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Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
Management of septic shock
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Management of septic shock

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Una breve revisión sobre la estrategia adecuada para el manejo del shock séptico... ojala nos sirva a todos....

Una breve revisión sobre la estrategia adecuada para el manejo del shock séptico... ojala nos sirva a todos....

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  • 1. Approach in the Management of Septic ShockEsteban Osorio SalazarResident of AnesthesiologyHUAVJuly -2012 “The sick girl” by Gabriel Metsu (1658)
  • 2. Questions/objectives.1. Introduction.2. Definition.3. Pathophysilogy of sepsis.4. Management of septic shock. 1. Stabilize respiration. 2. Therapeutic priorites (monitoring andr initial resuscitation) 3. Diagnosis-AB therapy- Source Control. 4. Fluid Therapy. 5. Vasopressors and Inotropic Therapy. 6. Additional therapies.
  • 3. 1. Introduction. 450.000-500.000 cases of sepsis/year in EU. 80.000 cases in SPAIN. Mortality Index 4-5 deaths/100.000/year. Hospital admission of sepsis : 3.4-28 cases/1000 admission. Incidence of Severe sepsis in ICU.
  • 4. 2. Definition.Septic Shock Severe sepsis +: *SMBP of <60 mm Hg (<80 mm Hg if hypertension) after 20 to 30 mL/kg starch or 40 to 60 mL/kg saline solution. *PCWP between 12 and 20 mm Hg + *Dopamine of >5 mcg/kg/min *Norepinephrine or epinephrine of <0.25 mcg/kg/min.Refractory Septic Shock *Dopamine at >15 mcg/kg/min *Norepinephrine or epinephrine at >0.25 mcg/kg/min Mean BP at >60 mm Hg (80 mm Hg if previous hypertension Schmidt Gregory A, MD, Mandel Jess, MD. Management of severe sepsis and septic shock in adults.Wolters Kluwer Healt and Uptodate, May 2012.
  • 5. 3. Pathophysiology of Sepsis. Richard S. Hotchkiss, M.D., and Irene E. Karl, Ph.D.The Pathophysiology and Treatment of Sepsis. N Engl J Med 2003 348;138-150.
  • 6. 3. Pathophysiology of Sepsis. Richard S. Hotchkiss, M.D., and Irene E. Karl, Ph.D.The Pathophysiology and Treatment of Sepsis. N Engl J Med 2003 348;138-150.
  • 7. 3. Pathophysiology of Sepsis Emanuel P. Riversa, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010,16:001–012.
  • 8. 3. Pathophysiology of Sepsis Emanuel P. Riversa, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010,16:001–012.
  • 9. 4. Management of Septic Shock.4.1.Stabilize respiration Supplemental oxygen to all patients and monitored continuously with pulse oximetry. Intubation and mechanical ventilation (may be required). Chest Rx Sedative and induction agents. Target in Mechanical ventilation of sepsis-induced ALI/ARDS *Tidal volume of 6 mL/kg (predicted). *Initial upper limit plateau pressure <30 cm H2O. *PEEP for prevent lung collapse in ALI/ARDS. *Prone position for ARDS patients with max FiO2/Pp? (2C) *Mild to moderate hypoxemic respiratory failure: NIMV. * Target in sedative, inductive agents and NMB in sepsis *Sedation protocols. *Intermittent bolus sedation or continuous infusion sedation (1C). *Avoid NMB where possible. Train-of-four when using continuous infusions(1B). *Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327. *Schmidt Gregory A, MD, Mandel Jess, MD. Management of severe sepsis and septic shock in adults.Wolters Kluwer Healt and Uptodate, May 2012.
  • 10. 4. Management of Septic Shock.4.1.Stabilize respiration Murray MJ, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med 2002; 30:142-156.
  • 11. 4. Management of Septic Shock.4.2.Therapeutic PrioritiesMonitoring and Initial ResuscitationMonitoringAssess perfusion:*Arterial catheter.*Signs of Hypoperfusion (cold, VC skin, olig/anuria and lactate>4mmol/l.Catheters:*Central venous catheter*Avoid PACs (SvO2 = ScvO2) + PAOP*Radial artery pulse pressure x Static Hemod. Measures*Aortic blood flow peak velocity Dynamic Hemod.Measures*brachial artery blood flow velocity Schmidt Gregory A, MD, Mandel Jess, MD. Management of severe sepsis and septic shock in adults.Wolters Kluwer Healt and Uptodate, May 2012.
  • 12. 4. Management of Septic Shock.4.2.Therapeutic PrioritiesMonitoring and Initial ResuscitationInitial Resuscitation Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis and Septic Shock. Infect Dis Clin N Am 23 (2009) 485–501.
  • 13. 4. Management of Septic Shock.4.2.Therapeutic PrioritiesMonitoring and Initial Resuscitation
  • 14. 4. Management of Septic Shock.4.3. Diagnosis-AB therapy- Source Control. Diagnosis *Obtain ≥ 2 BCs one drawn percutaneosuly. *Obtain ≥1 BCs of vascular access devices. *Obtain culture of other sites clinically indicated Antibiotics therapy 1º Appropiate antibioticsMatthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis andSeptic Shock. Infect Dis Clin N Am 2009;23:485–501.Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management ofsevere sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.
  • 15. 4. Management of Septic Shock.4.3. Diagnosis-AB therapy- Source Control.Antibiotics therapy 2º Early therapy (First hour of onset the hypotension) Anand Kumar, MD; Daniel Roberts, MD; Kenneth E. Wood, DO; Bruce Light, MD; Joseph E. Parrillo, MD; Satendra Sharma, MD; Robert Suppes, BSc; Daniel Feinstein, MD; Sergio Zanotti, MD; Leo Taiberg, MD; David Gurka, MD; Aseem Kumar, PhD; Mary Cheang, MSc. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006 ;34:1589-1596.
  • 16. 4. Management of Septic Shock. 4.3. Diagnosis-AB therapy- Source Control Antibiotics therapy 3ºApproach of antibiotics therapyMatthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsisand Septic Shock. Infect Dis Clin N Am 2009;23:485–501.
  • 17. 4. Management of Septic Shock. 4.3. Diagnosis-AB therapy- Source Control.Source Control*the drainage of infected fluids.*Removal of infected devices.*Debridement of infected soft tissues.*Definitive measures to correct anatomicderangement resulting in ongoingantimicrobial contamination. *Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis and Septic Shock. Infect Dis Clin N Am 2009;23:485–501. *Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.
  • 18. 4. Management of Septic Shock.4.4. Fluid Therapy  1000 mL of crystalloids or 300–500 mL of colloids over 30 mins.  More rapid and larger volumes in tissue hypoperfusion.  If there are not improvement in the hemodinamics paramethers, the rate of fluid administration should be reduced.*Emanuel P. Rivers, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and DavidAmponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010;16:001–012.*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines formanagement of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.
  • 19. 4. Management of Septic Shock. 4.4. Fluid Therapy  Target a CVP of 8 mm Hg (12mmHg MV).Design: Retrospective review of the use of intravenous fluids during the first4 days of care.Setting: Multicenter randomized controlled trial.Patients: The Vasopressin in Septic Shock Trial (VASST) study enrolled 778patients who had septic shock and who were receiving a minimum of 5 ugNA/minThe VASST patient database included daily fluid intake and urine output forthe first 4days of treatment, CVP and (APACHE) II score. John H. Boyd, MD, FRCP(C); Jason Forbes, MD; Taka-aki Nakada, MD, PhD; Keith R. Walley, MD, FRCP(C); James A. Russell, MD, FRCP(C).Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011 Vol. 39, No. 2
  • 20. 4. Management of Septic Shock. 4.4. Fluid Therapy  Target a CVP of 8 mm Hg (12mmHg MV).John H. Boyd, MD, FRCP(C); Jason Forbes, MD; Taka-aki Nakada, MD, PhD; Keith R. Walley, MD, FRCP(C);James A. Russell, MD, FRCP(C).Fluid resuscitation in septic shock: A positive fluid balance and elevated centralvenous pressure are associated with increased mortality. Crit Care Med 2011 Vol. 39, No. 2
  • 21. 4. Management of Septic Shock. 4.4. Fluid Therapy  Colloids vs Crystalloids??Colloids versus crystalloids for fluid resuscitation in critically ill patients.Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G.Update in Cochrane Database Syst Rev. 2007;(4):CD000567.“There is no evidence from randomised controlled trials that resuscitationwith colloids reduces the risk of death, compared to resuscitation withcrystalloids” Emanuel P. Rivers, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010;16:001–012.
  • 22. 4. Management of Septic Shock.4.4. Fluid Therapy Anders Perner, Nicolai Haase, Anne B. Guttormsen, Jyrki Tenhunen, Gudmundur Klemenzson, Anders Åneman, Kristian R. Madsen, Morten H. Møller, , Jeanie M. Elkjær, Lone M. PoulsenAsger BendtsenRobert WindingMorten SteensenPawel Berezowicz, Peter Søe-JensenMorten BestleKristian StrandJørgen Wiis, Jonathan O. White, Klaus J. Thornberg, Lars Quist, Jonas Nielsen, Lasse H. Andersen, Lars B. Holst, Katrin ThormarAnne-Lene Kjældgaard, Maria L. Fabritius., Frederik Mondrup, Frank C. PottThea P. MøllerPer Winkel, Jørn Wetterslev.Hydroxyethyl Starch 130/0.4 versus Ringers Acetate in Severe Sepsis. N Engl J Med 2012 .
  • 23. 4. Management of Septic Shock.4.5.Vasopressors and inotropes therapy Alpha 1 Receptor stimulation px VC Alpha 2 Receptor stimulation px VD by endothelial NO productionChristopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology andClinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.Timothy J. Ellender,MD, Joseph C. Skinner,MD.The Use of Vasopressors and Inotropes in the EmergencyMedical Treatment of Shock. Emerg Med Clin N Am 26 (2008) 759–786.
  • 24. 4. Management of Septic Shock. 4.5.Vasopressors and inotropes therapy Beta1 receptor produces inotropic and chronotropic effect by sinoatrial nodal conduction. Also Dromotrophic effect (A/V nodal conduction) Beta2 receptor px relaxation of smooth muscle and VD Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056. Timothy J. Ellender,MD, Joseph C. Skinner,MD.The Use of Vasopressors and Inotropes in the Emergency Medical Treatment of Shock. Emerg Med Clin N Am 26 (2008) 759–786.
  • 25. 4. Management of Septic Shock.4.5.Vasopressors and inotropes therapyNOREPINEPHRINE•NT and potent alpha 1 adrenergic receptor agonist.•Modest beta agonist effect.•Powerful VC•Increase systolic and diastolic pressures (coronary flow).•Direct toxicity in continue infusion (apoptosis)•NE doesn´t improve sublingual microcirculatory perfusion,intestinal [pCO2] or arterial lactate levels. *E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018. *Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.
  • 26. 4. Management of Septic Shock.4.5.Vasopressors and inotropes therapy n? Critical Care 2008, 12:R143 (doi:10.1186/cc7121)
  • 27. 4. Management of Septic Shock. 4.5.Vasopressors and inotropes therapyDOPAMINE•Inmediate precursor to NE•Low doses * D1: renal, coronary, mesenteric, cerebral beds * D2: vasculature and renal tissues.(natriureticeffects). RENAL DOSE???•Medium doses * B1: inotropy and chronotropy effect with mild VC•High doses * A1:VC *E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018. *Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.
  • 28. 4. Management of Septic Shock. 4.5.Vasopressors and inotropes therapy•58 RCTs studies (2,149 patients)/ 33 years.•Dopamine did not prevent mortality, the onset of acute renalfailure, or the need for dialysis.•Sufficient statistical power to exclude any large effect ofdopamine on the risk of acute renal failure or the need for dialysis.•“There is no evidence to support the use of low-dose dopamine toprevent or treat acute renal failure, and, therefore, dopamineshould be eliminated from routine clinical use for this indication.” *E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018.
  • 29. 4. Management of Septic Shock.4.5.Vasopressors and inotropes therapyDOBUTAMINE•Beta1: Beta2 (3:1).•Low doses (<5 ug/kg/min): * VD(beta2) vs VC(alpha1)•High doses (>15ug/kg/min): * VC>VD.•Increase myocardial oxygen consumption. *E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018. *Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.
  • 30. 4. Management of Septic Shock. 4.5.Vasopressors and inotropes therapyVasopressors therapy•Maintain MAP 65 mm Hg.•NE and DO are the initial vasopressors of choice (1C)•Epinephrine, phenylephrine, or vasopressin should not be administered asthe initialvasopressor in septic shock .•Use epinephrine if blood pressure is poorly responsive to norepinephrine ordopamine.•Do not use low-dose dopamine for renal protection.Inotropes therapy•Dobutamine is the firstchoice inotrope for patients low cardiac output inadequate left ventricular filling pressure and adequate mean arterialpressure. *Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327. *Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis and Septic Shock. Infect Dis Clin N Am 2009;23:485–501.
  • 31. 4. Management of Septic Shock. 4.6.Additional TherapiesCORTICOIDS Consider intravenous hydrocortisone for adult septic shock when hypotension responds poorly to adequate fluid resuscitation and vasopressors. ACTH stimulation test is not recommended. Hydrocortisone is preferred to dexamethasone. Fludrocortisone (50 g vo/d) if an alternative to hydrocortisone (IF lacks significant mineralocorticoid activity. *Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327. Kaufman, David,MD, Mancebo, Jordi,MD.Corticosteroid therapy in septic shock . Wolters Kluwer Healt and Uptodate, April 2012.
  • 32. 4. Management of Septic Shock.4.6.Additional TherapiesMETHODS Muticenter RCT, double-bind, placebo-controlled. 250 pts to receive 50 mg HCT ev and 248 pts to receive placebo every 6 hours for 5 days. At 28 days: primary outcomes were death among patients who did not have response to corticotropin test.RESULTS At 28 days, there was no significant difference in mortality between patients in the two study groups who did not have a response to corticotropin (39.2% HCT vs 36.1% PCB,P=0.69).CONCLUSIONS Hydrocortisone did not improve survival or reversal of shock in patients with septic shock. Charles L. Sprung,Djillali Annane,Didier Keh,Rui Moreno,Mervyn Singer, Klaus Freivogel,Yoram G. Weiss,Julie Benbenishty,Armin Kalenka, Helmuth Forst,Pierre-Francois Laterre, Konrad Reinhart,Brian H. Cuthbertson,Didier Payen,Josef Briegel for the CORTICUS Study Group.Hydrocortisone Therapy for Patients with Septic Shock.N Engl J Med 2008;358:111-24.
  • 33. Thanks!!

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