Disclosures CODE SEPSIS: I have no disclosures Surviving Severe - PDF document

5/31/2013 Disclosures CODE SEPSIS: • I have no disclosures Surviving Severe Sepsis and Septic Shock David Shimabukuro, MDCM Associate Professor Medical Director, 13 ICU Physician Lead, UCSF DSRIP Sepsis Project Agenda Agenda • Identification • Identification – How do we know if a patient has sepsis, severe – How do we know if a patient has sepsis, severe sepsis, or septic shock sepsis, or septic shock • Treatment • Treatment – The “Surviving Sepsis Campaign Bundles” – The “Surviving Sepsis Campaign Bundles” • The UCSF Experience • The UCSF Experience 1

5/31/2013 Systemic Inflammation in Sepsis What is Sepsis?? Inflammation is Activated in Sepsis • A variable condition that affects each of us differently and is initiated by an infectious 14 TNF (ng/L) IL-6 (U/mL) insult. Endotoxin (ng/L) 12 10 8 6 4 2 0 0 60 120 180 240 300 360 Minutes After LPS Infusion van Deventer SJ et al. Blood. 1990;76:2520-6. Coagulation Regulation Inflammatory Response Immunodepression Inflammatory Response • Normal response to injury is a contained explosion of thrombin generation Early mortality Late mortality • TNF and IL-1 activate coagulation pathway • Endothelium acts like a fire extinguisher “ Storm ” – Antithrombin – Thrombomodulin/Protein C Appropriate inflammatory response – Act to neutralize thrombin and prevent conversion of fibrinogen to fibrin “ Wake ” 2

5/31/2013 Loss of Homeostasis in Sepsis Pathophysiology of Sepsis • Proinflammatory mediators • Endothelial injury • Tissue factor expression • Thrombin production Coagulation Endothelial Inflammation Fibrinolysis Injury Organ Failure • Increased PAI-1 • Reduced Protein C homeostasis A Case… A Case… • 56 year-old female, on the orthopedic – 0830: Increase in FIO2 from 2LNC to 6LNC for floor, with tachypnea and tachycardia O2SAT 93% and RR 32. With intervention, – POD#5 right femoral shaft prosthesis O2SAT increases to 98% and RR decreases to revision 24. Afebrile. Back to baseline. Ortho Team – Medical history of breast cancer (radiation, informed by RN. No further action taken. tamoxifen), severe osteoporosis, and – 1200 to 1600: Multiple desaturations on 6L NC chronic pain with lowest O2SAT 82%. RR 24-44. HR 109- – No known cardiopulmonary disease, but is 142. BP 129/87 to 109/54. Afebrile . essentially wheelchair bound 3

5/31/2013 A Case… • The Primary Team and RRT are called to see the patient • The ICU fellow is also contacted – WBC: 17 (up from baseline of 12 over past 3 days) – ABG: 7.32/30/196/18/-5 – Continued “weepy” and non -purulent drainage from the surgical wound – Positive 10L over the past 5 days – ECG: Sinus tachycardia – CXR: A Case… Sepsis Definitions • What to do next: • SIRS A. Do nothing B. Give furosemide C. Get a chest CT with PE protocol • Sepsis D. Send a lactate, draw blood cultures, and give broadspectrum antibiotics E. Send a lactate, draw blood cultures, give • Severe Sepsis broadspectrum antibiotics, and bolus with IV fluids F. Do all of (E) plus transfer to the ICU, place • Septic Shock central line, and monitor ScvO2. 4

5/31/2013 Sepsis: ACCP/SCCM Definitions Sepsis Definition SIRS Sepsis Severe Sepsis Septic Shock T > 38.3 C or < 36 C SIRS plus confirmed SEPSIS plus evidence SEVERE SEPSIS plus HR > 90 beats/min or suspected infection of at least one hypotension (Systolic Tachypnea alteration in organ blood pressure < 90 or WBC > 12K or < 4K perfusion Mean Arterial Blood Pressure < 65) OR Lactate > 4 Crit Care Med February 2013 Volume 41 Number 2 pp. 580-637 Sepsis Screening Sepsis Screening Great….but when should we do it and how should it be done!!!! Crit Care Med February 2013 Volume 41 Number 2 pp. 580-637 Crit Care Med February 2013 Volume 41 Number 2 pp. 580-637 5

5/31/2013 Sepsis Screening Sepsis Screening Sepsis Screening Agenda • Important to have one that works for the • Identification hospital – How do we know if a patient has sepsis, severe • Should probably do once a shift (no clear sepsis, or septic shock • Treatment data) – The “Surviving Sepsis Campaign Bundles” • Screening works as a reminder for continued • The UCSF Experience vigilance 6

5/31/2013 Management of Severe Sepsis and Management of Severe Sepsis and Septic Shock Septic Shock Crit Care Med February 2013 Volume 41 Number 2 pp. 580-637 Management of Severe Sepsis and Septic Shock • Blood cultures should not delay administration of antibiotics. • Antibiotics should be administered within 60 minutes from the time of recognition. Crit Care Med 2006 Vol. 34, No. 6 7

5/31/2013 Management of Severe Sepsis and Management of Severe Sepsis and Septic Shock Septic Shock • Normalization of lactate as a resuscitation goal is suggested – Use of rate of lactate clearance is mentioned, but not endorsed as a sole target 8

5/31/2013 Management of Severe Sepsis and Management of Severe Sepsis and Septic Shock Septic Shock • Fluid Therapy – Crystalloids are first choice for the overwhelming majority of patients – Albumin can be used to reduce volume from crystalloids – Hydroxyethyl starches should not be used Management of Severe Sepsis and Management of Severe Sepsis and Septic Shock Septic Shock • Corticosteroids • Blood Products – For refractory hypotension despite fluids and – HGB level 7.0 – 9.0 g/dL after hypoperfusion has vasopressors/inotropes resolved – Do not perform ACTH stimulation test – FFP not to be used unless bleeding is present or for planned invasive procedure • Glucose – PLT to be given prophylactically when <10K in – Target level to less than 180 mg/dL absence of bleeding 9

5/31/2013 Management of Severe Sepsis and Back to the c ase… Septic Shock • Recombinant Activated Protein C • Furosemide recommended with transfer to “step - down” unit for closer hemodynamic and pulmonary monitoring for fluid overload. • Upon admission to “step - down” unit placed on 15L HFNC with FIO2 1.0 to maintain adequate oxygenation • Moderate UOP response • “stable” overnight per RRT notes Back to the case… Back to the case… • Medicine consulted the next day for • Central line and arterial line placed worsening tachypnea, tachycardia, hypoxia, • Antibiotics and vasopressors started and hypotension. • Worsening renal function – 82/54 130 35 95% 20L HFNC FIO2 1.0 • DIC – ABG: 7.22/30/96/12/-10 • CRRT started – WBC: 24 – ECG and CXR unchanged • ICU consulted and transferred to ICU 10

5/31/2013 Back to the case… • She expired 8 hours later. Is it really a surgical issue?? Sepsis in General Surgery ARCH SURG , vol 145 (no. 7) July 2010. 695-700 11

5/31/2013 Operative Procedures for Sepsis and Sepsis in General Surgery Septic Shock Sepsis Septic Shock • Partial removal of colon • Partial removal of colon • Removal of small intestines • Removal of small intestines • Arterial bypass graft • Arterial bypass graft • Partial removal of pancreas • Removal of colon • Removal of colon • Exploration of abdomen Sepsis in General Surgery Sepsis in General Surgery • 3 major risk factors for development of • Sepsis increased risk of 30-day mortality 4-fold sepsis/septic shock – OR 3.9 (CI 3.5-4.3) – Age older than 60 years – Emergency surgery • Septic shock increased risk of 30-day mortality – Presence of any comorbidity 33-fold – OR 32.9 (CI 30.9-35.1) 12

5/31/2013 Summary • A very heterogeneous disease that is difficult to diagnose in its early stages and difficult to treat in its later stages. • Routine screening can allow for earlier identification • Early intervention can attenuate its course, but the mainstay of treatment is supportive care. 13