Approach to Sepsis and Shock K A R E N T R A N P G Y 5 G I M F e - PowerPoint PPT Presentation

Approach to Sepsis and Shock K A R E N T R A N P G Y 5 G I M F e l l o w J U L Y 9 , 2 0 1 5

Objectives  To develop an approach to the evaluation of patient with fever  To develop an approach to assess a patient for the presence of SIRS, sepsis, severe sepsis, and septic shock  To learn how to triage and manage patients with sepsis  To learn evidence base management of sepsis  To become familiar with the sepsis protocols

Sepsis in Canada 30,000 Canadians are hospitalized for sepsis each year • 30.5% mortality rate all comers (45.2% with severe • sepsis) 9300 sepsis deaths in Canada per year (11% of all • hospital deaths) 56% increased death rate if diagnosed after admission • rather than in the ER Early recognition and antibiotics increases survival rate • by up to 50% Failure to recognize sepsis occurs most commonly in • post-op patients, elderly > 70 years old, or chronically ill/immunocompromised Canadian Institute for Health Information. 2009

Rationale:  Sepsis is a serious life threatening medical condition  One of most common admission to hospital/CTU/ICU  Increased awareness, modified triage tools and targeted management strategies have the potential to improve sepsis outcomes

“However, when detected early and “… inadequate patient assessment” treated aggressively, people can be spared the “ravage of sepsis”

Sepsis Video  https://vimeo.com/129916157

Mr. Rivers  45M presents to ER with 2 day history of fevers  PMHx: Hypertension and Type 2 DM  Medications: Ramipril 10 mg once daily and metformin 500 mg po BID  NKDA  ROS: Abdominal pain with N/V

What is your approach and differential diagnosis of fever?

Approach to Fever  M -malignancy (primary, hematologic, metastatic)  A -autoimmune (RA, SLE, vasculitis, CTD)  I -Infection  I - Inflammatory (Pancreatitis, hepatitis, IBD)  D -Drugs (Prescription medications, recreational drugs- intoxication, withdrawal, NMS, Serotonin syndrome, toxidromes)  E -Endocrine (Thyroid storm, Pheochromocytoma, Cushings, Adrenal insufficiency)  V -Vascular (ACS, PE, HUS/TTP)

What’s your approach to Infections?

Approach to Infectious Causes  CNS: meningitis, encephalitis, brain abscess  H&N: Sinusitis, Dental abscess  CVS: Bacteremia, Infective endocarditis, myocarditis Resp: Pneumonia (bacterial, mycobacterium, viral, fungal), Empeyma  Abdo: Ascending cholangitis, perforation, pancreatitis complications, abscess, diarrhea (C.diff), peritonitis  GU: Pyelonephritis, renal abscess, prostatitis, UTI  Gyne: Pelvic abscess  Derm: Cellulitis, Erysipelas, Necrotizing fasciitis  Other: Lines (IHD, portacath for chemo)

How do you recognize sepsis?

Definitions • Systemic Inflammatory Response System (SIRS) • Manifested by 2 of the following criteria: • Temp > 38.3 0 C or < 36 0 C • HR > 90 bpm RR > 20 or PaCO 2 <32 • WBC > 12 or < 4 or > 10% bands • • Infection: Pathological process caused by invasion of normal sterile fluid/body cavity by pathogenic or potentially pathogenic microorganisms Dellinger RP et al. Intensive Care Med. 2013l 39(2):165-228.

Definitions • Sepsis = SIRS + suspected/potential source of infection • Severe Sepsis = Sepsis + end organ dysfunction or hypoperfusion • Septic Shock = Sepsis + hypotension (SBP < 90, MAP < 70 or SBP decrease > 40 from baseline) not resolved with fluids Dellinger RP et al. Intensive Care Med. 2013l 39(2):165-228

Dellinger RP et al. Intensive Care Med. 2013l 39(2):165-228

! clinical insult inflammation SIRS ischemia → → severe sepsis septic shock trauma → Sepsis infection ! 2 of the following: SIRS w/ organ sepsis with BP ! temp >38.3 ° or <36 ° hypoperfusion or <90mmHg or organ dysfunction <70mmHg MAP ! WBC >12000,<4000,>10% IB despite adequate fluid ! HR > 90 bpm resuscitation ! RR>20 or PaCO 2 <32 mmHg MODS ! ! urine output <0.5ml/kg/h ! lactate >4mmol/L ! Cr>177 m mol/L ! Plt<100000 m L ! bili>34 m mol/L ! INR>1.5 ! ALI PaO2/FiO2<250 ! ALI PaO2/FiO2<200 w/ p Dellinger RP et al. Intensive Care Med. 2013l 39(2):165-228

Organ Dysfunction  CNS  Metabolic encephalopathy  CVS  Shock, demand ischemia  Resp  Acute lung injury, ARDS  GI  Gastroparesis, ileus  Liver  Cholestasis  Kidney  Acute tubular necrosis  Heme  Coagulopathy (DIC)  Endo  Adrenal insufficiency

Approach to Shock  Definition: Acute circulatory failure resulting in hypoperfusion and end organ injury  Does not necessarily imply hypotension  Patients can have “normal BP” and have relative hypotension if BP is normally high

Types of Shock  Etiologies  Cardiogenic = pump failure  Distributive = peripheral vascular resistance failure  Hypovolemic = lack of fluid/blood

BP = CO x SVR HR x Stroke Volume Contractility Afterload Preload

Distributive Shock BP = CO x SVR HR x Stroke Volume Contractility Afterload Preload Cardiogenic/Obstr Hypovolemic uctive Shock Shock

Approach to Shock  S- septic  H- hypovolemic  2 0 GI loss, hemorrhage, burns, third spacing, pancreatitis  O- obstructive  PE, RV infarct, tamponade  C- cardiogenic  ACS, heart failure  C- catch all  Anaphylaxis, neurogenic shock

Hemodynamic Profiles of Various Forms of Shock Type of RA PCWP CO SVR Shock Sepsis Variable Variable   Hypovolemic     Obstructive  N or    Tamponade     Cardiogenic N or    

Sepsis Management “The speed and appropriateness of therapy administered in the initial hours after severe sepsis develops will have a large influence on outcome” Recognize 1. clinical experience • screening tools • Triage 2. Order appropriate investigations, esp: lactate and cultures • IV fluids and IV antibiotics • Consult appropriate health care providers (ICU) • Respond 3. early goal directed therapy •

Sepsis Management  ABC  MOVII  Monitored setting, Oxygen, Vital signs, IV access, Investigations  IV fluids with crystalloid  Broad spectrum IV antibiotics  Oxygen supplementation  Early Goal Directed Therapy

Sepsis Management  Early Goal Directed Therapy  CVP 8-12 mm Hg  MAP > 65 mm Hg  S cV O 2 > 70%  Urine output ≥ 0.5cc/kg/hr  Target lactate as marker of hypoperfusion  Source Control – early OR for debridement, ERCP in cholangitis, chest tube for empeyma, etc.  Ask for help  Senior residents, staff physician, CA  Consult ICU early if not responding to medical therapy

What investigations would you want to order?

Investigations  CBCD  Consider:  Sputum C&S  Peripheral blood smear  CT head +/- LP  Lytes, BUN, Cr  CT Abdo  Lactate  Abdo U/S (if elevated LFT  INR, PTT and Bili)  Liver enzymes  Influenza NP Swab  Troponin  BCx x 2  U/A, Urine C&S  CXR PA/lateral  ECG

Rivers et al. NEJM. 2001. 345(19):1368-1377.

Rivers Trial  263 patients presenting to urban ER with sepsis or septic shock prior to admission to ICU  Randomized to EGDT vs. standard care  Primary endpoint: in hospital mortality  EGDT decreased mortality among patients with severe sepsis or septic shock (30.5% vs. 46.5%) Rivers et al. NEJM. 2001. 345(19):1368-1377.

NNT of 6 to prevent one hospital death Rivers et al. NEJM. 2001. 345(19):1368-1377 .

Criticisms  Single center study, ED staff not blinded to treatment  Difficult to determine which intervention was the most successful  S cv O 2 and CVP monitoring is controversial  RBC transfusion is controversial as other studies TRICC and TRISS have shown increased mortality with liberal blood transfusions  Control group had an above average mortality Rivers et al. NEJM. 2001. 345(19):1368-1377.

So what do we do?

Approach to Sepsis Management  1. Target CVP 8-12 with IV crystalloid for hypotension or lactate >4 mmol/L  Clinical volume assessment with JVP, urine output, U/S  2. Target MAP > 65 mm Hg  If MAP < 65, consult ICU for IV vasopressors (norepinephrine)  3. Target S cv O 2 > 70% or lactate clearance  If S cv O 2 < 70% and Hct > 30%, start IV inotropes (dobutamine)  If S cv O 2 < 70% and Hct < 30% or Hg <70, transfuse 1 U PRBC

Volume Resuscitation  Crystalloid preferred for hypotension or elevated lactate  Use NS or Ringers Lactate for bolus  If patient acidotic or severe sepsis consider Plasmalyte  Aim for 30 cc/kg  No survival benefit with colloid (hydroxyethyl starches)  Reassess the patient to see if intervention is improving hemodynamics, volume status, urine output and lactate clearance

Vasopressors  Aim for MAP >65 mm Hg  Need central line/arterial line  Consult ICU early  Preferred agent is norepinephrine (same as levophed)  Mostly α -adrengeric effect with vasoconstriction  Could consider low dose vasopressin (0.03 U/min) to be added to levophed

De Becker et al. NEJM. 2010. 362(9): 779-89.