Presentation on theme: "Early Goal Therapy in Severe Sepsis & Septic Shock"— Presentation transcript:
1 Early Goal Therapy in Severe Sepsis & Septic Shock Nabil Abouchala, MD, FCCP, FACPConsultant, Pulmonary and Critical Care MedicineKing Faisal Hospital & Research CenterRiyadh, Saudi Arabia1
2 SIRS = Systemic Inflammatory Response Syndrome Sepsis: Defining a Disease ContinuumInfection/ TraumaSIRSSepsisSevere SepsisA clinical response arising from a nonspecific insult, including 2 of the following:Temperature 38oC or 36oCHR 90 beats/minRespirations 20/minWBC count 12,000/mm3 or 4,000/mm3 or >10% immature neutrophilsSIRS with a presumed or confirmed infectious processSIRS = Systemic Inflammatory Response SyndromeAdapted from: Bone RC, et al. Chest 1992;101:1644Opal SM, et al. Crit Care Med 2000;28:S812Draft. For internal use only. Confidential, Eli Lilly and Company, 2001.
3 Sepsis: Defining a Disease Continuum Infection/ TraumaSIRSSepsisSevere SepsisSepsis with 1 sign of organ failureCardiovascular (refractory hypotension)RenalRespiratoryHepaticHematologicCNSMetabolic acidosisShockBone et al. Chest 1992;101:1644; Wheeler and Bernard. N Engl J Med 1999;340:2073Draft. For internal use only. Confidential, Eli Lilly and Company, 2001.
4 Mortality Increases in Septic Shock Patients IncidenceMortality7-17%Sepsis400,00020-53%Severe Sepsis300,000Septic Shock53-63%Balk, R.A. Crit Care Clin 2000;337:524Draft. For internal use only. Confidential, Eli Lilly and Company, 2001.
5 Sepsis Bundle A. Initial Resuscitation Serum Lactate Measured Resuscitation BundleSerum Lactate MeasuredBlood Culture Obtained Prior to Antibiotic AdministrationBroad-Spectrum Antibiotics Administered within 1 Hour of ED AdmissionFluid Resuscitation (30 ML/Kg) for Hypotension or Lactate >4mmol/LVasopressors for Ongoing HypotensionMaintain 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 articles2469N Engl J Med, 2001;345:
7 Protocol for Early Goal-Directed Therapy Central venous andarterial catheterizationCrystalloidColloidCVP8 -12 mm HgVasoactiveagentsMAP³65 and £90 mm HgTransf. of RBCuntil Hct ³30%Inotropic agentsScvO2³70%The protocol was as follows: A 500-ml bolus of crystalloid wasgiven every 30 minutes t achieve a central venous pressure of 8 to12 mm Hg. If the mean arterial pressure was less than 65 mm Hg,vasopressors were given t maintain a mean arterial pressure of atleast 65 mm Hg.If the mean arterial pressure was greater than90 mm Hg,vasodilators were given until it was 90 mm Hg or be-low. If the central venous oxygen saturation was less than 70 per-cent,red cells were transfused t achieve a hematocrit of at least30 percent. After the central venous pressure,mean arterial pressure,and hematocrit were thus optimized,if the central venous oxygensaturation was less than 70 percent, dobutamine administration wasstarted at a dose of 2.5 µg per kilogram of b dy weight per min-ute,a dose that was increased by 2.5 µg per kilogram per minuteevery 30 minutes until the central ven us xygen saturation was70 percent or higher or until a maximal d se of 20 µg per kilogramper minute was given. Dobutamine was decreased in dose or discon-tinued if the mean arterial pressure was less than 65 mm Hg or ifthe heart rate was ab ve 120 beats per minute.T decrease xygenconsumption,patients in whom hemodynamic ptimization couldnot be achieved received mechanical ventilation and sedatives.Goals achievedHospital admissionN Engl J Med, 2001;345:
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 ScvO2 closely paralleled SvO2 but averaged 5 – 7% higherScvO2 > SvO2(5-7%)Reinhart K, et al. Intensive Care Med. 2004;30:
10 ◦ If venous O2 saturation target not achieved: (2C) Consider further fluidTansfuse packed red blood cells if required to hematocrit of ≥30% and/orDobutamine infusion max 20 µg.kg−1 .min−1Rivers E, Nguyen B, Havstad S, et al. 2001;345:
13 In-hospital mortality (all patients) The Importance of Early Goal-Directed Therapy for Sepsis-induced HypoperfusionIn-hospital mortality (all patients)102030405060Standard therapyEGDT28-day mortality60-day mortalityNNT to prevent 1 event (death) = 6 - 8Mortality (%)Rivers E, Nguyen B, Havstad S, et al. 2001;345:
14 Results37 Observational studies showing improved outcomes with early quantitative resuscitation between 2001 and 2011MortalityEGT : 30.5 %Standard: 46.5 %Absolute Risk ReductionNNT =16%7Multicenter trial of 314 patients with severe sepsis in eight Chinese centers (2010).This trial reported a 17.7% absolute reductionmulticenter trial of 314 patients with severe sepsis in eight Chinese centers (14). This trial reported a 17.7% absolute reduction in 28-day mortality (survival rates, 75.2% vs. 57.5%)N Engl J Med, 2001;345:
15 Sepsis induced vasodilatation NELower amount of fluid required to fill the tank