1 R. Phillip Dellinger, MD, MCCM, FCCP Acting Chair & Chief of Department of MedicineHead, Division of Critical Care MedicineCooper University HospitalCamden, New JerseyProfessor of Medicine Cooper Medical School of Rowan University
2 What’s new with the 2012 guidelines and associated changes in the database R. Phillip Dellinger MD, MCCMChrista A. Schorr RN, MSN, FCCMCooper Medical School Rowan UniversityCooper University HospitalCamden, NJ
3 Potential Conflicts of Interest Neither has direct or indirect potential financial conflict of interest as to any material presented in this presentationAs to potential intellectual conflict of interest both hold leadership positions in Surviving Sepsis Campaign
4 management of severe sepsis and septic shock: 2012 Surviving Sepsis Campaign: International guidelines formanagement of severe sepsis and septic shock: 2012R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung, Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus, Clifford S. Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup.Crit Care Med 2013; 41:Intensive Care Medicine 2013; ..
5 Currently Funded with a Gordon and Betty Moore Foundation Grant No direct or indirect industry support for guidelines revision
6 Grading Quality of Evidence GRADE System A- high qualityB- intermediateC- lowD- very lowCase series or expert opinionUpgrade capabilityUngraded (UG) recommendation
7 Grading Strength of Recommendation GRADE System 1- strong recommendationWe recommend2- weak recommendationWe suggest
8 Early Screening and a Performance Improvement Program
9 Antibiotic TherapyWe recommend that intravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (1C).(Best Practice versus Stand of Care)
10 Resuscitation of Sepsis Induced Tissue Hypoperfusion Recommend MAP 65 mm Hg
12 Fluid therapyWe recommend crystalloids be used in the initial fluid resuscitation of severe sepsis (Grade 1B).
13 Fluid therapyWe suggest the use of albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (Grade 2C).
14 Fluid challenge Initial fluid challenge in sepsis-induced tissue hypoperfusion (hypotension or elevated lactate)A minimum of 30ml/kg of crystalloids(a portion of this may be albumin equivalent). (1B)
16 VasopressorsWe recommend norepinephrine as the first choice vasopressor (Grade 1 B).
17 Vasopressors2. We suggest epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain blood pressure (Grade 2B).
18 Vasopressors3. Vasopressin .03 units/min can be added to norepinephrine with the intent of raising MAP to target or decreasing or decreasing norepinephrine dosage. (UG)
19 PhenylephrinePure vasopressor and in general not recommended
20 Sepsis Induced Tissue Hypoperfusion (Recommend Quantitative Resuscitation) Requirement for vasopressors after fluid challengeorLactate ≥ 4 mg/dLThe initial resuscitation of the patient is of utmost importance and frequently occurs in the emergency department or on hospital wards.
21 Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion RecommendInsertion central venous catheterCentral venous pressure: 8–12 mm HgHigher with altered ventricular compliance or increased intrathoracic pressureGrade 1C
22 Arterial Systolic Pressure Variation Parry-Jones, et al. Int J Respir Crit Care Med 2003;2:67
23 Effect on Stroke Volume PartAOnce the initial Arterial thermodilution Cardiac Output is obtained the system is now calibrated to do the PCCO measurement.PCCO is the measurement of Continuous Cardiac Output which is measured beat to beat.How many of you look at the arterial line wave form to determine if the patient has adequate vascular volume ?Tall narrow and peaked waveform may be an indication of possible hypovolemia.Wide and Fat may be an indication of low vascular volume.The truth is that the area under the arterial wave form is proportional to stroke volume. We determine the stroke volume and multiply it buy the heart rate and get Cardiac Output.t