Sepsis in NY: The first 15K patients by Weingart
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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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Sepsis in NY: The first 15K patients by Weingart Sepsis in NY: The first 15K patients by Weingart Presentation Transcript

  • F*Ckin’ Process trial
  • Our first 15,000 Severe Sepsis Patients
  • The old days…
  • 60 Hospitals
  • Recognition Treatment
  • 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
  • How’d We Do It?
  • We really didn’t do
  • Ok there was some of stuff…
  • Administrative Buy-In
  • Recognition Treatment
  • Recognition Treatment
  • They’re Not Looking!
  • Occult or Cryptogenic Severe Sepsis
  • Triage Screen
  • Lactate
  • Lactate or Persistent Hypotension
  • Turnaround < 30 Minutes
  • Panic Value if ≥ 4
  • Why are more lactates a good thing?
  • How do Severe Sepsis Patients Die? Time Stability
  • Denominator Shift Crit Care 2010;14:R77
  • Pneumonia 14% Severe Sepsis 40% Pre-Lactate Screen
  • Pneumonia 8% Severe Sepsis 30% Post-Lactate Screen
  • What did they do after they found them?
  • Recognition Treatment
  • Treat the Source Perfuse the Tissues
  • Early Abx Source Control Don’t box ‘em with the tube A Wee bit of Fluid Pressors
  • Early Antibiotics Kumar et al.& Gaieski et al.
  • Individual Hospital Empiric Guidelines
  • Immediate Availability
  • Source Control
  • “He’s too sick to intervene”
  • Arterial Oxygen Saturation
  • How not to kill septic patients while intubating
  • Responsiveness Volume?
  • Empirically Gave 2-3 Liters
  • SWEAR ON YOUR PATIENT’S LIFE
  • 2nd Lactate?
  • Recognition Treatment
  • 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
  • ARISE ProCESS ProMISe
  • Gain from Sepsis Interventions Easy Crap Mental Masturbation 95% 5%
  • 5%
  • FOAMcc
  • Fluids Vasopressors Endpoints
  • Hemodynamics
  • Plumber’s Approach
  • Hemodynamic Resuscitation
  • EGDT
  • Fluids
  • Debate
  • Give everyone two liters of…
  • Balanced Crystalloid Ann Surg. 2012 May;255(5):821-9 JAMA. 2012 Oct 17;308(15):1566-72)
  • HIP
  • Give 1 (or max 2) liter(s) more
  • Tense the Tank
  • 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
  • Peripheral Pressor Administration Crit Care Med.2013 Sep;41(9):2108-15
  • First 24 hrs: Think you Need Additional Fluid?
  • Volume Loading by SV
  • After First 24 hrs: Better have a think about it
  • Microcirculatory Resuscitation?
  • Glycocalyx ?
  • Goals
  • MAP > 65 CI > 2.2 (2.5) Microcirc Goals?
  • ScvO2
  • 2nd Lactate?
  • Lack of Prognostic Value of Lactate Clearance in a Center with a Severe Sepsis Protocol
  • 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).
  • If you are already doing the good stuff, clearance doesn’t matter--unless they rebound…
  • May not be applicable to places without a team that wants to care about these patients
  • emcrit.org/smacc
  • The old days…
  • Gain from Sepsis Interventions Easy Crap Mental Masturbation 95% 5%
  • 5%
  • Stop Sepsis Deaths
  • You don’t need to do a whole lot of
  • You just need to give a