The Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy

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1 The Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy Cindy Goodrich RN, MS, CCRN Content Description Sepsis is caused by widespread tissue injury and systemic inflammation resulting from infection. The continuum of severity ranges from sepsis to septic shock. Despite advances in care, severe sepsis and septic shock are associated with significant mortality. Early identification and restoration of adequate perfusion are critical in preventing irreversible organ dysfunction and death. Management includes prompt identification and timely implementation of aggressive interventions aimed at source control and reversal of sepsis induced tissue hypoperfusion. Early Goal Directed Therapy (EGDT) is used to identify and manage severe sepsis and septic shock. Lactate and ScvO 2 are used to identify underlying global tissue hypoxia. Use of this evidence-based protocol has been shown to reduce mortality and has resulted in substantial cost savings. EGDT as a strategy for early identification and aggressive management of severe sepsis and septic shock will be the focus of this presentation. Learning Outcomes By the end of this session the participant will be able to: 1. Define and differentiate between SIRS, sepsis, severe sepsis and septic shock. 2. Discuss the clinical application of continuous ScvO 2 monitoring. 3. Describe the use of EGDT for the management of severe sepsis and septic shock. Summary of Key Points I. Sepsis Overview A. Introduction B. Definitions 1. Systemic Inflammatory Response Syndrome (SIRS): Inflammatory response, which includes 2 or more of the following: 2. Sepsis -temperature less than 36C or greater 38C -Increased respiratory rate greater than 20 -Decreased PaCO 2 (less than 32 mm Hg) -Increased heart rate greater than 90 -WBC greater than 12,000/mm 3 or less than 4,000/ mm 3 or greater than 10% bands 3. Severe Sepsis Presumed or confirmed site of infection 2 or more signs and symptoms of SIRS Presence of sepsis and 1 or more organ dysfunctions Organ dysfunction:

2 4. Septic Shock: presence of severe sepsis and refractory hypotension C. Pathophysiology 1. A disease of the microcirculation: impaired perfusion D. Early Identification and Early Aggressive Management 1. Who is at Increased Risk? II. ScvO 2 Monitoring A. Definition: oxygen saturation of superior vena cava blood B. Measurement of ScvO 2 1. Reflects blood returning to right atrium via the superior vena cava. 2. Measured using modified central venous catheter with fiberoptic technology C. Clinical Application 1. Global indicator of balance between O 2 supply and demand 2. Factors influencing ScvO 2 cardiac output (CO) SaO 2 Hemoglobin Oxygen consumption (VO 2 ) 3. Normal Value: greater than or equal to 70% 4. Abnormalities in ScvO 2 a. Low ScvO 2 1. Decreased oxygen delivery decreased CO decreased HB decreased SaO 2 2. Increased oxygen consumption (VO 2 ) b. High ScvO 2 1. Increased oxygen delivery increased CO increased HB increased SaO 2 2. Decreased oxygen consumption (VO 2 )

3 D. Clinical Indications for Use of ScvO 2 Monitoring 1. Global Indications Early goal directed therapy (EGDT) Early monitoring of tissue oxygenation Surrogate for SvO 2 when unable to place pulmonary artery catheter 2. Specific Clinical Indications Sepsis and EGDT Trauma and hemorrhagic shock Occult cardiogenic shock in severe HF Cardiac arrest Post resuscitation High risk surgery III. Clinical Use of EGDT for Severe Sepsis and Septic Shock A. Early Goal Directed Therapy (EGDT) 1. Rivers Study a. Randomly assigned pts arriving in the ED to one of 2 groups: -6 hours of EGDT or standard therapy b. ICU clinicians were blinded c. 263 patients enrolled 130 assigned to EGDT 133 to standard therapy d. Study Results: Benefits of EGDT -In-hospital mortality: EGDT group: 30.5% Standard group: 46.5% -EGDT group: lower APACHE II scores & shorter LOS e. A Question of Timing.. B. EGDT Protocol -Early recognition of patients at high risk -Two or more signs of systemic inflammatory response syndrome (SIRS) -Signs of occult global tissue hypoxia -Use ScvO 2 and lactate to identify global tissue hypoxia -The presence of low ScvO 2 less than 70% indicates inadequate balance between oxygen delivery and oxygen demand -Increased lactate and decreased ScvO 2 : inadequate resuscitation 1. Screen Early for Severe Sepsis/Septic Shock -presumed or confirmed site of infection -2 or more signs of SIRS -signs of global tissue hypoxia

4 2. Early Treatment Protocol a. Supplemental O 2 : intubation and mechanical ventilation if indicated b. Central venous oximetry and continuous arterial pressure monitoring c. Sedation, paralysis (if intubated) or both d. Treatment goals: -CVP 8-12 mmhg -MAP mmhg -ScvO 2 greater than or equal to 70% -U/O greater than or equal to 0.5cc/kg/hr IV. Surviving Sepsis Campaign Guidelines A. General Guidelines B. 6 Hour Bundles Early Goal Directed Therapy 2 or More Signs of SIRS + Signs of Global Tissue Hypoxia + Presumed or Confirmed Site of Infection or body temperature (< 36C > 38C) respiratory rate (> 20) Decreased PaCO 2 (< 32 mm Hg) Increased heart rate (> 90) WBC >12,000/mm 3 or <4,000/ mm 3 or > 10% bands Decreased systolic BP < 90 mmhg Elevated serum lactate > 4 mmol/l Early Treatment Protocol Supplemental Oxygen, Intubation if Indicated (Antibiotics per hospital protocol) Insertion of Central Venous Oximetry Catheter Continuous Arterial Pressure Monitoring Sedation and/or Paralysis as Indicated CVP < 8 mmhg Crystalloids Colloids 8-12 mmhg MAP < 65 mmhg Vasoactive Drugs > 65 and < 90 mmhg ScvO 2 < 70% Transfusion to HCT > 30% > 70% If HCT > 30% Inotropic Drug Goals Achieved Within 6 Hours

5 Speaker Contact: Selected References Dickens JJ. Central venous oxygenation saturation monitoring: a role for critical care? Current Anaesthesia & Critical Care. 2004;15: Goodrich, CA. Central Venous Oximetry Monitoring. Crit Care Clin North Am 2006:18: Reinhart K, Huhn HJ, Hartog C, et al. Continuous central venous and pulmonary artery oxygen saturation monitoring in the critically ill. Int Care Med. 2004;30: Rivers EP, et al. Early goal directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine 2001; 345(19): Rivers EP, Coda V, Whitmill M. Early goal-directed therapy in severe sepsis and septic shock: a contemporary review of the literature. Current Opinion in Anesthesiology 2008; 21(2): Shorr AF, Micek ST, Jackson WL, Kollef MH. Economic implications of an evidence-based sepsis protocol: can we improve outcomes and lower costs?. Crit Care Med 2007;35(5):

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