Sepsis教學講解課件

WarAgainstSepsisCaseBasedSepsisModule

(BasedonSurvivingSepsisGuidelines2008)CritCareMed2008Vol.36,No.296-327SurvivingSepsisCampaign

GuidelinesforManagementofSevereSepsis/SepticShock

AnOverviewSurvivingSepsiscampaignAGlobalprogramto:Reducemortalityratesinseveresepsis

SIRSANDSEPSISSepsisisdefinedasaninfectionplus2SIRScriteriaTemperature>38°Cor<36°CHR>90beats/minRespirations>20/minWBCcount>12,000/mm3

or<4,000/mm3or

>10%immatureneutrophilsSIRSSeveresepsisMODSSepticshockSIRSSevere

sepsisSepsisInfectionOtherPancreatitisTraumaBurnsSepsisLevyMM,etal.CritCareMed.2003;31:1250-1256.CritCareMed2008Vol.36,No.296-327DEFINITIONSSevereSepsisSepsis+sepsis-inducedorgandysfunction

orTissuehypo-perfusionDEFINITIONSSepsis-inducedhypotensionsystolicbloodpressure(SBP)<90mmHg

Ormeanarterialpressure<70mmHg

OrSBPdecrease>40mmHg

Or<2SDbelownormalforageintheabsenceofothercausesofhypotensionCritCareMed2008Vol.36,No.296-327DEFINITIONSSepticshocksepsis-inducedhypotensionpersistingdespiteadequatefluidresuscitationCritCareMed2008Vol.36,No.296-327Sepsis-inducedtissuehypo-perfusion:septicshockanelevatedlactate

OroliguriaDEFINITIONSCritCareMed2008Vol.36,No.296-327A50yroldsmokerpresentstoemergencywithfeverandacuteshortnessofbreathoftwodaysduration.Hehasarespiratoryrateof35/minB.Pof90/40,pulse120/minregular,Spo288%on10Lnasalcannula.Heisalertandcommunicating.Hehasbroughtachestx-raywhichshowsrightlowerzoneopacity.Whatdoesthispatienthave?Systemicinflammatoryresponsesyndrome(SIRS)SepsisSeveresepsisSepticshockEpidemiologySevereSepsis:

ComparativeIncidenceandMortalityPathophysiologyInflammation,Coagulation&

ImpairedFibrinolysisInSevereSepsisEndotheliumInflammatoryResponse

toInfectionThromboticResponse

toInfectionFibrinolyticResponse

toInfectionNeutrophilMonocyteIL-6IL-1TNF-IL-6PAI-1SuppressedfibrinolysisFactorVIIIaTissueFactorCOAGULATIONCASCADEFactorVaTHROMBINFibrinFibrinclotTissueFactorAdaptedfromBernardGR,etal.NEnglJMed.2001;344:699-709.MonocyteOrganismsTissueFactorChemoattractantstissuefactorCoagulationcascadeFactorVIIIFactorVIIIaFactorVFactorVaThrombinFibrinFibrinclotActivationofCoagulation

inSepsisAdaptedfromBernardGR,etal.NEnglJMed.2001;344:699-709.MonocyteOrganismsaPCTissueFactorCoagulationcascadeFactorVIIIFactorVIIIaFactorVFactorVaThrombinInhibitionofchemotacticresponsetochemokinesReducedchemotacticresponseleadingtolessrollingofleukocytesontheendotheliumFibrinFibrinclotInactivationInactivationReductionofrollingIL-6ChemoattractantstissuefactorActivationofCoagulationinSepsis:

RoleofEndogenousAPCAdaptedfromBernardGR,etal.NEnglJMed.2001;344:699-709.SevereSepsis

PathophysiologyMicrovasculardysfunction

Inflammation

Coagulation

FibrinolysisHypoperfusion/hypoxia Microvascularthrombosis

EndothelialdysfunctionOrgandysfunction Globaltissuehypoxia

DirecttissuedamageSpronk,P.,Zandstra,D.,Ince,C.Bench-to-bedsidereview:Sepsisisadiseaseofthemicrocirculation.CriticalCare.2004;8:462-468.RedistributionoforganbloodflowEndothelialactivationCongestionandhemorrhageIntravascularpoolingEdemaformationIncreasedmicrovascularpermeabilityDecreasedredcellpermeabilityOpeningofAVshuntsAlteredmicrovascularbloodflowandvascularresistanceVasoplegiaViscosityalterationsDisturbanceofredandwhitecellrheologyCardiopulmonarypathologyDICDisturbedMicrocirculationinSevereSepsisSepsisisaDiseaseofthe

….MicrocirculationMicrovascularBloodFlowIsImpaired

inSevereSepsis:VenousbloodArterialbloodSO2-0.98SO20.94SO2-0.65SO2-0.86SO20.65SO2-0.83SO2-0.65Lactate:

AnIndicatorofTissuePerfusion SerumlactatelevelsareusedtoassessthediseaseseverityandadequacyofglobaltissueperfusionBy-productofanaerobicmetabolismiftissuehypoxiaexistsInterpretationofelevatedbloodlactatelevelsinsepsisislimitedbyseveralimportantfactors1:ProductionofeliminationIncreasingglycolysisInhibitionofpyruvatemetabolismGlobalchangesBakkerJ,GrisP,ConerfilsM,etal.SerialBloodLactateLevelsCanPredicttheDevelopmentofMultiplePrganFailureFollowingSepticShock,AmJSurg1996;171:221-226.IdentifyingAcuteOrganDysfunction

asaMarkerofSevereSepsisModifiedfromcriteriapublishedin:Balk,R.,Pathogenesisandmanagementofmultipleorgandysfunctionorfailureinseveresepsisandsepticshock.CritCareClinics.2000;16(2):337-351;andKleinpell,R.Theroleofthecriticalcarenurseintheassessmentandmanagementofthepatientwithseveresepsis.CritCareNursClinNAm.2003;15:27-34.Cardiovascular:TachycardiaHypotensionAlteredCVP&PAOPRenal:OliguriaAnuriaCreatinineHematologic:PlateletsPT/INR,aPTTProteinCD-dimerHepatic:Jaundice,LiverenzymesAlbuminCNS:AlteredconsciousnessConfusionRespiratory:TachypneaPaO2PaO2/FiO2ratioMetabolic:MetabolicAcidosisLactatelevelLactateClearanceSevereSepsisPathophysiology:

SummarySeveresepsisisaninflammatory,prothrombotic,impairedfibrinolyticprocessassociatedwithalterationsinthemicrovasculatureCoagulopathyisprevalentinseveresepsisMANAGEMENTOFSEPSISA50yroldsmokerpresentstoemergencywithfeverandacuteshortnessofbreathoftwodaysduration.Hehasarespiratoryrateof35/minB.Pof90/40,pulse120/minregular,Spo288%on10Lnasalcannula.Heisalertandcommunicating.Hehasbroughtachestx-raywhichshowsrightlowerzoneopacity.ClarificationsRecommendationsgroupedbycategoryandnotbyhierarchyGradingofrecommendationimpliesliteraturesupportandnotpriorityofimportanceSponsoring

OrganizationsInfectiousDiseaseSocietyofAmericaInternationalSepsisForumIndianSocietyofCriticalCareMedicineSocietyofCriticalCareMedicineSurgicalInfectionSocietyCanadianCriticalCareSocietyJapaneseSocietyofCriticalCareMedicineJapaneseAssociationofAcuteMedicineGermanSepsisSocietyLatinAmericanSepsisInstituteAmericanAssociationofCritical-careNursesAmericanCollegeofChestPhysiciansAmericanCollegeofEmergencyPhysiciansAmericanThoracicSocietyAustralianandNewZealandIntensiveCareSocietyEuropeanSocietyofClinicalMicrobiologyandInfectiousDiseasesEuropeanSocietyofIntensiveCareMedicineEuropeanRespiratorySocietySurvivingSepsisCampaign:

2008UpdateInternationalefforttoincreaseawarenessandimproveoutcomesinseveresepsisEndorsedbyvariousorganizationsincludingSCCM,ACCP,ACEP,SHM,AACCN,andESICMCritCareMed2008;36:296-327ModifiedGRADESystemGradingofEvidence1A:Strongrecommendation,highqualityevidence1B:Strongrecommendation,moderatequalityofevidence1C:Strongrecommendation,lowqualityorverylowqualityevidence2A:Weakrecommendation,highqualityevidence2B:Weakrecommendation,moderatequalityevidence2C:Weakrecommendation,lowqualityorverylowqualityofevidenceGuyattG,etal.Chest2006;129:174-81InitialResuscitationSevereSepsis:

InitialResuscitation(1st6hours)ShouldbeginassoonasthesyndromeisrecognizedandshouldnotbedelayedpendingICUadmission.Elevatedserumlactateconcentrationidentifiestissuehypoperfusioninpatientsatriskwhoarenothypotensive.ResuscitationGoalsGoalsinthefirst6hours:CVP:8-12mmHgMAP>65mmHgUrineoutput>0.5ml/kg/hr.Centralvenous(SVC)ormixedvenousoxygen(SvO2)saturation>70%GRADE1CFigureB,page948,reproducedwithpermissionfromDellingerRP.Cardiovascularmanagementofsepticshock.CritCareMed2003;31:946-955.EGDT:

TreatmentAlgorithmEGDTsubjectsgotmorefluid,blood,andvasoactivemedsLessoftenventilatedorgivenPACHospitalmortality30.5%vs.46.5%(p=0.009)Riversetal,NEJM2001;345:1368TheImportanceofEarlyGoal-Directed

TherapyforSepsisInducedHypoperfusionAdaptedfromTable3,page1374,withpermissionfromRiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001;345:1368-1377In-hospitalmortality

(allpatients)0102030405060StandardtherapyEGDT28-daymortality60-daymortalityNNTtoprevent1event(death)=6-8Mortality(%)Whatwasdone?SupplementaloxygenstartedIVlineestablished,1literNSgivenInvestigationssentBloodcultures:twosetsSputumforgramstainandcultureCompletebloodcountBloodsugar,ureacreatinine,LFTABGwithlactateandelectrolytesPT.PTTXraychestAfterinitialresuscitationPatienthadpulserate-110/mtBP90/60mmHgCentrallinewasputinontherightsideCVPwas8cmH20Patientwasgiven500mlofnormalsalineover30mtCVPwas12BPwas80/40mmHgNorepinephrinewasstarted8mcg/mttomaintainmeanBPof70mmHgHisPCVwas35Scvo2wasfoundtobe65%Dobutaminewasstartedat6mcg/kg/mtUrineoutputwas.75ml/kg/hrCaseAfter2hrsPatientBPagaindroppedto70/40mmHgCVP–10cmH2OSodecidedtogivefluidchallengeof500mlnormalsalineover30mtsFluidTherapyFluidresuscitationwitheithernaturalorartificialcolloidsorcrystalloids.Grade1BFluidchallengeinpatientswithsuspectedhypovolemiamaystartwith>1000mlofcrystalloidsor300-500mlofcolloidsover30mins.Grade1DRateoffluidadministrationshouldbereducedsubstantiallywhencardiacfillingpressures(CVPorPAOP)increasewithoutconcurrenthemodynamicimprovementGrade1DSSCGuidelines,CritCareMed2008AlbuminandSalineforFluid

ResuscitationintheICU

(SAFETrial)RCT~7,000pts.in16Australian/NZICUsExcludedpts.aftercardiacsurgery,livertransplantandburns4%albuminorNSNosignificantdifference:28-daymortalityNeworganfailure,durationofCRRT,ormechanicalventilationICUandHospitalLOSGrade1DNEJM2004;350:2247-2256FluidChallenge

4AspectsWhichfluidWhatrateClinicalEndpointStopfluidifreachedPressureend-pointStopfluidifreachedSafetylimitsFLUIDCHALLENGEWhenToStopWhenToStartFLUIDCHALLENGE

HOWTOGIVEITBaseline30mtsAIMPulsepermin.130110MeanBPmmHg5070CVPCmHO21016SPO297%ChestExamClear500mlnormalsalineover30minutesFLUIDCHALLENGEBaseline30mtsAIMPulsepermin.130128110MeanBPmmHg505570CVPCmHO2101116SPO297%97%ChestExamClearClear500mlnormalsalineover30minutesFLUIDCHALLENGEBaseline30mtsAIMPulsepermin.130128110MeanBPmmHg505570CVPCmHO2101116SPO297%97%ChestExamClearClear500mlnormalsalineover30minutesAnotherfluidchallengeFLUIDCHALLENGE500mlnormalsalineover30mint.BaselineAIMPulsepermin.130110MeanBPmmHg5070CVPCmH2O1016Safetylimits↓SpO2creptsatbaseFLUIDCHALLENGE500mlnormalsalineover30minutesBaseline10mts30mtsAIMPulsepermin.130110MeanBPmmHg5070CVPCmH2O1016SPO297%

ChestClear

Clear125651197%

ContinueClearFLUIDCHALLENGE500mlnormalsalineover30minutesBaseline10mts30mtsAIMPulsepermin.130110MeanBPmmHg5070CVPCmH2O1016SPO297%

ChestClear

Clearcontinue125651197%

ContinueClearFLUIDCHALLENGE500mlnormalsalineover30minutesBaseline10mts30mtsAIMPulsepermin.130110MeanBPmmHg5070CVPCmH2O1016SPO297%

ChestClear

Clear125651197%

ContinueClear115751297%ClearFLUIDCHALLENGE500mlnormalsalineover30minutesBaseline10mts30mtsAIMPulsepermin.130110MeanBPmmHg5070CVPCmH2O1016SPO297%

ChestClear

ClearSTOP125651197%

ContinueClear115751297%ClearFLUIDCHALLENGE500mlNormalsalineover30minutesBaseline10mtsPulsepermin.130128MeanBPmmHg5060CVPcmH2O1012ChestClearClearAIM1107016FLUIDCHALLENGE500mlNornalsalineover30minutesBaseline10mts20mtsPulsepermin.130128120MeanBPmmHg506062CVPcmH2O101216ChestClearClearClearAIM1107016FLUIDCHALLENGE500mlNornalsalineover30minutesBaseline10mts20mtsPulsepermin.130128120MeanBPmmHg506062CVPcmH2O101216ChestClearClearClearAIM1107016STOPFLUIDCHALLENGEBaseline

10mts

20mts

AIM

Pulsepermin.130110MeanBPmmHg5070CVPCmH2O1016SPO297%

ChestClear

Clear500mlnormalsalineover30minutes130501197%

ClearFLUIDCHALLENGEBaseline

10mts

20mts

AIM

Pulsepermin.130110MeanBPmmHg5070CVPCmH2O1016SPO297%

ChestClear

Clear500mlnormalsalineover30minutes130501197%

Clear128551186%CreptsatbasesFLUIDCHALLENGEBaseline

10mts

20mts

AIM

Pulsepermin.130110MeanBPmmHg5070CVPCmH2O1016SPO297%

ChestClear

ClearSTOP500mlnormalsalineover30minutes130501197%

Clear128551186%CreptsatbasesFLUIDCHALLENGEBaseline30minutesPulsepermin.110MeanBPmmHg70CVPCmH2O5U.O40FLUIDCHALLENGENoFluidChallengeBaseline30minutesPulsepermin.110MeanBPmmHg70CVPCmH2O5U.O40ml/hrDiagnosisAppropriateculturesMinimum2bloodcultures1percutaneous1fromeachvascularaccess48hrsGradeDSevereSepsis:PrimarySourcePulmonary:50%Abdomen/Pelvis:~25%Primarybacteremia:~15%Urosepsis:10%Skin:5%Vascular:5%Other:~15%MartinGS,etal.NEJM2003;348:1546MicrobiologyofSepsisMartinGS,etal.NEJM2003;348:1546AntibioticTherapyBeginintravenousantibioticswithinfirsthourofrecognitionofseveresepsis.GradeEDurationofhypotensionbeforeinitiationof

effectiveantimicrobialtherapyisthe

criticaldeterminantofsurvivalKumarA,etal.CritCareMed2006;34:1589Grade1BAntibioticTherapyOneormoredrugsactiveagainstlikelybacterialorfungalpathogens.Considermicroorganismsusceptibilitypatternsinthecommunityandhospital.GradeDAntibioticTherapy Reassessantimicrobialregimenat48-72hrsMicrobiologicandclinicaldataNarrow-spectrumantibioticsNon-infectiouscauseidentifiedPreventresistance,reducetoxicity,reducecostsGradeESourceControlEvaluatepatientforafocusedinfectionamendabletosourcecontrolmeasuresincludingabscessdrainageortissuedebridement.MoverapidlyConsiderphysiologicupsetofmeasureIntravascularaccessdevicesGradeESourceControlGrade1CVasopressorsEithernorepinephrineordopamineadministeredthroughacentralcatheteristheinitialvasopressororchoice.FailureoffluidresuscitationDuringfluidresuscitationGradeDEffectsofDopamine,Norepinephrine,

andEpinephrineontheSplanchnic

CirculationinSepticShockFigure2,page1665,reproducedwithpermissionfromDeBackerD,CreteurJ,SilvaE,VincentJL.Effectsofdopamine,norepinephrine,andepinephrineonthesplanchniccirculationinsepticshock:Whichisbest?CritCareMed2003;31:1659-1667VasopressorsDonotuselow-dosedopamineforrenalprotection.GradeBBellomoR,etal.Lancet2000;356:2139-2143VasopressorsInpatientsrequiringvasopressors,placeanarterialcatheterassoonaspossible.GradeECirculatingVasopressinLevelsinSepticShockFigure2,page1755reproducedwithpermissionfromSharsharT,BlanchardA,PaillardM,etal.Circulatingvasopressinlevelsinsepticshock.CritCareMed2003;31:1752-1758VasopressinandSepticShockVersuscardiogenicshockDecreasesoreliminatesrequirementsoftraditionalpressorsAsapurevasopressorexpectedtodecreasecardiacoutputVasopressorsVasopressinNotareplacementfornorepinephrineordopamineasafirst-lineagentConsiderinrefractoryshockdespitehigh-doseconventionalvasopressorsIfused,administerat0.01-0.04units/minuteinadultsGradeEInotropicTherapyConsiderdobutamineinpatientswithmeasuredlowcardiacoutputdespitefluidresuscitation.Continuetotitratevasopressortomeanarterialpressureof65mmHgorgreater.GradeEInotropicTherapyDonotincreasecardiacindextoachieveanarbitrarilypredefinedelevatedlevelofoxygendelivery.GradeAYu,etal.CCM1993;21:830-838Hayes,etal.NEJM1994;330-1717-1722Gattinoni,etal.NEJM1995;333:1025-1032STEROIDSLowDoseSteroidsinSepticShock

StudyDesignAnnaneD,etal.JAMA2000;283:1038-45LowDoseSteroidsinSepticShock:

28DayMortalityAllPatientsAnnaneD,etal.JAMA2000;283:1038-45CorticusStudyMulticenter,double-blind,RCT52ICUs,March2002–Nov2005(3?yrs)Pts.>18yrswithsepsisandonsetofshockwithintheprevious72h(SBP<90despitefluidsorneedforvasopressorsfor>1hour)HydrocortisoneorPlacebo:50mgIVq6hx5days50mgIVq12hondays6to850mgIVq24hondays9to11thenstoppedSprungC,etal.NEJM2008;358:111-24CorticusStudyACTH250μgstimulationtestNon-responder:<9μg/dLIntendedsamplesize:800500patientsenrolled499analyzableSprungC,etal.NEJM2008;358:111-24ACTHStimulationTest*SprungC,etal.NEJM2008;358:111-24CORTICUS:ConclusionsHydrocortisoneRXDidnotdecreasemortalityDeceasedtimetoshockreversalWasassoc.withanincreasedincidenceof:Superinfections,includingnewepisodesofsepsisorsepticshockHyperglycemiaHypernatremiaSprungC,etal.NEJM2008;358:111-24CorticosteroidTherapyIVhydrocortisoneshouldbegivenonlytoadultsepticshockpatientsafterithasbeenconfirmedthattheirBPispoorlyresponsivetofluidresuscitationandvasopressortherapy.CritCareMed2008SSCUpdateGrade2CConsensusStatementACTHstimtestshouldnotbeusedtoidentifythesubsetofadultpts.withsepticshockwhoshouldreceivehydrocortisone(2B)Treatmentregimens:100mghydrocortisoneIVq8h100/200mgbolusofhydrocortisonethen10mg/h50mghydrocortisoneIVq6hFulldosehydrocortisonetreatmentshouldbecontinuedfor5-7daysbeforetaperingassumingthereisnorecurrenceofsignsofsepsisorshock(2C)MarikPE,PastoresSM,AnnaneD,MeduriGU,SprungC,etal.CritCareMed2008(underreview)ConsensusStatementPatientswithsepticshockshouldnotreceivedexamethasoneifhydrocortisoneisavailable(2B)Fludrocortisoneisoptionalifhydrocortisoneisused(2C)Dosesofcorticosteroidscomparableto>300mgofhydrocortisonedailynotbeusedinsepticshock(1A)CaseHisbloodsugarwas170mg%Bloodurea94mg%andcreatinine2.6mg%Serumlactate6mmol/ltSerumbilirubinwas3mg%,AST90U,ALT87UHisSpo2droppedto82on10litresofoxygenHisABG-pH-7.232,PaO2-58,HCO3-15Patientwasput-onassistedventilationVolumecontrol-TV-6ml/kgidealbodyweightRR-20/mtFio2-1PEEP-10Plateaupressurewaskeptbelow30cmH2oCaseThepossibilityofusingActivatedProteincwasdiscussedwiththefamilyanditwasstartedat24mcg/kg/hraspatienthadfourorganfailureandnocontraindicationsDrotrecoginalfa(activated)

(rhAPC)inSevereSepsisProcoagulantResponse

inSepsisRussellJ.NEJM2006PROWESSTrial

Drotrecoginalfa(activated)24μg/kg/hror

placebofor96hours

AdministrationofDrotAAin

EarlyStageSevereSepsis

(ADDRESS)International,randomized,placebo-controlledstudytoevaluatetheefficacyofDrotAAforadultswithseveresepsisandlowriskofdeathAPACHEII<25orsingle-organfailureN=2640patientsTrialterminatedearlybecauseofaprojectedlackofeffectAbrahamE,etal.NEJM2005;353:1332-41ADDRESSTrial

Drotrecoginalfa(activated)24μg/kg/hror

placebofor96hours

AbrahamE,etal.NEJM2005;353:1332-1341RecombinantHumanActivated

ProteinCRecommendedinadultptswithsepsis-inducedorgandysfunctionassociatedwithahighriskofdeath(APACHEII>25)ormultipleorganfailureandwithnocontraindicationsrelatedtobleeding

Grade2BAdultpatientswithseveresepsisandlowriskofdeath(APACHEII<20)oroneorganfailure(especiallysurgicalpts)shouldnotreceiveAPC

Grade1ASSCGuidelines,CritCareMed2008SeriousBleedingwithrhAPCClinicalTrials:PROWESS(3.5%vs.2%,p=0.06)ADDRESS(3.9%vs.2.2%,p=<0.01)ENHANCE(6.5%)RegistrystudiesreporthigherbleedingratesthanRCTsRiskofbleedinginactualpracticemaybehigherMechanicalVentilationofSepsis-InducedALI/ARDS%MortalityARDSnetMechanicalVentilationProtocolResults:MortalityAdaptedfromFigure1,page1306,withpermissionfromTheAcuteRespiratoryDistressSyndromeNetwork.NEnglJMed2000;342:1301-1378MechanicalVentilationof

Sepsis-InducedALI/ARDSReducetidalvolumeover1–2hrsto6ml/kgpredictedbodyweightMaintaininspiratoryplateaupressure<30cmH20GradeBMechanicalVentilationof

Sepsis-InducedALI/ARDSMinimumPEEPPreventendexpiratorylungcollapseSettingPEEPFIO2requirementThoracopulmonarycomplianceGradeETheRoleofPronePositioninginARDS70%ofpronepatientsimprovedoxygenation70%ofresponsewithin1hour10-daymortalityrateinquartilewithlowestPaO2:FIO2ratio(88)Prone—23.1%Supine–47.2%GattinoniL,etal.NEnglJMed2001;345:568-73;SlutskyAS.NEnglJMed2001;345:610-2.Kaplan-Meierestimatesofsurvivalat6monthsSurvival(%)10075502503060901201501800DaysSupinegroupPronegroupP=0.65TheRoleofPronePositioninginARDSConsiderpronepositioninginARDSwhen:PotentiallyinjuriouslevelsofF1O2orplateaupressureexistNotathighriskfrompositionalchanges

GradeEMechanicalVentilation

ofSevereSepsisSemirecumbentpositionunlesscontraindicatedwithheadofthebedraisedto45oGradeCDrakulovicetal.Lancet1999;354:1851-1858MechanicalVentilation

ofSepticPatientsUseweaningprotocolandaspontaneousbreathingtrial(SBT),atleastdailyGradeAEly,etal.NEJM1996;335:1864-1869Esteban,etal.AJRCCM1997;156:459-465Esteban,etal.AJRCCM1999;159:512-518MechanicalVentilationofSepticPatientsSBToptionsLowlevelofpressuresupportwithcontinuouspositiveairwaypressure5cmH2OT-piecePriortoSBTArousableHemodynamicallystable(withoutvasopressoragents)NonewpotentiallyseriousconditionsLowventilatoryandend-expiratorypressurerequirementsRequiringlevelsofFIO2thatcouldbesafelydeliveredwithafacemaskornasalcannulaConsiderextubationifSBTisunsuccessfulBloodProductAdministrationTransfusionStrategy

intheCriticallyIllFigure2A,page414,reproducedwithpermissionfromHebertPC,WellsG,BlajchmanMA,etal.Amulticenter,randomized,controlledclinicaltrialoftransfusionrequirementsincriticalcare.NEnglJMed1999;340:409-417BloodProductAdministration

RedBloodCellsTissuehypoperfusionresolvedNoextenuatingcircumstancesCoronaryarterydiseaseAcutehemorrhageLacticacidosisTransfuse<7.0g/dltomaintain7.0-9.0g/dLGradeBBloodProductAdministrationDonotuseerythropoietintotreatsepsis-relatedanemia.Erythropoietinmaybeusedforotheracceptedreasons.GradeBBloodProductAdministrationDonotuseantithrombintherapy.GradeBWarrenetal.JAMA2001;1869-1878BloodProductAdministrationPlateletadministrationTransfusefor<5000/mm3–Transfusefor5000/mm3–30,000/mm3withsignificantbleedingriskTransfuse<50,000/mm3forinvasiveproceduresorbleedingGradeESedationandAnalgesiainSepsisSedationprotocolformechanicallyventilatedpatientswithstandardizedsubjectivesedationscaletarget.IntermittentbolusContinuousinfusionwithdailyawakening/retitrationGradeBKollef,etal.Chest1998;114:541-548Brook,etal.CCM1999;27:2609-2615Kress,etal.NEJM2000;342:1471-1477NeuromuscularBlockersAvoidifpossibleUsedlongerthan2-3hrsPRNbolusContinuousinfusionwithtwitchmonitorGradeETheRoleofIntensive

InsulinTherapyintheCriticallyIllAt12months,intensiveinsulintherapyreducedmortalityby3.4%(P<0.04)AdaptedfromFigure1B,page1363,withpermissionfromvandenBergheG,WoutersP,WeekersF,etal.Intensiveinsulintherapyincriticallyillpatients.NEnglJMed2001;345:1359-67In-hospitalsurvival(%)10000IntensivetreatmentConventionaltreatmentDaysafteradmission808488929650100150200250P=0.01GlucoseControlAfterinitialstabilizationGlucose<150mg/dLContinuousinfusioninsulinGivenutritionMonitoringInitiallyq30–60minsAfterstabilizationq4hAvoidhypoglycemiaGradeDRenalReplacementAbsenceofhemodynamicinstabilityIntermittenthemodialysisandcontinuousvenovenousfiltrationequal(CVVH)HemodynamicinstabilityCVVHpreferredGradeBBicarbonatetherapynotrecommendedtoimprovehemodynamicsinpatientswithlactateinducedpH>7.15GradeCCooper,etal.AnnInternMed1990;112:492-498Mathieu,etal.CCM1991;19:1352-1356BicarbonateTherapyDeepVeinThrombosisProphylaxisHeparin(UHorLMWH)ContraindicationforheparinMechanicaldevice(unlesscontraindicated)HighriskpatientsCombinationpharmacologicandmechanicalGradeAPrimaryStressUlcerRiskFactorsFrequentlyPresentinSevereSepsisMechanicalventilationCoagulopathyHypotensionChoiceofAgentsfor

StressUlcerProp