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Surviving Sepsis

• Barcelona declaration (ESICM congress, 2002)
• Surviving Sepsis Campaign Guidelines (CCM ICM,
  2004)
• SSC guidelines Version 2

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Potential conflicts of interest
 The challenges involved in producing first-rate
guidelines and performance standards are only
exacerbated by the intrusion of marketing
strategies masquerading as evidence-based
medicine. 
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Population-adjusted Incidence of Sepsis, USA,
1979-2000
Severe Sepsis 34
France Choc septique 9
Severe Sepsis 34
G.Martin et al, NEJM 2003 348 1546-54.
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Surviving Sepsis?
Recommandations SFAR SRLF 2006

• 1. Identification initial assessment

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SIRS and Organ Dysfunction Criteria

• SIRS Conventional criteria
• Fever / hypothermia
• Tachypnea
• Tachycardia
• Leukocytosis / leukopenia
• Others
• Biomarkers
• Elevated PCT, ..

• Organ dysfunctions
• lactates gt 4 mmol/l
• - SBP lt 90 mm Hg
• - PaO2/FiO2 lt 300
• - Oliguria, creatinine gt 176 mmol/L
• - INR gt 1,5 / PT gt 60 sec
• - thrombocytopenia lt 100 000/mm3
• bilirubin gt 34 µmol/l
• Glasgow coma score 13

But lt 50 of patients with SIRS have documented
infection
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Infection/Sepsis Initial assessment
Evaluation of sepsis
Recommandations SFAR SRLF 2006
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Algorithm for disposition of patients in ED
Suspected Severe Sepsis

• Monitoring HR, RR, AP, Urine
• Oxygen to SpO2gt95
• Biochemistry (lactate) microbiology
• Cristalloids (500 ml/15 min) to mAP gt65
• Call referent intensivist

Organ failure?
No
YES
ICU Admission
Recommandations SFAR SRLF 2006
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Infection/Severe Sepsis initial steps
Sev Sepsis ?
0 3 hrs
Recommandations SFAR SRLF 2006
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Surviving Sepsis Campaign

• 2. Recommendations and Guideline Revision
  (2006-07)

Sponsored exclusively by supporting societies
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Impact on survival of early antibiotic
administration
Kumar et al, Crit Care Med 2006 34 1589-96
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E. Rivers, 2001 - EGT
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EGT Mortality rates
RR 0.58 0.58
0.67 P 0.01
0.01 0.03
E. Rivers et al, NEJM 2001
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EGT - Volume of fluid infused
Plt0.01


E. Rivers et al, NEJM 2001
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Fluid Therapy

• We recommend fluid resuscitation with either
  natural/artificial colloids or crystalloids.
• There is no evidence-based support for one type
  of fluid over another. 1B

Supportive Care Glucose Control

• Recommend glucose control with intravenous
  insulin after initial stabilization 1B
• Suggested glucose target
• Normal and lt 150 mg/dL 2C

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Potential conflicts of interest
Pour un moratoire sur lutilisation des
hydroxyéthylamidons L. Brochard1, F. Schortgen1,
C. Brun-Buisson1, D. Dreyfuss2, J.-J. Rouby3, J.
Chastre4, D. Robert5, G. Hilbert6, D. Payen7, E.
LHer8, C. Richard9, M. Gainnier10, J. Pugin11,
J.-C. M. Richard12.
Conclusion Les données dont nous disposons
actuellement suggèrent fortement que la balance
entre les bénéfices attendus et les risques
observés avec ladministration des
hydroxyéthylamidons est défavorable. Dans ces
conditions, il ne parait pas justifié de
continuer à utiliser ces produits pour le
remplissage vasculaire en réanimation, alors que
des alternatives moins toxiques (et moins
coûteuses) sont disponibles. Il ne sagit pas à
notre sens dune querelle dexperts, et nous
suggérons à titre protecteur quun moratoire soit
mis en place sur lutilisation des
hydroxyéthylamidons dans le remplissage
vasculaire chez les patients de réanimation, dans
lattente de nouveaux essais démontrant de
manière convaincante leur avantage et leur
innocuité.
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Vasopressors

• We recommend either norepinephrine or dopamine as
  the first choice vasopressor agent to correct
  hypotension in septic shock (administered through
  a central catheter as soon as one is available)
  (1C)
• We suggest that epinephrine, phenylephrine, or
  vasopressin should not be administered as the
  initial vasopressor in septic shock (2C).

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SSC Objectives for the first 6 hours

1. Mesure arterial lactate level
2. Obtain blood cultures before administering
   antibiotics
3. Prescribe within 3 (1) hrs broad-spectrum empiric
   antibiotic therapy
4. If hypotension (PAS lt 90 mmHg or mAP lt 70mmHg) or
   hyperlactatemia (lactate gt 4 mmol/l)
5. Start fluid loading with cristalloïds (or
   equivalent colloïd) 20-40 ml /kg estimated ideal
   body weight.
6. Administer vasopressors to maintain mAP 65
   mmHg, if persisting hypotension despite adequate
   fluid loading.

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SSC Objectives for the first 6 hours

• If persisting hypotension or hyperlactatemia (gt 4
  mmol/l) despite initial fluid loading, measure
  PVC and ScvO2 (or SvO2), and
• Maintain CVP at 8 - 12 mmHg.
• Consider inotropic therapy and/or RBC transfusion
  if hematocrit is 30 when ScvO2 is lt 70 , or
  SvO2 lt 65 and CVP 8 mmHg. (2B)

Recommandations SFAR SRLF 2006
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Low-dose Steroids 28 d survival
Non-Responders
HR 0.67 p0.023
D. Annane al, JAMA 2002288 862-871.
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Low-dose Steroids

• We suggest intravenous hydrocortisone be given
  only to adult septic shock patients after blood
  pressure is identified to be poorly responsive to
  fluid resuscitation and vasopressor therapy
• 2C
• We recommend corticosteroids not be administered
  for the treatment of sepsis in the absence of
  shock.
• 1D

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Low-dose Steroids

• ACTH stimulation test (250-?g) not recommended
  (2B)
• Variability in assay
• Variability in response on same day
• Free versus protein bound measurement
• Fludrocortisone optional (2C)
• Dexamethasone only if hydrocortisone not
  available (2B)

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Recombinant HumanActivated Protein C (rhAPC)

• Suggest use in patients with clinical assessment
  of high risk of death due to sepsis induced organ
  dysfunction, typically with APACHE II 25 or
  multiple organ failure (2B)
• And no absolute contraindications
• Weighing the risk/benefit of relative
  contraindications
• We recommend that adult patients with severe
  sepsis and low risk of death, most of whom will
  have APACHE II lt20 or one organ failure, do not
  receive rhAPC (1A )

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Surviving Sepsis

• 3. Experience with implementation of the
  guidelines

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Probability of survival of patients with septic
shock managed before or after (open circles) the
implementation of standardized hospital order set
Micek S. Crit Care Med 2006 34 2707.
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Many Leaks from research to practice
If 80 achieved at each stage then0.8 x 0.8 x
0.8 x 0.8 x 0.8 x 0.8 x 0.8 0.21