Sepsis-3

Abdul Hakeem Al Hashim, MD, FRCPC
Senior Consultant
Internal Medicine & Critical Care
Sultan Qaboos University Hospital

Topics
• Definition of Sepsis

• Resuscitation strategy

• Use of Vasopressors

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History

1991

2001

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Surgery hypotension . Intensivists characterized by fluid resuscitation . Task of: circulatory failure persistent despite . Pulmonary hypoperfusion & unexplained by medicine organ other causes dysfunction 4 . Septic Shock Definitions 1991 2001 2016 Sepsis induced State of acute Sepsis-3 hypotension. ID persistent arterial along with .

000 or > 10% immature (band ) forms Sepsis: SIRS with definitive evidence of infection Severe Sepsis: Sepsis with organ dysfunction.000 or < 4. hypoperfusion or hypotension Septic shock: Sepsis with hypotension despite adequate fluid resuscitation 5 . Old Definition SIRS: ( 2 or more of:) : 1) Temperature >38 or < 36C 2) HR > 90/min 3) RR >20/min or PaCO2 < 32 mmHg 4) WBC > 11.

Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.000 or < 4.000 or > 10% immature (band ) forms [Adapted from Bone RC et al. Chest 1992. 101:1644-55 6 . Old definition SIRS: ( 2 or more of:) : 1) Temperature >38 or < 36C 2) HR > 90/min 3) RR >20/min or PaCO2 < 32 mmHg 4) WBC > 11.

The Netherlands 60% 7 . hypoperfusion or hypotension • Mortality: . Australia 22% . Old definition • Severe Sepsis: Sepsis with organ dysfunction. Germany 60.5% .

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Sepsis 2016: Definition • Sepsis: a life-threatening organ dysfunction caused by a dysregulated host response to infection 9 .

Clinical Criteria of Sepsis • Sepsis: Infection with organ dysfunction Organ Dysfunction: Acute change in total SOFA score ≥ 2 from baseline (Previous healthy patient: take baseline SOFA as zero) SOFA: Sequential (Sepsis-related) Organ Failure Assessment 10 .

SOFA score 11 .

Scoring Outside ICU. qSOFA has similar predictive validity to more complex scores Outside the ICU. consider Sepsis if: Infection + ≥ 2 qSOFA points 12 .

Altered mental status .Tachypnia (RR ≥ 22/min) 13 . qSOFA • Respiratory Rate • Mental Status • Systolic BP HAT .Hypotension (sBP ≤ 100) Mnemonic .

Important • qSOFA doesn’t define sepsis • A predictor of increase ICU stay and mortality 14 .

Systolic BP ≤ infusion qSOFA ≥ 2? Serum creatinine or urine output 100 mmHg Bilirubin Platelet count YES Assess for YES evidence of SOFA ≥ 2? Sepsis organ dysfunction 15 . Clinical Criteria Patients with qSOFA: SOFA Variables: PaO2/FiO2 ratio suspected infection .RRComa Glasgow ≥ 22/min Scale score Mean .Altered arterial pressure Administration of vasopressors mentation with type and dose rate of .

cellular & metabolic abnormalities are associated with a greater risk of mortality 16 . Sepsis Shock • Sepsis: a life-threatening organ dysfunction caused by a dysregulated host response to infection • Septic Shock: a subset of sepsis in which profound ciruculatory.

Cellular / Metabolic 17 .Circulatory dysfunction . Septic Shock 2016 • Who are those sickest patients with higher mortality?? • What clinical criteria? .

Cellular/ Metabolic: lactate 18 .

3 19 . In hospital Mortality Patients Hospital Mortality (%) 18.7 No Hypotension & Lactate < 2 Lactate > 2 only 25.7 Hypotension only 30.1 Hypotension + Lactate > 2 42.

Septic Shock Sepsis Despite adequate fluid resuscitation: 1)Vasopressors required to maintain MAP ≥ 65 mmHg & 2) Serum lactate ≥ 2 mmol/L YES Septic Shock 20 .

Use sepsis mostly 21 .Confusing . Sepsis & Septic Shock • SIRS .Non specific Out • Severe Sepsis .

Sepsis & Septic Shock • New sepsis ≈ old severe sepsis (with better defined criteria of organ dysfunctin {SOFA} ) • Septic shock: bad sepsis with higher mortality 22 .

Emergency medicine societies . New definition • Not widely accepted or endorsed .No change recommended for regulatory agencies and hospital Quality dept Why? 23 .American College of Chest Physicians .

you want to identify patients at risk 24 . New criteria criticism • Sepsis I – II: Suspected Infection + (SIRS) • Sepsis III: Suspected Infection + (qSOFA + SOFA) • qSOFA & SOFA are mortality indicator In ER.

79 68 67 qSOFA ≥ 2 0.81 55 84 25 .76 64 65 SOFA ≥ 2 0. SIRS vs qSOFA Test Area under Sensitivity Specificity ROC curve for Mortality for Mortality % SIRS ≥ 2 0.

Asking too much? .Questions about their sensitivity / specificity (no prospective studies) .Not all ICUs use SOFA score • Lactate Not all hospitals measure lactate 26 .What about centers with limited resources? . New Criteria Criticism • qSOFA: screening with low BP (too late?) • SOFA score: .

culture. SIRS still has a role Steps of new sepsis • 1st step: Identification of infection.Crystalloid Note: No 30change mL / kg in pathobiology or . and antibiotic administration • 2nd step: screening of organ dysfunction and management of sepsis: qSOFA / SOFA Three-hour bundle elements • 3rd step: Identification and management of initial hypotension: .Reassessment of tissue perfusion / volume responsiveness management 27 .

0 28 .Sepsis definition 3.

Topics • Definition of Sepsis • Resuscitation strategy • Use of Vasopressors 29 .

?Early Goal Directed Therapy? Resuscitation 30 .

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Management of septic shock 32 .

EGDT in severe sepsis and septic shock .

Management of septic shock 34 .

NEJM: March 2014: ProCESS trial 35 .

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Protocol

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Central venous saturation (SvO2) 41 .Does it mean no Central line? • Unstable patients need central line for: .Multiple drug infusions .Vasopressor infusion .

Does it mean no central line? 42 .

Management of septic shock 43 .

ALBIOS trial 44 .

NEJM March 2014 45 .

Crystalloids vs Colloids 46 .

Management of septic shock 47 .

SvO2 48 .

Management of septic shock 49 .

What is the target BP? 50 .

SEPSISPAM • Randomized trial of 776 patients with septic shock in France • High target ( MAP 80-85) vs Low MAP (65-70) x 5 days. • Inclusion: – >18 – Refractory shock – Septic shock < 6 hours – Norepinephrine > 0.1mcg/kg/min 51 .

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Increased abdominal pressure . Initial renal impairment 54 . Hx of chronic HTN . Target BP • At least MAP 65 mmHg • Probably higher value if: .

Management of septic shock 55 .

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randomized control trial • 1005 patients • Low Hb threshold (7g/dl) and High Threshold (9 g/dl) 57 . TRISS trial • Multicenter.

– Reaction to transfusion. 58 . – Acute coronary syndrome – Prior transfusion in the ICU. TRISS trial • Inclusion: – Septic Shock – > 18 years – Hb < 9g/dl • Exclusion: – Active Bleeding.

TRISS trial .

TRISS trial .

Management of septic shock 61 .

Sepsis • Primarily treat sepsis with IV fluids • Use crystalloids • MAP > 65 mmHg adequate • Early antibiotics (within 1 hour) • Hb threshold 7 is adequate • No use of ScvO2 62 .

Topics • Definition of Sepsis • Resuscitation strategy • Use of Vasopressors 63 .

Intensive Care Med 2013.Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock.637 . 41(2): 580. 39(2): 165- 228 and Crit Care Med 2013.

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Vasopressor therapy initially to target MAP 65mmHg .

Vasopressors 68 .

Vasopressors 69 .

Vasopressors 70 .

Norepinephrine VS Dopamine 71 .

Norepinephrine VS DA 72 .

• Improves systemic blood pressure • Does not substantially worsen end-organ ischemia in most studies of crystalloid-resuscitated septic shock patients • Equivalent efficacy in increasing mean arterial pressure. oxygen consumption. and oxygen delivery compared with other catecholamine pressors • Gastric pH has been observed to increase (not decrease) .

01 to 0. Presneill JJ. Granton JT.358(9):877 . Holmes CL. N Engl J Med. 2008.Vasopressin and Septic Shock Trial (VASST) • 778 patients with septic shock randomly assigned to either low dose vasopressin (0. Storms MM. similar incidence of serious adverse events Russell JA. Singer J. Hébert PC. Gordon AC. Mehta S. Cooper DJ. VASST Investigators. Cook DJ. Ayers D.03 units per minute) norepinephrine (5 to 15 mcg per minute) • similar 28-day and 90-day mortality rates. Vasopressin versus norepinephrine infusion in patients with septic shock. Walley KR.

Vasopressors 1st choice: Norepinephrine &/or Epinephrine /Vasopressin Dopamine in ONLY highly selected patients. Absolute bradycardia 75 .

alhashim@gmail. Thanks Questions / Discussion ah.com 76 .