1. Shock and Sepsis 2 of 2 William Whitehead, M.D., Ph.D. Department of Anesthesiology

2. Management “Surviving Sepsis Campaign”: An international group of experts published in 2004 the first guidelines for the bedside clinician to use to improve outcomes in severe sepsis and septic shock. Therapeutic Bundles

3. What are “bundles”? A group of interventions related to a disease that, when implemented together, result in better outcomes than when implemented individually. The science behind the elements of the bundle is so well-established that their implementation should be considered a generally accepted practice. Bundle components can easily be measured as completed or not completed. As such, the overall bundle – all the elements taken together – can also be measured as completed or not completed.

5. 10 Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Dellinger, R; Levy, Mitchell; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; MD, PhD; Opal, Steven; Sevransky, Jonathan; Sprung, Charles; Douglas, Ivor; Jaeschke, Roman; Osborn, Tiffany; MD, MPH; Nunnally, Mark; Townsend, Sean; Reinhart, Konrad; Kleinpell, Ruth; PhD, RN-CS; Angus, Derek; MD, MPH; Deutschman, Clifford; MD, MS; Machado, Flavia; MD, PhD; Rubenfeld, Gordon; Webb, Steven; MB BS, PhD; Beale, Richard; Vincent, Jean-Louis; MD, PhD; Moreno, Rui; MD, PhD Critical Care Medicine. 41(2):580-637, February 2013. DOI: 10.1097/CCM.0b013e31827e83af Figure 1. Surviving Sepsis Campaign Care Bundles.

7. Critical Care Medicine 36(1):296-327 (2008)

11. Patient randomized N=263 Early goal directed therapy N=130 Standard therapy N=133 CVP > 8-12 mm Hg MAP > 65 mm Hg Urine Output > 0.5 ml/kg/hr CVP > 8-12 mm Hg MAP > 65 mm Hg Urine Output > 0.5 ml/kg/hr ScvO 2 > 70% SaO 2 > 93% Hct > 30% Antibiotics given at discretion of treating clinicians As soon as possible Mean 6.2hrs ICU MDs blinded to study treatment NEJM 2001;345:1368-77. At least 6 hours of EGDT Mean 8hrs Transfer to ICU

14. Therapy Across the Sepsis Continuum. Chest 1992;101:1644. SepsisSIRS Severe Sepsis Septic Shock Early Goal Directed Therapy Antibiotics and Source Control Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O 2 delivery with O 2 demand *

15. CVP: MAP: ScvO2: Hgb:

16. CVP: central venous pressure MAP: mean arterial pressure ScvO 2 : central venous oxygen saturation Early Goal- Directed Therapy NEJM 2001;345:1368-77.

17. Lactate: An Indicator of Tissue Perfusion Serum lactate levels are used to assess the disease severity and adequacy of global tissue perfusion By-product of anaerobic metabolism if tissue hypoxia exists Interpretation of elevated blood lactate levels in sepsis is limited by several important factors1: Production of elimination Increasing glycolysis Inhibition of pyruvate metabolism Global changes Bakker J, Gris P, Conerfils M, et al. Serial Blood Lactate Levels Can Predict the Development of Multiple Prgan Failure Following Septic Shock, Am J Surg 1996; 171:221-226.

18. 15 Figure 2. Algorithm for time sensitive, goal-directed stepwise management of hemodynamic support in infants and children. Reproduced from Brierley J, Carcillo J, Choong K, et al: Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666-688.