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Management of Sepsis

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Dr.Mahmoud Abbas
Dr.Mahmoud Abbas
Health & MedicineTechnology
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Management of Sepsis Luca Bigatello, MD Director, Surgical ICU, Massachusetts General Hospital Associate Professor of Anesthesia, Harvard Medical School
Definitions ,[object Object],[object Object],[object Object],Bone et al ., Crit Care Med ‘92 SCCM/ etc ., Crit Care Med ‘03
Sepsis & Septic Shock ,[object Object],[object Object],[object Object],Hotchkiss & Karl, NEJM ‘03
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],20 Societies- CCM ’08;36:296
Early Antibiotic Therapy ,[object Object],[object Object],Kumar et al ., CCM ’06;34:1589 ,[object Object],[object Object],[object Object],[object Object]
Early Goal-Directed Therapy: RCT ,[object Object],[object Object],[object Object],[object Object],Rivers et al ., NEJM ’01;345:1368 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],Comments Rivers et al ., NEJM ’01;345:1368
Does it Change Practice in the ICU? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rivers et al ., NEJM ’01;345:1368
A Word of Caution on ScvO 2 ,[object Object],[object Object],Chawla et al ., Chest ’04, Dueck et al ., Anesthesiology ’05 Reinhardt et al ., ICM ’04, Scheinman et al ., Circulation ‘69
Steroids in Septic Shock ,[object Object],30 mg/kg MP x 4 doses No diff. in death, prevention or reversal of shock MP: higher death in pts with  ’d Crea., from infection
Relative Adrenal Deficiency in Septic Shock (SS) ,[object Object],[object Object],[object Object],[object Object],[object Object]
76% of pts. were non-responders! ,[object Object],[object Object],[object Object],[object Object],Annane et al ., JAMA ’02;288:862 ,[object Object],[object Object]
Comments ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Annane et al ., JAMA ’02;288:862
[object Object],[object Object],[object Object],CORTICUS, NEJM ’08;358:111
CORTICUS…….. N=251 Steroids N=248 Placebo 28-day Mortality
Stim - test, non-responders (~51%) Stim - test, responders (~47%) P=0.8 P=1.0 28-day Mortality ,[object Object],[object Object]
So, Who Should Get Steroids? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Guidelines, 20 Societies- CCM ’08;36:296
Tight Glucose Control- I > 5 days ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Van den Berghe et al ., NEJM ’01;345:1359
[object Object],[object Object],[object Object],[object Object],[object Object],Van den Berghe et al ., NEJM ’01;345:1359 Langouche et al ., J Clin Invest ’05;115:2277 Angus & Abraham, AJRCCM ’05;172:1358 Comments
Aftermath ,[object Object],[object Object],http://www.ihi.org/IHI/Topics/PatientSafety/ http://www.jointcommission.org/
Tight Glucose Control- II ,[object Object],[object Object],[object Object],[object Object],Van den Berghe et al ., NEJM’06;354:449 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],Tight Glucose Control- III VISEP, NEJM ’08;358:125
Tight Glucose Control- IV, V…. GLUCONTROL, in press……. ,[object Object],[object Object],NICE-SUGAR, ongoing….. ,[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],Insulin Infusion Protocols Wilson et al., Diabetes Care 2007;30:1005
So, Who Should Get…. How Tight …? ,[object Object],[object Object],[object Object],[object Object],[object Object],Guidelines, 20 Societies- CCM ’08;36:296
Vasopressin ,[object Object],[object Object],Landry et al ., Circulation ‘97
Vasopressin Holmes et al ., Int. Care M. ’97 Patel et al ., Anesthesiology ’02 Dunser et al ., Circulation ‘04
Vasopressin- Concerns ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],VASST, NEJM ’08;358:877
[object Object],[object Object],So, Who Should Get Vaso.? Guidelines, 20 Societies- CCM ’08;36:296
r-Human Activated Protein C for Severe Sepsis PROWESS, NEJM ‘01 ,[object Object],[object Object]
r-aPC for Severe Sepsis Angus et al ., CCM ‘04 PROWESS, NEJM ‘01 ,[object Object],2% 3.5% bleeding 31% 25% mortality placebo rAPC 1700 pts .
r-aPC for Less- Severe Sepsis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Abraham et al ., NEJM ’05;353:1332
r-aPC in Kids ,[object Object],[object Object],[object Object],Nadel et al., Lancet 2007;369:836-43
So, Who Should Get r-a PC? ,[object Object],[object Object],[object Object],[object Object]
Conclusions ,[object Object],[object Object],[object Object]
Quantifying the Impact ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Management of Sepsis

  • 1. Management of Sepsis Luca Bigatello, MD Director, Surgical ICU, Massachusetts General Hospital Associate Professor of Anesthesia, Harvard Medical School
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  • 15. CORTICUS…….. N=251 Steroids N=248 Placebo 28-day Mortality
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  • 27. Vasopressin Holmes et al ., Int. Care M. ’97 Patel et al ., Anesthesiology ’02 Dunser et al ., Circulation ‘04
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