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.

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Sepsis in NY: The first 15K patients by Weingart

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

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