A Decade of Evidence
Emanuel P. Rivers, MD, MPH, IOM Vice Chairman and Research Director Emergency and Surgical Critical Care Medicine Henry Ford Hospital Clinical Professor, Wayne State University Detroit, Michigan
I have no disclosures
HealthGrades analyzed over 5 million Medicare records of patients admitted through the emergency department at 4,907 hospitals from 2006 through 2008, to identify the top 5% of the best-performing hospitals in emergency medicine.
Golden Hours
Bundles
2,154 septic shock patients Received antibiotics after the onset of recurrent or persistent hypotension Each hour of delay over 6 hrs was associated with 7.6% decrease in survival.
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Can you describe the evidence and benefit associated with lactate clearance and the importance of repeating within 4 hours?
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11 10 9 8 7 6 5 4 3 0 6 12
60 50 Mortality (%) 40 30 20 10 0 1 2 3
MODS
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36
48
60
Time (hr)
53 42 29
72 p<0.05
Debaker, 2006
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Its primary focus was on individually randomized trials with 2 parallel groups that assess the possible superiority of one treatment compared with another but is now being extended to other trial designs. Noninferiority and equivalence trials have methodological features that differ from superiority trials and present particular difficulties in design, conduct, analysis, and interpretation. The quality of reporting of those that are published is often inadequate. CONSORT checklist. The intent is to improve reporting of noninferiority and equivalence trials, enabling readers to assess the validity of their results and conclusions.
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Lactate
SvO2
EGDT
JAMA
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It is common knowledge, however, that many septic patients develop multiple organ failure and die despite normal blood lactate levels.
Vallet B, Chopin C, Curtis S E, et al: Prognostic value of the dobutamine test in patients with sepsis syndrome and normal lactate values: A prospective, multicenter study. Crit Care Med 1993; 21:18681875. De Backer D, Creteur J, Silva E, et al: The hepatosplanchnic area is not a common source of lactate in patients with severe sepsis. Crit Care Med 2001; 29:256261. Oud L, Haupt MT: Persistent gastric intramucosal ischemia in patients with sepsis following resuscitation from shock. Chest 1999; 115:13901396.
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Alactemic Sepsis
Multicenter Study (2,424 lactates)
11.6% have Lactate < 2 and SBP < 90 (vasopressors) 16% have Lactate < 2.5 and SBP < 90 (vasopressors) 25% have Lactate < 4.0 and SBP < 90 (vasopressors)
Cannon CM, for the Multicenter Severe S, Septic Shock Collaborative G. The GENESIS Project (GENeralization of Early Sepsis InterventionS): A Multicenter Quality Improvement Collaborative. Acad Emerg Med 2010;17:1258.
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Alactemic Sepsis
Nguyen, East Asian Study (512 lactates) 9.1% with LA < 2 and SBP < 90 (vasopressors) 24.2% have LA < 4 and SBP < 90 (vasopressors)
Na S, Joshi M, Li C-h, et al. Implementation of a 6-hour severe sepsis bundle in multiple asian countries is associated with decrease mortality. Chest 2009;136:20S.
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50% of vasopressor-dependent septic shock patients do not express lactic acidosis and have higher mortalities
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Goal Directed
Septic Shock
CNS and Systemic VO2 - Stress - Pain - Hyperthermia - Shivering - Work of breathing
DO2
- PaO2 - Hemoglobin - Cardiac Output Cardiac Optimization - Preload (CVP, PCWP, SVV, IVC) - Afterload (MAP, SVR) Contractility (SV) - Heart Rate (BPM) - Coronary Perfusion Pressure
Endpoints of Resuscitation
SvO2
Lactate
(a-v)CO2
Microcirculation
Happy Cell
Base Deficit
pHi
P.E.
VO2
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Lactate
Treatment and Comments Volume Vasopressors Adrenal Dysf. Correct anemia Inotropic Therapy Vasodilators, r-APC
Variable
Variable
Variable
Normal
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What is your take determining fluid responsiveness (Marik meta-analysis from Chest 2008)?
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No outcome difference
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Cardiac Output
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Are the things that the SAFE trial provides enough data to suggest using albumin?
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Baseline Characteristics
Control
(n = 10)
Treatment
(n = 7)
p-value 0.91 0.79 0.44 0.26 0.25 0.64 0.67 0.38 0.74
Age APACHE MODS SAPS Lactate ScvO2 CVP Heart Rate MAP
65 + 15 24.6 + 4.1 10.0 + 3.2 48.5 + 5.5 9.9 + 5.2 46.3 + 14 5.0 + 4.2 103 + 25 78 + 31
65 + 17 25.1 + 1 8.9 + 2.5 45.4 + 5.0 7.0 + 4.2 40.5 + 16 8.2 + 13.0 108 + 35 84 + 41
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Mechanical Ventilation
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Mortality
Control EGDT p-value (n= 10) (n = 7) In-Hosp 70 % 14 %
0.0498
30-Day
70 %
14 %
0.0498
60-Day
80 %
14 %
0.0150
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What do you think about pre-hospital use of low dose vasopressin in moderate to severe sepsis to replenish the reserves?
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Steroids in shock?
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Effect of Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients with Septic Shock (Annane JAMA 2002) Design: Randomized, double-blind, multi-center Patients: Septic shock Intervention: Hydrocortisone (50 mg every six hours) Fludrocortisone (50 ug once per day) Main Outcome: 28-day survival in nonresponders to CST 229 Non-responders Randomized 115 Treatment & 114 controls 10% decrease in 28-day mortality 17% reduction in vasopressors use
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No Outcome Benefit
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14.5% Reduction in Vasopressor Use if Optimized with EGDT Hold steroid use until the patient has been resuscitated and endpoints met (6-8 hours)
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Inflammatory Mediators
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Early Goal-Directed Therapy for Sepsis in Patients With Preexisting Left Ventricular Dysfunction: A Retrospective Comparison of Outcomes Based Upon Protocol Adherence
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Ms. Peterson
Infected foot clostridium Perf (anaerobe) Lactate of 10 and oliguric BNP -3467 BUN-77 and creatinine 4.3 CXR Ultrasound
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Activated Protein C
Activated Protein C
Coagulation Inflammation
Fibrinolysis
Hypoperfusion/Ischemia
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CCM, 2010
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Among patients presenting with septic shock, early treatment with activated protein C may be associated with reduced hospital mortality.
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< 6 hours
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How do you implement EGDT in a community hospital with single ED coverage where you cant spend 6 hrs with one patient, and dont have central lines with ScvO2?
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California Pacific Medical Center University of Kansas Hospital University Medical Center at Brackenridge Barnes Jewish Hospital
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The Multi-Center Severe Sepsis and Septic Shock Collaborative Group 11 Medical Centers (5 Community / 6 Tertiary ) 9 States
2003 2005
to
2005 2008
to
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16% ARR
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12000 10000 IL-1ra pg/ml 8000 6000 4000 2000 0 0 3 6 12 24 36 48 60 72 Hours after the start of treatment
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Statins in shock?
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