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Surviving Sepsis: Early Goal Directed Therapy
Surviving Sepsis: Early Goal Directed Therapy
Surviving Sepsis: Early Goal Directed Therapy
SIRS
Microorganism
invading
sterile tissue
A clinical
response arising
from a nonspecific
insult, with 2 of
the following:
T >38oC or
<36oC
HR >90
beats/min
RR >20/min
WBC
>12,000/mm3
or <4,000/mm3
or >10% bands
Sepsis
SIRS with a
presumed
or confirmed
infectious
process
Sepsis with
organ failure
Vascular collapse
Renal
Hemostasis
Lung
LA
Refractory
hypotension
Chest 1992;101:1644
Sepsis Syndromes
1992: SCCM/ACCP
Parasite
Virus
Severe
Sepsis
Infection
Fungus
Shock
Sepsis
SIRS
S ev
e
SIR re
S Trauma
BSI
Bacteria
Burns
24 Hour Bundle
Glucose control maintained <
150 mg/dL
Drotrecogin alfa (activated)
administered in accordance
with hospital guidelines
Steroids given for septic
shock requiring continued use
of vasopressors for > 6 hours
Lung protective strategy with
plateau pressures < 30 cm
H2O for mechanically
ventilated patients
http://www.ihi.org
Society of Critical Care Medicine (SCCM) 38th Critical Care Congress. Late breaker. Presented February 2, 2009
DVT Prophylaxis
Antibiotics within 1 hr
for Septic Shock
Glycemic Control
Fluid Challenge
Crystalloid = Colloid
BC prior to Abx
Source Control
Dopamine or
Norepinephrine
H2 Blocker PUD
Prophylaxis
No Routine Use
of SGC
No Renal Dose
Dopamine
No High Dose
Steroids
HOB >45
Limited Transfusion
No Antithrombin II
No Erythropoietin
Intermittent =
Continuous sedation
Weaning Protocol/SBT
Avoid NMB
D
Antibiotics within 1
hr in No septic
Shock Patients
7-10 day Antibiotic
Duration
Consider Limiting
Support
PRBCs or
Dobutamine
Wean Steroids
equivalency
of continuous
veno-veno
hemofiltration
or intermittent
hemodialysis
SIRS
Sepsis
Steroids
Drotrecogin Alpha
Early Goal Directed Therapy
Antibiotics and Source Control
Insulin and Tight Glucose Control
Chest 1992;101:1644
SIRS
Sepsis
49.2%
P = 0.01*
40
Mortality %
Vascular
Collapse
33.3%
p=0.02
30
MODS
20
22% vs 16%
10
0
21% vs 10%
P=0.27
Standard Therapy
N=133
EGDT
N=130
60
Mortality (%)
50
40
30
20
10
0
In-hospital
mortality
(all patients)
28-day
mortality
60-day
mortality
SIRS Screen
First section screens for SIRS
Infection Screen
Second section screens for infection
SBAR
The RN should approache the MD, informing
him using SBAR technique, that the patient has
screened positive for severe sepsis.
Hg
Mean arterial pressure (MAP) 65mm Hg
Urine output 0.5mL.kg1.hr 1
Central venous (superior vena cava) or
mixed Venous oxygen saturation 70% or
65%, respectively
Hemoglobin >10 mg/dL
Rivers E, Nguyen B, Havstad S, et al. 2001;345:1368-1377.
monitoring
500 mL 0.9% NaCl bolus every 15
minutes to maintain a CVP goal
Colloids if CVP <4
Transfuse 1 unit of PRBCs if Hg <10
compliance
Increased intra-abdominal pressure
hours
ScvO2 <70%
Arterial line placement
Transfuse 1 PRBCs if Hg level <10 mg/dL
Start Dobutamine 2.5-20 mcg/kg/min IV
infusion
Intubation and ventilation
mmHg
Target a mean arterial blood pressure target of 65
mmHg
Target a central venous O2 saturation of 70%
Target your urine output to >0.5 mL/Kg/Hour
Thank You