2. SHOZAB AHMED New Era In The Treatment of Septic & Occult Shock

3. Objectives  Define septic and occult shock  Review the current literature in management of septic shock  Importance of volume resuscitation  How to assess volume status?  Old and new protocol used at UNMH

4. SIRS Temp ≥38 or ≤36 HR ≥90 WBC ≥12000, ≤4000, or >10% bands RR ≥20 Sepsis SIRS plus suspected source of infection Severe sepsis Sepsis plus evidence of organ dysfunction Septic shock Sepsis plus hypotension SBP ≤ 90 or ≥30 drop from baseline [Bone RC, et al. Chest 1992; 101: 1644-55

5. DEFINITION Occult shock  Sepsis with elevated lactate >4  High mortality

6. Howell, Int care Med 2007

7. Mikkelsen CCM 2009

13. Frustrations with the protocol CVP?? As a measure of volume status and responsiveness?? Invasive Complications

14. BACKGROUND Early aggressive resuscitation of critically ill patients Limit and/or reverse tissue hypoxia Limit progression to organ failure Improve outcome Chest 2004; 124 (Suppl.):120S

15. BACKGROUND Overzealous fluid resuscitation Increased complications Increased length of ICU Increased hospital stay N Engl J Med 2006; 354: 2564–75.

16. BACKGROUND Only 50% of hemodynamically unstable critically ill patients are volume responsive Crit Care Med 2009; 37: 2642–7.

17. BACKGROUND Annals of Intensive Care 2011, 1:1

19. Systematic review of the literature to determine the following  Relationship between CVP and blood volume  Ability of CVP to predict fluid responsiveness

20. 24 studies human adult subjects healthy control subjects ICU and operating room patients 803 patients 5 studies compared CVP with measured circulating blood volume 19 studies determined the relationship between CVP/CVP and change in cardiac performance following a fluid challenge

21. Conclusions  This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/CVP to predict the hemodynamic response to a fluid challenge  CVP should not be used to make clinical decisions regarding fluid management

23. The only study we could find demonstrating the utility of CVP in predicting volume status was performed in seven standing, awake mares undergoing controlled hemorrhage!

24. SCCM Guidelines Initial Resuscitation Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ≥ 4 mmol/L). Goals during the first 6 hrs of resuscitation: Central venous pressure 8–12 mm Hg Mean arterial pressure (MAP) ≥ 65 mm Hg ) Urine output ≥ 0.5 mL/kg/hr d) Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C) In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C). Crit Care Med. 2013; 41:580-637

26. PROCESS TRIAL 31 Emergency Departments in US 1341 patients 6 hours of resuscitation  Randomly assigned patients to 3 gps  Protocol based EGDT  Protocol based standard therapy  Usual care End points  Primary End Point  60 day in hospital mortality  Secondary End Points  Longer term mortality  Need for organ support

40. Usual care is not bad huh..?  No central lines for CVP measurements  No ScVO2 measurements  No blood transfusions  No Dobutamine infusions But usual care was carried out by intensivist and ER physicians In our unit and ER care is provided by trainee physicians Objective marker of volume responsiveness

41. So if not CVP then what?

42. BACKGROUND

43. Other measures of volume assessment  IVC  Trained (not all residents and interns can do it)  Repitition q15 mins by doctors ( never gonna happen )  PLR

44. PASSIVE LEG RAISING Self-volume challenge Reversible Non intubated patients Breathing spontaneously Arrhythmias

45. PASSIVE LEG RAISING Annals of Intensive Care 2011, 1:1

46. PASSIVE LEG RAISING Critical Care 2009, 13:R111

47. PASSIVE LEG RAISING Intensive Care Medicine 2010: 36, 1475-1483

48. Limitation  How to perform PLR  Our wedge failed terribly

49. Instead of PLR, we used fluid challenge 500cc bolus followed by SV change measurement with flo-trac and if responsive, continue with volume assessment till volume unresponsive and if still hypotensive use pressors

50. Indications: 1. Septic Shock 2. Lactate of ≥4 3. Initiate protocol after 3L in the first 3hrs of SMITE protocol given 1. 500cc Bolus (over 10 minutes) No Pump 2. Check SV (no. 2) 1. Arterial Line for hemodynamic monitoring 2. Flo Trac 3. Record SV (no. 1) SV: Stroke Volume NS: Normal Saline LIP: Licensed Independent Practitioner Responsive ≥10% increase in SV from baseline (from SV no.1 and SV no.2) If the pt is hypotensive start vasopressors Not Responsive Yes Hypotension No Continue to monitor Start Vasopressors Inform MD/LIP Sepsis Fluid Responsiveness Protocol 1 Hour 6 Hour 1.Record SV ( no.2) 2. 500 cc NS bolus (over 10 minutes) 3.Record SV( no.3) 4. If responsive (from SV no.2 and SV no.3) continue with 500 cc boluses (over 10 minutes) with SV before and after each bolus to check responsiveness. Stop at 3L. Inform MD/LIP

51. THE CHANGE PROCESS

52. Time 0 Hour 6 Hour 3 Hour 5 Hour 4 Hour 2 Hour 1 Pt. # Admit Date Sepsis Report 1635 Resus Rm – AMS – Fluid Running 3L T37.7, HR123, RR22, BP 142/80 1 55y Male7/1 1841 1700 Bolus 2L 1801 Abx (86) ordered @ 1752 1736 Lact 4.2 (44 Minutes) 2002 A-Line Placed 1807 MICU @ BS 1652 Bcx – Lact Ordered ED Resident – Barkhuff ED Attending –Miller ED RN – A Ulibarri MICU Fellow – Ass’ad MICU Attending – Ahmed MICU RN – A Martinez 2049 SV = 87 1700 Lact 4.01 (iSTAT) 1747 MICU Called 1958 CVC Placed RIJ 2015 Trans to MI 8 2130 Bolus 1L 2049 Bolus 500mL 2059 SV = 86 -1% EGDT Unmet Preventable Sepsis Scorecard Bcx Abx Bolus Fluid Response VP’s

55. TIPS Always be aware of T0 Have the charge nurse involved sooner Please do not block anyone with lactate of >4(infection or no infection) without discussing the case with the attending. Day or night Always go with the first lactate Know your patients baseline BP Make sure that SMITE protocol got initiated Click the levophed order If there is reason that the patient has a surgical issue, please do whats best for the patient

56. QUESTIONS?

57. CASE # 1 48 y.o male with PMH of HTN, DM, HLD, COPD coming in with increasing SOB HR- 101, BP-100/55, RR-24, T-38 CXR with a RLL infiltrate Lactate 1.8 s.p 3L of IVF bolus BP is 110/58 What are we going to do?

58. CASE #2 66 y.o female with no PMH coming in with increasing urinary frequency, some suprapubic tenderness, and fever HR-88, BP-115/75, RR-18, Temp-37.8 UA is positive for LCE, WBC of 55 Lactate of 6.5 What should we do now?

59. CASE # 3 45 y.o male with DM, HTN, coming in with fever, and with LLE cellulitis and swelling HR-120, BP-100/65, RR-18, Temp-38.4 Leukocytosis present What should be the course of action?

60. CASE # 3 Flo trac was attached, patient is fluid responsive. He is getting fluid boluses, however his BP is still with MAPS in the 55 range What should we do now?

61. Questions???