
656 645
622 616
593 596
579 584
569 576
563 567
557 561
553 555
But
Impact is modest Indications for use poorly defined
<5 mg/kg/hr
> 5mg/kg/hr 0 1 2 3 4 5 6
TNF (ng/ml)
5 4 3 2 1 0 Pre 2 24
72
Hours Post-Infusion
Sepsis Syndrome
(Bone et al; 1987)
Suspected or proven infection, in association with: Tachycardia Tachypnea Hyper- or hypothermia Dysfunction of one or more organs
Sepsis Syndrome
24 year old man with penetrating injury to colon 86 year old woman with CHF and Enterococcal UTI 51 year old man with COPD exacerbation; Candida in sputum
83 965 2130
Organ dysfunction
- Crit Care Med 31:1250, 2003
Prognosis
Potential to respond to treatment
Insult
Inflammatory Response
Organ Dysfunction
Inflammation Iatrogenic
95% CI
1.14 2.57 1.25 3.12 2.47 13.7 1.32 15.4 0.16 8.99
Disease
Meningococcemia (deaths)
Septic shock (deaths) Septic shock (deaths)
Cases Controls p.
0.56 0.29 0.03
Mira
0.52
0.24
0.008
Tang
0.40
0.08
<0.05
*p=0.001
-1
-2 -3
-4
Etanercept (N=455)
Infliximab (N=453)
-40
-20
20
40
60
Salmonella
N=11
Candida
N=14
Listeria
N=10
M. tuberculosis
N=11
-40
-30
-20
-10
10
20
30
N 31 30
95% CI
0.56-3.40 0.74-4.47
Bacteremia
Urinary Tract
57
23
1.83
0.49
0.79-4.26
0.15-1.60
Impact of Source Control in Patients with Low IL-6 Levels Source Control Mortality
Adequate
(N=545)
126 (23.1%)
48 (39.7%)*
* p<0.001
Inadequate
(N=121)
Impact of Source Control in Patients with High IL-6 Levels Source Control Mortality
Adequate
(N=419)
177 (42.3%)
40 (47.1%)*
* p=0.49
Inadequate
(N=85)
p.
0.81
2/27 (7%)
16/43 (37%)
0.006
60
40
20
Sepsis is an
iatrogenic disorder:
It develops in the survivors of acute life-threatening infection ICU care shapes its evolution
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome
Mortality (%)
Controls
39.8
Volume-limited 31.0*
*P=0.007
ARDSNet; NEJM 342:1301, 2000
Fluid resuscitation
p.
0.30 <0.001
25.8%
16.2%
0.02
62.0%
42.1%
0.04
95% CI
0.79 0.93 0.62 0.71 0.68 0.96
p.
<0.00001 <0.00001 0.02
Steroids
Low Vt
1.06
0.70
0.96 1.17
0.62 0.78
0.24
<0.00001
Conclusions
Improved understanding of biology of response to injury
Thank you!