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Bohomolets septic shock

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Bohomolets septic shock

  1. 1. Septic Shock Absolute hypovolemia Relative hypovolemia Distributive shock :areas of VD/VC Cardiac dysfunction Impaired O2 extraction
  2. 2. History of Septic Shock60’s hypotension vasopressors  normalize BP70’s Inadequate flow  measure CO + inotrope80’s Inadequate DO2  DO2/VO2 + inotrope90’s Regional circulations + dopexamine  phi, lactate + dopexamine00’s Microcirculation failure + vasodilators  « open » capillary beds
  3. 3. CCM , 2008 , 36 , 296-327
  4. 4. Initial ResuscitationMAP  65 mmHg CVP 8-12 mmHg UF  0.5 ml.kg -1.hr-1ScvO2  70% SvO2  65%
  5. 5. BE SURE THE PATIENTIS ADEQUATLY FLUID-RESCUCITATED
  6. 6. Fluid challenge Respiratory variation under MV Parameter threshold SAP 10 mmHg or 9%5-6 % down PP SVV CVP 5 mmHg 12-13 % 9-10% < 5 mmHg French Consensus Conference 2005
  7. 7. Am J Respir Crit Care Med 2000; 162:134-8 162:134- 100 PP 80 SPVSensitivity (%) 60 RAP 40 20 PAOP 0 0 20 40 60 80 100 100- Specificity(%)
  8. 8. Passive Leg Rising Predicts Response to Fluid Loading Rapid fluid loading :300 ml, > 20 min. Boulain, Chest 2002, 121, 1245
  9. 9. Fluid challenge 500 ml (7 ml/kg) (either colloid or crystalloid 20 – 30 min
  10. 10. Fluid Challenge and Severe SepsisCristalloids Colloids Schierhout BMJ 1998, 316, 961 Wilkes Ann Int Med 2001, 135, 149 Choi CCM 1999, 27, 200 Sibbald www.uptodate.com 2003, 1/03
  11. 11. Safe StudyNEJM 2004 , 350 ,2247-2256
  12. 12. Safe Study NEJM 2004 , 350 , 2247-2256
  13. 13. HEA or Gelatine for Severe Sepsis ? Schortgen et al Lancet 2001 , 357 , 911Patients without Acute Renal Failure Gelatine HES
  14. 14. HEA or Gelatine for Severe Sepsis ? Schortgen et coll Lancet 2001 , 357 , 911 Survivors
  15. 15. P=0.09Subgroup Analysis (</= 22mL/Kg/day) P<0.001 (> 22mL/Kg/day)
  16. 16. Hydroxyethyl StarchHES 200,000/0.6 HES 200,000/0.56% solution (60g/l) 6% solution (60g/l)Na+ 154 mmol/l Na+ 154 mmol/l12 - 24h 4 - 8h 33 ml / kg / 24h
  17. 17. 32 patients randomized : dopamine (Until 25 µg/kg/min) or norepi ( Until 5 µg/kg/min) Objectif : PAM > 80 mmHg 6 h Dopa (n=16) Norepi (n=16) success (n=5) échec (n=11) success (n=15) failure (n=1) 10 to 25 µg/kg/min 25 µg/kg/min 1.5±1.2 µg/kg/min 1.5± 5 µg/kg/minincrease in urine output increase in urine output decrease in lactate decrease in lactate 10 success with Dopa + Norepi (25 µg/kg/min +1.7±1.8 µg/kg/min) +1.7± increase in urine output and decrease in lactate Chest 1993, 103:1826-31
  18. 18. Dopamine or Norepinephrine ? 93% 69% P < 0.001 31% 7% p < O. 001Success Failures Success Failures Dopamine Norepinephrrine C. Martin et al Chest 1993, 103, 1826
  19. 19. Dopamine or Norepinephrine ? Hyperdynamic septic shockDopamine Norepinephrine(2.5-25 g /kg/min) (0.5-5.0 g/kg/min) 16 patients 16 patientssuccess : 5/16 (31%) success : 15/16 -93%) p<0.001failure : 11/16 failure : 1/16success : 0/1 success : 10/11 C. Martin et al Chest 1993, 103, 1826
  20. 20. Resistance to Dopamine110 patients MAP < 70 mmHg with 20 g/kg/min 60% P < 0.001 40% Dopa S Dopa R Levy et al CCM 2005, 33.
  21. 21. Resistance to Dopamine Levy et al CCM 2005, 33.
  22. 22. % Survival Septic Shock :100 Norepinephrine 90 80 70 60 Norepinephrine 50 40 p<0.0001 30 20 Martin C et al Crit Care Med 10 Other vasopressors 2000 , 28 , 2758 . 0 0 5 10 15 20 25 30 35 40 45 50 Days
  23. 23. CATS Study (Epinephrine / norepi-dobu) Epinephrine Norepi-dobu n = 161 (n = 169)Hospital survival Hospital survival 47.8% 51.5% p = 0.51 D. Annane et al Lancet 2007,370,676-684
  24. 24. D. Annane et al Lancet 2007,370,676-684
  25. 25. MAP : 65-75-85mmHg ???
  26. 26. 150 Renal Blood Flow Renal Autoregulation (% baseline) in Disease Control 3 weeks100 1 week500 20 40 60 80 100 Renal Artery Pressure (mmH g)
  27. 27. 150 Renal Blood Flow Renal Autoregulation (% baseline) in Disease Control 3 weeks100 1 week500 20 40 60 80 100 Renal Artery Pressure (mmH g)
  28. 28. 150 Renal Blood Flow Renal Autoregulation (% baseline) in Disease Control 3 weeks100 1 week500 20 40 60 80 100 Renal Artery Pressure (mmH g)
  29. 29. 150 Renal Blood Flow Renal Autoregulation (% baseline) in Disease Control 3 weeks100 1 week500 20 40 60 80 100 Renal Artery Pressure (mmH g)
  30. 30. 65 85
  31. 31. UF Increasing MAP ?65 Creatinine 85 Cr Cl A Bourgoin et al CCM 2005,33,780-786
  32. 32. MAP :65 mmHg
  33. 33. Septic shock. Inotropic Therapy. Dobutamine is the firstchoice for patients with low CO < 2.5 l/min/m2 after fluid resuscitation after an adequate MAP (Level E). Dobutamine may cause hypotensionand /or tachycardia in some patients: especially those with low filling pressureTask Force of the SCCM. Crit. Care Med 2004,32,1928-1948
  34. 34. Initial ResuscitationMAP  65 mmHg CVP 8-12 mmHg UF  0.5 ml.kg -1.hr-1ScvO2  70% SvO2  65%
  35. 35. Early « Goal-directed therapy » 4981 ml 64.1% p < 0,001 P < 0,001 3499 ml 18.5% contrôles GDT contrôles GDTExpansion volémique Transfusion (% patients) 13.7% 0.8% p < 0,001 contrôles GDT Dobutamine (% patient) Rivers et coll N Eng J Med 2001, 345, 1368-1377
  36. 36. Early « Goal-directed Therapy » Hospital mortality 46.5% 30.5% (p = 0.009) Controls GDT Rivers et al NEJM, 2001, 345, 1368-1377
  37. 37. Rescue Therapy
  38. 38. 1-AR AC AC     Gs protein   P P P Receptor arrestin resensitization clathrinReceptor endosome Receptorinternalization Receptor degradation dephosphorylation
  39. 39. VASOPRESSIN• Regulation of plasmatic osmolarity and volemia• Heterogeneous vasoconstriction Liard et al. Am J Physiol 1982• Vasodilation in some circulatory beds Walker. Am J Physiol 1986
  40. 40. AVP
  41. 41. Norepinephrine > 15 mcg/min
  42. 42. Norepinephrine 5-14 mcg/min
  43. 43. Only asrescue therapy
  44. 44. Terlipressin?  15 patients with catecholamine - resistant septic shock: NE ( 2.2 mcg/kg/min ) dopamine ( 25 mcg/kg/min ) Terlipressin 1 or 2 bolus of 1 mgMAP CI l/min/m2mmHg 5.3+/-1.2 84+/- 6 4.7+/-1.3 55+/- 5 P< 0.01 NE + dopa TER NE + dopa TER 1147+/-134 SVRI dyn.sec 654+/-108 .cm-5.m-2 NE + dopa TER Albanese , Martin Shock 2004,22,314-319
  45. 45. Terlipressin? 15 patients with catecholamine - resistant septic shock: NE ( 2.2 mcg/kg/min ) dopamine ( 25 mcg/kg/min ) Terlipressin 1 or 2 bolus of 1 mg UF 67+/- 33 P<0,01 ml/min 11+/-15 Cr CL ml/min NE + dopa TER 49+/-37 P<0.01 / 1.74 m2 17+/-44 NE + dopa TERAlbanese , Martin Shock 2004,22,314-319
  46. 46. Dynamic Aspect 6th hour 2nd hour 1st hour  blood gas MAP>65 mmHg  lactate ScvO2 70%  arterial%  cultures line SvO2 > 65  ATB  CVC SvO2  plateau pressure  peripheral IV  <CVP > 5 mmHg 30 mmHg  vasopressor  fluid
  47. 47. Dynamic Aspect1st hour 2nd hour 6th hour blood gas MAP 65 mmHg ScvO2 > 70% lactate  arterial line SvO2 > 65 % cultures  CVC SvO2  plateau pressure ATB  CVP > 5 mmHg < 30 mmHg peripheral IV vasopressor fluid

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