Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 A Guide To T

1. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012A Guide To The Guidelines … Nabil Abouchala, MD, FCCP, FACP Consultant, Pulmonary and Critical Care Medicine King Faisal Hospital & Research Center Riyadh, Saudi Arabia

2. Surviving Sepsis Campaign: History of the guidelines…

3. Surviving Sepsis Campaign: History of the guidelines… 2001 2004 2008 2012

4. Crit Care Med 2013; 41:580–637

5. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 • 1. Initial Resuscitation and Infection Issues • 2. Hemodynamic Support and Adjunctive Therapy​ • 3. Other Supportive Therapy of Severe Sepsis • 4. Special Considerations in Pediatrics​​

6. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

9. lactic Acid clearance JAMA. 2010;303(8):739

10. fluid in septic shock, How much ?

11. 2012: IVF recommendation • Initial fluid challenge ≥ 1000 mL of crystalloids or minimum of 30 mL/kg of crystalloids in the 1st 4-6 hours • (Strong recommendation; Grade 1C). • Crystalloids is the initial fluid for resuscitation • (Strong recommendation; Grade 1A). • Adding albumin to the initial fluid resuscitation • (Weak recommendation; Grade 2B). • Against hydroxyethyl starches (hetastarches) with MW >200 dalton • (Strong recommendation; Grade 1B).

12. Timing of Antibiotic Administration

13. % Survival % Total receiving antibiotics Only 50% of patients in Septic Shock received antibiotics w/in 6 hrs. Septic Shock: Timing of Antibiotics Percent 1.00 14 ICUs; n = 2,731 .80 .60 .40 .20 0.0 .5 – 1.0 1 - 2 2 - 3 3-4 4 - 5 5 - 6 6 - 9 9 - 12 12 - 24 24 - 36 > 36 0 - .5 Time, hrs Kumar Crit Care Med 2006

14. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

16. Adrenergic Agents Beta Alpha

17. Which Inotropes to use? Norepinephrine as the first choice ( Grade 1B) Adding or substituting epinephrine when an additional drug is needed (Strong recommendation; Grade 1B). Vasopressin 0.03 units/min may be added (Weak recommendation; Grade 2A) Dopamine only in highly selected patients at very low risk of arrhythmias or low heart rate (Weak recommendation; Grade 2C). Dobutamine infusion be started or added with low cardiac output) or ongoing signs of hypoperfusion, even after adequate intravascular volume (Strong recommendation; Grade 1C)

18. Norepinephrine Compared With Dopamine in Severe Sepsis Summary of Evidence

19. Adequate fluid resuscitation …

20. Crit Care Med 2007; 35:64–68

21. Crit Care Med 2007; 35:64–68

22. CHEST 2008; 134:172–178

23. Passive Leg raising

24. Passive Leg raising

25. Challenging the Frank–Starling curve with the passive leg raising (PLR) Normal Heart Failing Heart

27. Stroke volume variation SVV = SV max – SV min / SV mean

28. Pleth Variability index (PVI) to Help Clinicians Optimize Preload / Cardiac Output Stroke Volume Lower PVI = Less likely to respond to fluid administration 10 % 24 % Higher PVI = More likely to respond to fluid administration 0 Preload 0 MaximeCannesson, MD, PhD

29. Target MAP ≥ 65 …

30. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

32. K. Blood Product Administration Target Hemoglobin (7-9 g/dl) unless … • L. Immunoglobulins: Not recommended • M. Selenium: Not recommended • N. History of Recommendations Regarding Use of Recombinant Activated Protein C • R. Renal Replacement Therapy • S. Bicarbonate Therapy

33. The Rise and Fall of xigris!

34. The Rise and Fall of xigris!

35. The Rise and Fall of xigris! -6.5% +1.2%

36. K. Blood Product Administration Target Hemoglobin (7-9 g/dl) unless … • L. Immunoglobulins: Not recommended • M. Selenium: Not recommended • N. History of Recommendations Regarding Use of Recombinant Activated Protein C • O. Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS) • P. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis • Q. Glucose Control • R. Renal Replacement Therapy • S. Bicarbonate Therapy • T & U. Prophylaxis: Deep Vein Thrombosis and Stress Ulcer • V. Nutrition • W. Setting Goals of Care

37. O. Mechanical Ventilation of Sepsis-Induced (ARDS) • 1. Target a TV of 6 mL/kg predicted body weight (grade 1A vs. 12 mL/kg) • 2. Plateau pressures be measured in patients with ARDS be ≤30 cm H2O (grade 1B) • 3. (PEEP) be applied (grade 1B) • 4. Higher rather than lower levels of PEEP for moderate or severe ARDS (grade 2C) • 5. Recruitment maneuvers be used with severe refractory hypoxemia (grade 2C) • 6. Prone positioning be used Pao2/Fio2 ratio ≤ 100 mm (grade 2B) • 7. HOB elevated to 30-45 (grade 1B) • 8. (NIV) be used in minority of patients in whom the benefits of NIV (grade 2B) • 9. Weaning protocol be in place • 10. Against the routine use of the pulmonary artery catheter (grade 1A) • 11. A conservative rather than liberal fluid strategy (grade 1C) • 12. not using beta 2-agonists for treatment of sepsis-induced ARDS (grade 1B)

38. ARMA Trial Reducing from 12 to 6 ml/kg VT saved lives NNT 12 14000 Lives Saved/Year

39. Consequences of Fluid Overload

42. FACTT: Fluid management Protocols • Conservative: • CVP < 4 and PAOP < 8 • Liberal: • CVP 10 -14 and PAOP 14 -18

43. Wet First –Dry later CHEST 2009; 136:102–109 Approach that combines both adequate initial fluid resuscitation followed by conservative late-fluid management was associated with improved survival

44. Wet First –Dry later CHEST 2009; 136:102–109

46. JAMA. 2010;303(9):865-873

47. Higher PEEP is betterin Moderate to Severe ARDS (PO2/FiO2 ≤ 200 mmHg) JAMA. 2010;303(9):865-873

48. Higher PEEP is betterin Moderate to Severe ARDS (PO2/FiO2 ≤ 200 mmHg) Death in ICU  6.3 % NNT 16 Days off the MV -5 days JAMA. 2010;303(9):865-873