Sepsis in NY: The first 15K patients by Weingart

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Scott Weingart simplifies emergent data on our approaches to early, goal-directed therapy in sepsis. How a little goes a long way.

Scott Weingart simplifies emergent data on our approaches to early, goal-directed therapy in sepsis. How a little goes a long way.

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  • 1. F*Ckin’ Process trial
  • 2. Our first 15,000 Severe Sepsis Patients
  • 3. The old days…
  • 4. 60 Hospitals
  • 5. Recognition Treatment
  • 6. 0%   10%   20%   30%   40%   50%   Jan-­‐11   Feb-­‐11  Mar-­‐11   Apr-­‐11  May-­‐11   Jun-­‐11   Jul-­‐11   Aug-­‐11   Sep-­‐11   Oct-­‐11   Nov-­‐11  Dec-­‐11   Jan-­‐12   Feb-­‐12  Mar-­‐12   Apr-­‐12  May-­‐12   Jun-­‐12   Jul-­‐12   Aug-­‐12   Sep-­‐12   *  N  =  9,133   January  2011   41%   September2012   19%   January  2012     27%   22% ARR of In-Patient Mortality
  • 7. How’d We Do It?
  • 8. We really didn’t do
  • 9. Ok there was some of stuff…
  • 10. Administrative Buy-In
  • 11. Recognition Treatment
  • 12. Recognition Treatment
  • 13. They’re Not Looking!
  • 14. Occult or Cryptogenic Severe Sepsis
  • 15. Triage Screen
  • 16. Lactate
  • 17. Lactate or Persistent Hypotension
  • 18. Turnaround < 30 Minutes
  • 19. Panic Value if ≥ 4
  • 20. Why are more lactates a good thing?
  • 21. How do Severe Sepsis Patients Die? Time Stability
  • 22. Denominator Shift Crit Care 2010;14:R77
  • 23. Pneumonia 14% Severe Sepsis 40% Pre-Lactate Screen
  • 24. Pneumonia 8% Severe Sepsis 30% Post-Lactate Screen
  • 25. What did they do after they found them?
  • 26. Recognition Treatment
  • 27. Treat the Source Perfuse the Tissues
  • 28. Early Abx Source Control Don’t box ‘em with the tube A Wee bit of Fluid Pressors
  • 29. Early Antibiotics Kumar et al.& Gaieski et al.
  • 30. Individual Hospital Empiric Guidelines
  • 31. Immediate Availability
  • 32. Source Control
  • 33. “He’s too sick to intervene”
  • 34. Arterial Oxygen Saturation
  • 35. How not to kill septic patients while intubating
  • 36. Responsiveness Volume?
  • 37. Empirically Gave 2-3 Liters
  • 38. SWEAR ON YOUR PATIENT’S LIFE
  • 39. 2nd Lactate?
  • 40. Recognition Treatment
  • 41. 0%   10%   20%   30%   40%   50%   Jan-­‐11   Feb-­‐11  Mar-­‐11   Apr-­‐11  May-­‐11   Jun-­‐11   Jul-­‐11   Aug-­‐11   Sep-­‐11   Oct-­‐11   Nov-­‐11  Dec-­‐11   Jan-­‐12   Feb-­‐12  Mar-­‐12   Apr-­‐12  May-­‐12   Jun-­‐12   Jul-­‐12   Aug-­‐12   Sep-­‐12   *  N  =  9,133   January  2011   41%   September2012   19%   January  2012     27%   22% ARR of In-Patient Mortality
  • 42. ARISE ProCESS ProMISe
  • 43. Gain from Sepsis Interventions Easy Crap Mental Masturbation 95% 5%
  • 44. 5%
  • 45. FOAMcc
  • 46. Fluids Vasopressors Endpoints
  • 47. Hemodynamics
  • 48. Plumber’s Approach
  • 49. Hemodynamic Resuscitation
  • 50. EGDT
  • 51. Fluids
  • 52. Debate
  • 53. Give everyone two liters of…
  • 54. Balanced Crystalloid Ann Surg. 2012 May;255(5):821-9 JAMA. 2012 Oct 17;308(15):1566-72)
  • 55. HIP
  • 56. Give 1 (or max 2) liter(s) more
  • 57. Tense the Tank
  • 58. Critical Care 2007,11(Suppl 2):P37 Crit Care Med 2011;39(4):689-94 Critical Care 2010,14:R142 Crit Care Med. 2012;40(12):3146-3153 Crit Care Med.2013 Jan;41(1):143-50
  • 59. Peripheral Pressor Administration Crit Care Med.2013 Sep;41(9):2108-15
  • 60. First 24 hrs: Think you Need Additional Fluid?
  • 61. Volume Loading by SV
  • 62. After First 24 hrs: Better have a think about it
  • 63. Microcirculatory Resuscitation?
  • 64. Glycocalyx ?
  • 65. Goals
  • 66. MAP > 65 CI > 2.2 (2.5) Microcirc Goals?
  • 67. ScvO2
  • 68. 2nd Lactate?
  • 69. Lack of Prognostic Value of Lactate Clearance in a Center with a Severe Sepsis Protocol
  • 70. 199 patients received aggressive monitored severe sepsis care. 39 patients expired during their hospital course (18% mortality) The mean arrival lactate was 4.8 (± 3.0) in the survivors compared to 7.3 (± 4.4) in those patients who died (p<0.0001). Lactates ≥4 were significantly associated with increased mortality (p<0.05). However, the patients who achieved lactate clearance did not have significantly improved survival when compared to those patients in whom clearance was not achieved (p=.60). In addition, patients with rebound in lactate ≥4, after initial clearance, showed a 10-fold increase in mortality (p<.05).
  • 71. If you are already doing the good stuff, clearance doesn’t matter--unless they rebound…
  • 72. May not be applicable to places without a team that wants to care about these patients
  • 73. emcrit.org/smacc
  • 74. The old days…
  • 75. Gain from Sepsis Interventions Easy Crap Mental Masturbation 95% 5%
  • 76. 5%
  • 77. Stop Sepsis Deaths
  • 78. You don’t need to do a whole lot of
  • 79. You just need to give a