Microsoft PowerPoint - Sepsis SMI [Compatibility Mode]

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Microsoft PowerPoint - Sepsis SMI [Compatibility Mode]

  1. 1. Septic Shock
  2. 2. Maternal MortalityMaternal Mortality -- Safe Motherhood InitiativeSafe Motherhood Initiative -- In 2002 the “Safe Motherhood Initiative” was launched as a joint venture between NYS Dept of Health and ACOG District II.of Health and ACOG District II. The goals of the program : 1. - Overall decrease in maternal mortality: 2. - Eliminates the disparity between white and black women
  3. 3. Maternal MortalityMaternal Mortality -- Safe Motherhood InitiativeSafe Motherhood Initiative -- Reporting Maternal Deaths through the S.M.I. was on a voluntary basis from 8/03 through 6/05 there were 37 Maternal Deaths reported6/05 there were 37 Maternal Deaths reported to ACOG District II through the S.M.I.
  4. 4. Maternal MortalityMaternal Mortality -- Safe Motherhood InitiativeSafe Motherhood Initiative -- Embolism 24% Most common causes of M.M. PIH 24% Hemorrhage 15% Infectious 15% Cardiac 6%
  5. 5. Maternal MortalityMaternal Mortality -- Safe Motherhood InitiativeSafe Motherhood Initiative -- 1.- Hemorrhage Protocol 2.- Preconceptional counselling2.- Preconceptional counselling 3.- Management of Sepsis and septic shock 4.- Obesity 5.- Critical Care in Obstetrics
  6. 6. Septic Shock - Case presentation - C/O - Fever, nausea, vomiting 2-3d - Other fam members same symptoms Mrs X , 36y old P2 at 34wks V.S. -Temp 104, BP 97/57, Pulse 150, R.R. 22 P.E. - Non-focal: Lungs clear, Abd non-tender Labs - WBC 8,000 Hct 33%, Hb 11g Fever etiology ?? - Hydration, Temp, EFM - Sepsis workup
  7. 7. Septic Shock - Case presentation - Initial FHR: - Bseline 200bpm, variability, no decels Hospital Course - Bseline 200bpm, variability, no decels 2hrs after Adm: - Temp 102, BP 94/45, Pulse 150, R.R. 18, O Sat 95% 4 hrs after Adm: - FHR Decelerations 430 hrs after Adm: - Decision for C/S
  8. 8. Adhesion molecules Septic Shock - Case presentation -
  9. 9. Septic Shock -Case presentation –
  10. 10. Septic Shock - Case presentation - Delivery 401 A.M. (EBL=800cc) To R.R. 430 A.M. 4:45A.M. Temp 98.9o F 5:00A.M. BP 80/40 Ephedrine BP 100/55 6:45A.M. O2 Sat 85%, -75% O2 Rpt Sat 95% 7:00A.M. pH=7.27 pO2=47 pCO2=41 HCO3=18 7:30A.M. Temp 99.5o F, CxR Bil pleural effusion
  11. 11. Septic Shock - Case presentation - Delivery 401 A.M. (EBL=800cc) To R.R. 430 A.M. Urinary Output 5A.M. 50cc5 50cc 6A.M. 50cc 7A.M. 45cc 8A.M. 25cc 9A.M. 25cc 10A.M. 20cc 11A.M. 10cc 12P.M. 30cc 1P.M. 60cc Fluids
  12. 12. Septic Shock - Case presentation - Pregnancy Post surgery Ac resp distress R/O Pulmonary Embolus - 8A.M. Heparin theray started - 2P.M. CT - No evidence of Emboli - Infiltrates sugg of pulm. edema - 8A.M. Heparin theray started - CT of chest requested Temp 99-101o F, O2 Sat 95-97%, UO > 30cc/h
  13. 13. Septic Shock - Case presentation - CT Bil Infiltrates Rpt WBC 15,000 Fever 1010 F O2 desaturation Pneumonia – Sepsis -ARDS O2 desaturation Low BP’s - 5P.M. Antibiotic Rx ICU -10P.M. Respiratory Distress Intubated Vent (PEEP=15cm H2 O) Rpt CxR ARDS
  14. 14. Septic Shock - Case presentation - No improvement Pulmonary Status Levophed Maintain BP’s Blood Culture Strep Pneumonia Rx Imipenem, Gentamycin Day 1-7 Rx Imipenem, Gentamycin Xigris (APC) started WBC’s 18-33,000 Temp 102-103 F Day 8-9 2nd Septic Source ?
  15. 15. Septic Shock - Case presentation - CxR No empyema No other studies done (Pat unstable) #9 Explor laparotomy TAH* in ICU 2nd Septic Source #9 Explor laparotomy TAH* in ICU Temp’s 98-100 F WBC’s 17,000 Pulmonary – No Change Pressor agents – No Change #14 Cardiac Arrest Death * Endomyometritis with abcess formation
  16. 16. Septic Shock - Case presentation - -Delay in Dg -Delay in initiation of antibiotic therapy Mrs X , 36y old P2 at 34wks 2A.M. -Delay in initiation of antibiotic therapy -Delay in initiation of hemodynamic monitoring - Delay in initiation of aggressive fluid management ICU Admission in Septic Shock 5 P.M. Maternal Mortality 2wks later
  17. 17. Septic Shock Consensus conference of American College of Chest Physicians and Society of Critical Care Medicine on Sepsis and related disorders – 1992 - Systemic inflamatory response syndrome- Systemic inflamatory response syndrome - Sepsis - Severe Sepsis - Septic Shock - Multiple Organ Dysfunction Syndrome
  18. 18. Systemic Inflamatory Response Syndrome
  19. 19. Septic Shock The organisms response to any insult SIRS* - Infectious, Trauma, Toxic >2 of the following : Definition Diagnosis *Systemic Inflamatory Response Syndrome >2 of the following : -Temperature >380C or <360C - Heart Rate > 90 bpm - Respiratory Rate >20/min - WBC >12,000 or <4,000 - Organ dysfunction (Neuro, Renal, Clotting, Acidosis, etc) Diagnosis
  20. 20. Septic Shock Bacteremia Presence of bacteria in the blood SIRS Systemic Inflamatory Response Syndrome Sepsis Severe sepsis Septic Shock Documented infection + Evidence of SIRS SIRS Sepsis associated with organ dysfunction (MODS) Sepsis induced hypotension despite adequate hydration Response Syndrome
  21. 21. Septic Shock 1.- Individual entities ? Increasingly severe responses to same insult 2.- Do they develop sequentially ? Progression after2.- Do they develop sequentially ? 3.- Risk of specific end-organ failure ? 4.- Mortality Rates ? Progression after hospitalization ? ARDS, DIC, ARF
  22. 22. Septic Shock A large study of 2,527 patients that met at least 2 criteria for SIRS and were followed for 28d in the hospital or until discharge/death.28d in the hospital or until discharge/death. Rangel-Fausto et al JAMA-1995
  23. 23. Septic Shock SIRS 1301 (52%) Sepsis 649 (26%) Final Diagnosis Rangel-Fausto et al JAMA-1995 Sepsis 649 (26%) Severe Sepsis 467 (18%) Septic Shock 110 (4%)
  24. 24. Septic Shock Final Dg Present on Admission Progressed in Hospital Sepsis 56% 44% Rangel-Fausto et al JAMA-1995 Sepsis 56% 44% Severe Sepsis 42% 58% Septic Shock 29% 71%
  25. 25. Septic Shock SIRS Advance to higher level Advance to Septic Shock Rangel-Fausto et al JAMA-1995 2 criteria 32% 11% 3 criteria 36% 21% 4 criteria 45% 27%
  26. 26. Septic Shock Sepsis 16% ⊕⊕⊕⊕ Blood Cultures Rangel-Fausto et al JAMA-1995 Sepsis 16% Severe Sepsis 25% Septic Shock 69%
  27. 27. Septic Shock Dg ARDS DIC ARF SIRS-2 2% 8% 9% SIRS-3 3% 15% 13% Rangel-Fausto et al JAMA-1995 SIRS-3 3% 15% 13% SIRS-4 6% 19% 19% Sepsis 6% 16% 19% Severe Sepsis 8% 18% 23% Septic Shock 18% 38% 31%
  28. 28. Septic Shock
  29. 29. Septic Shock SIRS and related conditions represent a hierarchical continuum of increased inflammatory response to infection Conclusions Rangel-Fausto et al JAMA-1995 response to infection End organ failure rates blood culture rates and mortality rates are all increased with each subsequent stage of systemic inflamatory response.
  30. 30. Septic Shock Diagnosis - Clinical presentation - Lab workup Pathophysiology - Lab workup Treatment
  31. 31. Septic Shock - Pathophysiology - Infection Bacteremia Release of toxins ComplexComplex inflammatory response Multiple Organ Dysfunction Death
  32. 32. Septic Shock - Pathophysiology - Coagulation system Endothelium Cell metabolism Bacterial toxins Bacteremia Cell metabolism Lungs Kidney Cardio-vascular Bacterial toxins Inflamatory Response
  33. 33. Septic Shock -Coagulation – Procoagulants Anticoagulants - Coagulation cascade - Platelet Activation Factor - Vasoconstriction - TF Inhibitor - AT Complex - Prot C Complex - Fibrinolysis
  34. 34. Septic Shock - Coagulation - Activated Protein C - Inhibits Factor VIII-a, V-a - TF expression - Inhibits PAI – 1 Anticoagulant Fibrinolysis- Inhibits PAI – 1 - Leukocytes adhesion - TNF levels Fibrinolysis Anti-Inflamatory Low Prot C and APC Mortality Rates Septic Shock
  35. 35. Septic Shock - Coagulation - Procoagulants Anticoagulants Bacterial Toxins Bacterial Toxins - Expression of TF - Edothelial damage - Platelet agregation - levelTF Inhibitor - level ofAT - level of Prot C - Prot C to APC - Fibrinolysis Microvascular thrombosis
  36. 36. Septic Shock - Cellular metabolism - Sepsis -Hypoxemia - Hypotension -Microvascular abn Microvascular thrombosis Tissue hypoxia -Microvascular abn Microvascular thrombosis Shunting Mitochondrial dysfunction Anaerobic metabolism ATP Lactic ac
  37. 37. Septic Shock - Cellular metabolism - Acidosis ( pH < 7.35 ) Respiratory pCO2 > 45mmHg Metabolic HCO3 < 22mEq/LpCO2 > 45mmHg HCO3 22-26 mEq/L HCO3 < 22mEq/L ⊕Anion Gap -Lactic ac -Ketoacidosis -Intoxication ∅ Anion Gap -Renal ac Anion Gap = (Na + K ) – (Cl + HCO3 ) ⊕ Anion Gap >14mEq/L
  38. 38. Septic Shock - Endothelial Cell - Endothelial cell - Prevent coagulation - Prevent migration of cells TM,, APC receptors TF Adhesion molecules- Prevent migration of cells - Regulate vasopermeability - Regulate microcirculation Adhesion molecules Leukocyte activation Vasoactive substances
  39. 39. Septic Shock - Endothelial Cell - Adhesion molecules Complement activation Permeability Sepsis Endothelial cells Complement activation TF, PAF Permeability Coagulation Leakage Edema Microvascular thrombosis Cell death
  40. 40. Septic Shock Endothelial cell injury Alveolar flooding Lung compliance Capillary permeability - ARDS - Lung compliance Shunting Hypoxemia Recovery DeathPulmonary fibrosis Pulmonary HTN
  41. 41. Septic Shock - ARDS - Onset Acute PaO / FiO < 200mmHgHypoxemia PaO2 / FiO2 < 200mmHg Chest X-ray Bilateral alveolar or interstitial infiltrates PCWP < 18mmHg
  42. 42. Septic Shock - Cardio-vascular - Myocardial Depression Refractory Vasodilation Sepsis Hypotension Tissue perfusion Capillary permeability Loss of intravascular volume Cell Death
  43. 43. Septic Shock - Diagnosis - Coagulation - Hypoxemia - CxR changes - Metabolic ac. Renal Pulmonary Tissue -Ac renal failure -D.I.C. - Thrombosis -Decreased E.F. -Hypotension - Metabolic ac. (Anion gap) - Lactic acid RenalTissue metabolism Cardio vascular -Ac renal failure -Hepatic failureLiver -Alteration of mental status C.N.S.
  44. 44. Septic Shock - Diagnosis - Fever - Common symptom - Viral syndrome - Non infectious -Regional anesthesia - Anxiety - Pain Pulse BP - Pregnancy - Steroids (FLM) - Labor -Regional anesthesia -Supine hypotension - NPO - Nausea/Vomiting WBC’s BP Output
  45. 45. Septic Shock - Diagnosis - Coagulation -Low BP (Refractory), PCWP, EF - pH, HCO3 BD, Anion gap, LactateTissue metabolism Cardio-vascular -Fibrinogen, FSP, PT, PTT, INR, Plts -Low BP (Refractory), PCWP, EF - O2 Sat, CxR Renal Pulmonary Cardio-vascular - Urinary Output, BUN, CR, Lytes - Liver function tests C.N.S. Liver - Physical exam
  46. 46. Septic Shock - Diagnosis - Acidosis Oliguria Hypotension Hypoxemia Fever Abn WBC’s BP, Pulse Hypoxemia Coagulopathy Abn mental status Pulse R.R. Prompt Dg and Management
  47. 47. Septic Shock - Management - Patients seen in the E.R. with the Dg of septic shock were randomly allocated to Rivers et al NEJM 2001 1.- Standard therapy (n=133) 2.- Early goal-directed therapy (n=130)
  48. 48. Septic Shock - Management - “Early goal directed therapy” is a complex approach to septic shock involving manipulation of cardiac preload afterload and contractility to achieve a balance between O2 delivery and O2 demand.delivery and O2 demand. End points used to confirm that balance - Mixed venous O2 Sat - Lactate level - Base Deficit - pH Rivers et al NEJM 2001
  49. 49. Septic Shock - Management - Controls A-lines, CVP placed Management of fluids, drugs up to MD’s Study A-line, CVP placed Rivers et al NEJM 2001 Study Fluids 500cc q 30min CVP = 8-12mmHg If MAP < 65mmHg Vasopressors If CV O2 Sat < 70% Blood Hct > 30% If CV O2 Sat still < 70% Dobutamine During the 1st 6hrs
  50. 50. Septic Shock - Management - Therapy 0-6hrs 0-72hrs Fluids-Control 3,499ml 13,300ml Fluids-Study 4,981ml* 13,400mlns Rivers et al NEJM 2001 Fluids-Study 4,981ml* 13,400ml Blood-Control 18% 44% Blood-Study 64%* 68%* Dobutamine-Control 1% 9% Dobutamine-Study 14%* 15%ns *p< 0.01
  51. 51. Septic Shock - Management - End-Point Baseline 0-6hrs 7-72hrs CVP-C 6.1 11.8 11.6 CVP-S 5.3ns 13.8* 11.9ns MAP-C 76 81 80 Rivers et al NEJM 2001 MAP-C 76 81 80 MAP-S 74ns 95* 87* Lactate-C 6.9 4.9 3.9 Lactate-S 7.7ns 4.3* 3.0* Base Deficit-C 8.9 8.0 5.1 Base deficit-S 8.9ns 4.7* 2.0* C Control, S Study *p< 0.01
  52. 52. Septic Shock - Management - End-Point Baseline 0-6hrs 7-72hrs PT-C 16.5 17.5 17.3 PT-S 15.8ns 16.0* 15.4ns PTT-C 32.9 37.6 37.0 Rivers et al NEJM 2001 PTT-C 32.9 37.6 37.0 PTT-S 33.3ns 32.6* 34.6* FSP-C 39 54.9 62.0 FSP-S 44ns 45.8ns 39.2* MODS-C 7.3 6.8 6.4 MODS-S 7.6ns 5.9* 5.1* C Control, S Study *p< 0.01
  53. 53. Septic Shock - Management - Mortality Controls (n=133) Study (n=130) All inpatients 59(46%) 38(30%)* Rivers et al NEJM 2001 All inpatients 59(46%) 38(30%)* 28 day 61(49%) 40(33%)* 60 Day 70(57%) 50(44%)* *p< 0.01
  54. 54. Septic Shock - Management - To determine the impact of delays in initiating Objective Kumar et al Crit Care Med, 2006 To determine the impact of delays in initiating adequate antibiotic therapy on mortality rates of patients in septic shock
  55. 55. Septic Shock - Management - A retrospective cohort study including 14 ICU’s Methods Kumar et al Crit Care Med, 2006 A retrospective cohort study including 14 ICU’s in the USA and Canada. A total of 2,731 adult patients with documented septic shock were included.
  56. 56. Septic Shock - Management - A. The primary outcome variable was survival to hospital discharge. Methods Kumar et al Crit Care Med, 2006 hospital discharge. B. The primary independent variable was the time to initiation of effective antimicrobial therapy relative to the first occurrence of shock (persistent hypotension)
  57. 57. Septic Shock - Management - A. Mortality for the entire population 56% B. Survival was similar: Outcome Kumar et al Crit Care Med, 2006 B. Survival was similar: - Infection documented or suspecetd - A plausible pathogen identified or not - Bacteremia present or absent
  58. 58. Septic Shock - Management - Antibiotics Rx (from onset of shock) Mortality Rates < 1hr 82% Kumar et al Crit Care Med, 2006 At 6hrs 42% < 1hr 82%
  59. 59. Septic Shock - Management - Antibiotics Rx (from onset of shock) Mortality Rates < 1hr 82% Kumar et al Crit Care Med, 2006 At 6hrs 42% Each hour of delay was associated with a in survival of 7.6%
  60. 60. Septic Shock - Management - Antibiotic Rx and Intensive therapy (goal directed therapy ) started at the earliest stages of severe sepsis/septic shockstages of severe sepsis/septic shock Lower mortality rates

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