SEPSIS: Whats New in Diagnosis & Management 10.22.16 Sepsis: A - - PDF document
10/22/16 Disclosures I have no conflicts of interest to disclose. SEPSIS: Whats New in Diagnosis & Management 10.22.16 Sepsis: A Core Hospitalist Dz: 22% of deaths The Case A 32-year-old man with a history of plundering &
I have no conflicts of interest to disclose.
Epstein et al, CDC MMWR 2016
A 32-year-old man with a history of plundering & pillaging presents with an infected sword wound. Gen Surg is called to r/o nec fasc. He is hypotensive, febrile, tachy & altered.
Our Roadmap for Today
Management
Updates
SEPSIS
SEVERE SEPSIS
Burns Trauma Pancreatitis Tox
§ Severity is on a spectrum § SIRS criteria: HR > 90, RR > 20 or PaCO2 < 32, WBC > 12 or < 4 or > 10 % bands, T > 38 or < 36 § Severe Sepsis = SIRS + Acute Organ Dysfunction § Septic Shock = Severe Sepsis + hypotension not reversed w/ IVF § Multi-system Organ Failure (MSOF)
§ Hypotension - SBP < 90 § Hypoxemia § UOP < 0.5 mL/kg-hr § INR > 1.5 § Plt < 100k § Total Bilirubin > 4 § Lactate > 2 § New Altered Mental Status
§ 19-member task force by SCCM & European Society of Intensive Care Medicine § Definitions last revised in 2001 § Non-specificity of SIRS criteria & patients with SIRS “at baseline” § New research w/ better correlations with clinical outcomes
New! But Improved?
Singer et al, JAMA 2016 From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
Sequential [Sepsis-Related] Organ Failure Assessment Scorea Table Title:
is . . .
Singer et al, JAMA 2016
Jones et al, Crit Care Med 2009
§ ΔSOFA from HD1 to HD3 § If you get sicker . . .
§ 12% of ICU patients have 0 SIRS criteria § In ICU patients with suspected infection, SOFA (AUROC = 0.74; 95% CI, 0.73-0.76) was superior to SIRS (AUROC = 0.64) for predicting hospital mortality § AUROC ~ Email spam filter
Kaukonen et al, NEJM 2015
§ Sepsis-3 defined new diagnostic criteria but uses TBD . . . § Remember qSOFA (BP, AMS, Tachypnea) in non-ICU § SOFA score helps prognosticate mortality in ICU – ΔSOFA > 2? § No more severe sepsis in the new criteria but still think of
§ Not yet endorsed by ATS, ACEP, Medicare, and more . . .
Our Roadmap for Today
Management
Updates
q Early recognition (with our detection tools) q Adjunctive diagnostic measures (such as lactate) q Early IV fluids q Early broad-spectrum antibiotics q Vasopressors if unresponsive to fluids q Central access if you need vasopressors
q Elderly q ESRD on HD q HIV q Immunocompromised q Transplant pts
Non-Shock Shock Low 8.7 15.4 Intermediate 16.4 37.3 High 31.8 46.9 10 20 30 40 50 28-day mortality (%)
Mikkelsen et al, Crit Care Med 2009
q It all starts with a careful history & physical! q Consider blood, urine, sputum, stool cx (depending) q Always do basic imaging (CXR, bedside U/S/TTE) q Consider advanced imaging (CT Head, Abdomen/Pelvis, Lower Extremities) q Consider advanced dx procedures (LP, bronch, etc)
(post-NSG) CNS
HEENT
Pulmonary
Cardiac
GI/GU
MSK
Skin
Bloodstream
Other non- infectious etiologies
q
Cardiogenic shock
q
Hypovolemia/Blood loss
q
Pulmonary embolism
q
Myxedema coma
q
Toxidromes
q
Acute liver failure
q Cardiac Tamponade q Acute valvular dysfxn q Aortic Dissection q Anaphylaxis q Adrenal crisis q HLH q And more!
q Narrow Abx based on cx data (esp Vanco!) q Consider diuresis to counteract your flooding q Limit ICU Harms: PT/OT, Delirium, De-Line q Recognize differing trajectories of illness
Skrupsky et al, Anesthesiology 2011
§ Early diagnostics (including lactate) & resuscitation matter § Hunt aggressively for the source – step-wise approach § Think head-to-toe and consider septic shock mimics § Harness the power of the EHR to identify sepsis, but remember limitations § Recognize different clinical trajectories of sepsis
Our Roadmap for Today
Management
Updates
EGDT ‘ROIDS
XIGRIS
§ RCT of early goal directed therapy (EGDT) versus standard
§ Mortality was primary outcome § There was a 15% absolute risk reduction in mortality § Issues: Conflict-of-interest, heavy ED influence, high baseline mortality, & many more!
§ No significant difference in the 90-day mortality between the EGDT and usual care groups (29.5% vs 29.2%, p=0.90), despite EGDT having (in first 6 hours): u Higher rate of vasopressors u More RBC transfusions u More IVF fluids
ProMISE, NEJM 2015
ARISE, NEJM 2014
ProCESS, NEJM 2014
§ Strict protocol for EGDT did not lead to improved outcomes § Increased costs with EGDT protocol § All patients basically got Abx + 2 L IVF pre-randomization, suggesting usual care has changed since Rivers § Only 50% got central lines in usual care group
Keh et al, JAMA 2016
§ Randomized patients to continuous infusion of 200 mg of hydrocortisone for 5 days + taper to d11 vs placebo § Goal was to prevent severe sepsis à septic shock
Gordon et al, NEJM 2016
§ LeoPARDS RCT double blind placebo-controlled trial of this Ca-sensitizer § Not currently licensed in the USA § No difference in mean SOFA score or mortality
EGDT ‘ROIDS
XIGRIS
§ Well-designed RCT! § No reduction in mortality or LOS § Trial was of IV Tylenol, of note § Treat for comfort
Young et al, NEJM 2015
§ Passive leg raise vs CVP vs A-line PPV vs IVC U/S § No reduction in mortality or LOS § Trial was of IV Tylenol, of note § Treat for comfort
Bentzer et al, JAMA 2016
§ Retrospective study of matched 1:3 cases (~33K:99K) pts w/ ICU day 1 PCT testing vs no PCT testing § Decreased hospital LOS, ICU LOS, lower hospital costs, lower Abx days § No mortality difference § $81 per test difference in cost
Balk et al, Chest 2016
§ More trials for the sepsis graveyard – EGDT, steroids § Treat fevers in the ICU for comfort § Some high-tech (procalcitonin) & low-tech (leg raise) dx for sepsis § More literature on sepsis management controversies
Our Roadmap for Today
Management
Updates
Lekshmi.Santhosh@ucsf.edu