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Sino-Fr Symposium - Oct 07C. Brun-Buisson Surviving Sepsis Barcelona declaration (ESICM congress, 2002) Surviving Sepsis Campaign Guidelines (CCM & ICM,

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Presentation on theme: "Sino-Fr Symposium - Oct 07C. Brun-Buisson Surviving Sepsis Barcelona declaration (ESICM congress, 2002) Surviving Sepsis Campaign Guidelines (CCM & ICM,"— Presentation transcript:

1 Sino-Fr Symposium - Oct 07C. Brun-Buisson Surviving Sepsis Barcelona declaration (ESICM congress, 2002) Surviving Sepsis Campaign Guidelines (CCM & ICM, 2004) SSC guidelines Version 2 Crit Care Med 2004; 32: Intensive Care Med 2004 ; 30 : 536.

2 Sino-Fr Symposium - Oct 07C. Brun-Buisson Potential conflicts of interest « The challenges involved in producing first-rate guidelines and performance standards are only exacerbated by the intrusion of marketing strategies masquerading as evidence-based medicine. »

3 Sino-Fr Symposium - Oct 07C. Brun-Buisson Severe Sepsis: 34% G.Martin et al, NEJM 2003; 348: Population-adjusted Incidence of Sepsis, USA, Severe Sepsis: 34% France: Choc septique 9%

4 Surviving Sepsis ? 1. Identification & initial assessment Recommandations SFAR – SRLF 2006

5 Sino-Fr Symposium - Oct 07C. Brun-Buisson SIRS and Organ Dysfunction Criteria SIRS: Conventional criteria Fever / hypothermia Tachypnea Tachycardia Leukocytosis / leukopenia Others Biomarkers: Elevated PCT,.. Organ dysfunctions - lactates > 4 mmol/l - SBP < 90 mm Hg - PaO2/FiO2 < Oliguria, creatinine > 176 mmol/L - INR > 1,5 / PT > 60 sec - thrombocytopenia < /mm3 - bilirubin > 34 µmol/l - Glasgow coma score 13 But < 50% of patients with SIRS have documented infection

6 Sino-Fr Symposium - Oct 07C. Brun-Buisson Infection/Sepsis: Initial assessment Biochemistry Hematology And coagulation Tachycardia Tachypnea Fever or hypothermia Skin perfusion Neurologic status Arterial pressure Urine output Lactate Sev Sepsis? Initial assessment (H0-H3) Evaluatio n of sepsis Recommandations SFAR – SRLF 2006

7 Sino-Fr Symposium - Oct 07C. Brun-Buisson Algorithm for disposition of patients in ED Suspected Severe Sepsis Organ failure? Monitoring HR, RR, AP, Urine Oxygen to SpO2>95% Biochemistry (lactate) & microbiology Cristalloids (500 ml/15 min) to mAP >65 Call referent intensivist ICU Admission Urine < 0,5 ml/kg/h ? Urine < 0,5 ml/kg/h ? mAP < 65 ? YESYES YES Clinical Hypoperfusion ? Clinical Hypoperfusion ? mAP <65 ? Lactate >4 ? Comorbidity ? Etiology at risk ? YESI YES YES YES YES YES Acute care area Maintain non-invasive monitoring + urine output No No No NoNo No Recommandations SFAR – SRLF 2006

8 Sino-Fr Symposium - Oct 07C. Brun-Buisson Infection/Severe Sepsis: initial steps Sev Sepsis ? 0 – 3 hrs Source Control: Drainage? Surgery? Re-assessment of organ dysfunctions Antibiotics Blood cultures + site samples Fluid Challenge Imaging? Recommandations SFAR – SRLF 2006

9 Surviving Sepsis Campaign 2. Recommendations and Guideline Revision ( ) Sponsored exclusively by supporting societies

10 Sino-Fr Symposium - Oct 07C. Brun-Buisson Impact on survival of early antibiotic administration Kumar et al, Crit Care Med 2006; 34:

11 Sino-Fr Symposium - Oct 07C. Brun-Buisson

12 Sino-Fr Symposium - Oct 07C. Brun-Buisson E. Rivers, EGT

13 Sino-Fr Symposium - Oct 07C. Brun-Buisson EGT – Mortality rates * * * RR = P = E. Rivers et al, NEJM 2001

14 Sino-Fr Symposium - Oct 07C. Brun-Buisson EGT - Volume of fluid infused * P<0.01 ** * * E. Rivers et al, NEJM 2001

15 Sino-Fr Symposium - Oct 07C. Brun-Buisson Fluid Therapy We recommend fluid resuscitation with either natural/artificial colloids or crystalloids. There is no evidence-based support for one type of fluid over another. 1B Supportive Care: Glucose Control Recommend glucose control with intravenous insulin after initial stabilization 1B Suggested glucose target: Normal and < 150 mg/dL 2C

16 Sino-Fr Symposium - Oct 07C. Brun-Buisson

17 Sino-Fr Symposium - Oct 07C. Brun-Buisson Potential conflicts of interest Pour un moratoire sur lutilisation des hydroxyéthylamidons L. Brochard1, F. Schortgen1, C. Brun-Buisson1, D. Dreyfuss2, J.-J. Rouby3, J. Chastre4, D. Robert5, G. Hilbert6, D. Payen7, E. LHer8, C. Richard9, M. Gainnier10, J. Pugin11, J.-C. M. Richard12. Conclusion Les données dont nous disposons actuellement suggèrent fortement que la balance entre les bénéfices attendus et les risques observés avec ladministration des hydroxyéthylamidons est défavorable. Dans ces conditions, il ne parait pas justifié de continuer à utiliser ces produits pour le remplissage vasculaire en réanimation, alors que des alternatives moins toxiques (et moins coûteuses) sont disponibles. Il ne sagit pas à notre sens dune querelle dexperts, et nous suggérons à titre protecteur quun moratoire soit mis en place sur lutilisation des hydroxyéthylamidons dans le remplissage vasculaire chez les patients de réanimation, dans lattente de nouveaux essais démontrant de manière convaincante leur avantage et leur innocuité.

18 Sino-Fr Symposium - Oct 07C. Brun-Buisson Vasopressors We recommend either norepinephrine or dopamine as the first choice vasopressor agent to correct hypotension in septic shock (administered through a central catheter as soon as one is available) ( 1C) We suggest that epinephrine, phenylephrine, or vasopressin should not be administered as the initial vasopressor in septic shock (2C).

19 Sino-Fr Symposium - Oct 07C. Brun-Buisson SSC: Objectives for the first 6 hours 1.Mesure arterial lactate level 2.Obtain blood cultures before administering antibiotics 3.Prescribe within 3 (1) hrs broad-spectrum empiric antibiotic therapy 4.If hypotension (PAS 4 mmol/l) : 1.Start fluid loading with cristalloïds (or equivalent colloïd) ml /kg estimated ideal body weight. 2.Administer vasopressors to maintain mAP 65 mmHg, if persisting hypotension despite adequate fluid loading.

20 Sino-Fr Symposium - Oct 07C. Brun-Buisson SSC: Objectives for the first 6 hours 5.If persisting hypotension or hyperlactatemia (> 4 mmol/l) despite initial fluid loading, measure PVC and ScvO2 (or SvO2), and: Maintain CVP at mmHg. Consider inotropic therapy and/or RBC transfusion if hematocrit is 30 % when ScvO2 is < 70 %, or SvO2 < 65 % and CVP 8 mmHg. (2B) Recommandations SFAR – SRLF 2006

21 Sino-Fr Symposium - Oct 07C. Brun-Buisson Low-dose Steroids: 28 d survival HR = 0.67 p=0.023 D. Annane & al, JAMA 2002;288: Non-Responders Responders

22 Sino-Fr Symposium - Oct 07C. Brun-Buisson Low-dose Steroids We suggest intravenous hydrocortisone be given only to adult septic shock patients after blood pressure is identified to be poorly responsive to fluid resuscitation and vasopressor therapy 2C We recommend corticosteroids not be administered for the treatment of sepsis in the absence of shock. 1D

23 Low-dose Steroids ACTH stimulation test (250- g) not recommended (2B) Variability in assay Variability in response on same day Free versus protein bound measurement Fludrocortisone optional (2C) Dexamethasone only if hydrocortisone not available (2B)

24 Sino-Fr Symposium - Oct 07C. Brun-Buisson

25 Sino-Fr Symposium - Oct 07C. Brun-Buisson Recombinant Human Activated Protein C (rhAPC) Suggest use in patients with clinical assessment of high risk of death due to sepsis induced organ dysfunction, typically with APACHE II 25 or multiple organ failure (2B) And no absolute contraindications Weighing the risk/benefit of relative contraindications We recommend that adult patients with severe sepsis and low risk of death, most of whom will have APACHE II <20 or one organ failure, do not receive rhAPC (1A )

26 Surviving Sepsis 3. Experience with implementation of the guidelines

27 Sino-Fr Symposium - Oct 07C. Brun-Buisson Probability of survival of patients with septic shock managed before or after (open circles) the implementation of standardized hospital order set Micek S. Crit Care Med 2006; 34: 2707.

28 Sino-Fr Symposium - Oct 07C. Brun-Buisson Many Leaks from research to practice Aware Accept Target Doable Recall Agree Done Valid Research If 80% achieved at each stage then 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21


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