Sepsis medical therapy: Difference between revisions
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A problem in the adequate management of septic patients has been the delay in administering therapy after sepsis has been recognized. Published studies have demonstrated that for every hour delay in the administration of appropriate antibiotic therapy there is an associated 7% rise in mortality. A large international collaboration was established to educate people about sepsis and to improve patient outcomes with sepsis, entitled the "Surviving Sepsis Campaign." The Campaign has published an evidence-based review of management strategies for severe sepsis,<ref name="campaign">Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM; Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004 Mar;32(3):858-73. Erratum in: Crit Care Med. 2004 Jun;32(6):1448. Correction of dosage error in text. Crit Care Med. 2004 Oct;32(10):2169-70. PMID 15090974.</ref> with the aim to publish a complete set of guidelines in subsequent years. | A problem in the adequate management of septic patients has been the delay in administering therapy after sepsis has been recognized. Published studies have demonstrated that for every hour delay in the administration of appropriate antibiotic therapy there is an associated 7% rise in mortality. A large international collaboration was established to educate people about sepsis and to improve patient outcomes with sepsis, entitled the "Surviving Sepsis Campaign." The Campaign has published an evidence-based review of management strategies for severe sepsis,<ref name="campaign">Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM; Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004 Mar;32(3):858-73. Erratum in: Crit Care Med. 2004 Jun;32(6):1448. Correction of dosage error in text. Crit Care Med. 2004 Oct;32(10):2169-70. PMID 15090974.</ref> with the aim to publish a complete set of guidelines in subsequent years. | ||
Early Goal Directed Therapy (EGDT), developed at [[Henry Ford Hospital]] by E. Rivers, MD, is a systematic approach to resuscitation that has been validated in the treatment of severe sepsis and [[septic shock]]. It is meant to be started in the Emergency Department. The theory is that one should use a step-wise approach, having the patient meet physiologic goals, to optimize cardiac preload, afterload, and contractility, thus optimizing oxygen delivery to the tissues.<ref name="EGDT">{{cite journal |author=Rivers E, Nguyen B, Havstad S, ''et al'' |title=Early goal-directed therapy in the treatment of severe sepsis and septic shock |journal=N. Engl. J. Med. |volume=345 |issue=19 |pages=1368-77 |year=2001 |pmid=11794169 |doi=}}</ref> | Early Goal Directed Therapy (EGDT), developed at [[Henry Ford Hospital]] by E. Rivers, MD, is a systematic approach to resuscitation that has been validated in the treatment of severe sepsis and [[septic shock]]. It is meant to be started in the Emergency Department. The theory is that one should use a step-wise approach, having the patient meet physiologic goals, to optimize cardiac preload, afterload, and contractility, thus optimizing oxygen delivery to the tissues.<ref name="EGDT">{{cite journal |author=Rivers E, Nguyen B, Havstad S, ''et al'' |title=Early goal-directed therapy in the treatment of severe sepsis and septic shock |journal=N. Engl. J. Med. |volume=345 |issue=19 |pages=1368-77 |year=2001 |pmid=11794169 |doi=}}</ref> More recently, the GENESIS Project has validated this approach.<ref name="pmid22902347">{{cite journal| author=Cannon CM, Holthaus CV, Zubrow MT, Posa P, Gunaga S, Kella V et al.| title=The GENESIS Project (GENeralized Early Sepsis Intervention Strategies): A Multicenter Quality Improvement Collaborative. | journal=J Intensive Care Med | year= 2012 | volume= | issue= | pages= | pmid=22902347 | doi=10.1177/0885066612453025 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22902347 }} </ref> | ||
In EGDT | In EGDT: | ||
* fluids are administered until the [[central venous pressure]] (CVP), as measured by a [[central venous catheter]] reaches 8-12 cm of water (or 10-15 cm of water in mechanically ventilated patients). | |||
* If the [[mean arterial pressure]] is less than 65 mmHg or greater than 90 mmHg, vasopressors or vasodilators are given as needed to reach the goal. Then, | |||
* The central venous saturation (ScvO2), i.e. the oxygen saturation of venous blood as it returns to the heart as measured at the superior vena cava, is optimized. If the ScvO2 is less than 70%, blood is given to reach a hemoglobin of 10 g/dl and then inotropes are added until the ScvO2 is optimized. Elective intubation may be performed to reduce oxygen demand if the ScvO2 remains low despite optimization of hemodynamics. | |||
Urine output is also monitored, with a goal of 0.5 ml/kg/h. In the original trial, mortality was cut from 46.5% in the control group to 30.5% in the intervention group.<ref name="EGDT" /> The Surviving Sepsis Campaign guidelines recommends EGDT for the initial resuscitation of the septic patient with a level B strength of evidence (single [[randomized control trial]]).<ref name="campaign" /> | |||
The protocol per the GENESIS Project is:the GENESIS Project has validated this approach.<ref name="pmid22902347">{{cite journal| author=Cannon CM, Holthaus CV, Zubrow MT, Posa P, Gunaga S, Kella V et al.| title=The GENESIS Project (GENeralized Early Sepsis Intervention Strategies): A Multicenter Quality Improvement Collaborative. | journal=J Intensive Care Med | year= 2012 | volume= | issue= | pages= | pmid=22902347 | doi=10.1177/0885066612453025 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22902347 }} </ref> | |||
* Measure serum lactate | |||
* Obtain blood cultures and administer broad-spectrum antibiotic within 3 hours of emergency department admission | |||
* If hypotensive or serum lactate 4 mmol/L | |||
** 20 mL/kg of crystalloid | |||
** If needed, add [[vasopressor]]s to keep mean arterial pressure >65 mm Hg | |||
** If needed, aim for central venous pressure 8 mm Hg | |||
** If needed, aim for central venous oxygen saturation 70% | |||
Most therapies aimed at the inflammatory process itself have failed to improve outcome, however [[drotrecogin alfa]] (activated [[protein C]], one of the [[coagulation factor]]s) has been shown to decrease mortality from about 31% to about 25% in severe sepsis. To qualify for drotrecogin alfa, a patient must have severe sepsis or septic shock with an [[APACHE II]] score of 25 or greater and a low risk of bleeding.<ref>Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8;344(10):699-709. PMID 11236773 [http://content.nejm.org/cgi/content/abstract/344/10/699 Full Text].</ref> Low dose [[cortisol|hydrocortisone]] treatment has shown promise for septic shock patients with relative [[adrenal insufficiency]] as defined by [[Cort-stim test|ACTH stimulation testing]].<ref>Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21;288(7):862-71. PMID 12186604.</ref> | Most therapies aimed at the inflammatory process itself have failed to improve outcome, however [[drotrecogin alfa]] (activated [[protein C]], one of the [[coagulation factor]]s) has been shown to decrease mortality from about 31% to about 25% in severe sepsis. To qualify for drotrecogin alfa, a patient must have severe sepsis or septic shock with an [[APACHE II]] score of 25 or greater and a low risk of bleeding.<ref>Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8;344(10):699-709. PMID 11236773 [http://content.nejm.org/cgi/content/abstract/344/10/699 Full Text].</ref> Low dose [[cortisol|hydrocortisone]] treatment has shown promise for septic shock patients with relative [[adrenal insufficiency]] as defined by [[Cort-stim test|ACTH stimulation testing]].<ref>Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21;288(7):862-71. PMID 12186604.</ref> | ||
Revision as of 23:32, 10 September 2012
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
If you have sepsis, you will be admitted to a hospital, usually the intensive care unit (ICU). Antibiotics are given through a vein (intravenously).Oxygen, fluids given through a vein, and medications that increase blood pressure may be needed. Dialysis may be necessary if there is kidney failure. A breathing machine (mechanical ventilation) is necessary if there is lung failure.For some patients, treatment with powerful anti-inflammatory medications called corticosteroids or recombinant human activated protein C may be helpful.
Medical Therapy
The therapy of sepsis rests on antibiotics, surgical drainage of infected fluid collections, fluid replacement and appropriate support for organ dysfunction. This may include hemodialysis in kidney failure, mechanical ventilation in pulmonary dysfunction, transfusion of blood products, and drug and fluid therapy for circulatory failure. Ensuring adequate nutrition, if necessary by parenteral nutrition, is important during prolonged illness.
A problem in the adequate management of septic patients has been the delay in administering therapy after sepsis has been recognized. Published studies have demonstrated that for every hour delay in the administration of appropriate antibiotic therapy there is an associated 7% rise in mortality. A large international collaboration was established to educate people about sepsis and to improve patient outcomes with sepsis, entitled the "Surviving Sepsis Campaign." The Campaign has published an evidence-based review of management strategies for severe sepsis,[1] with the aim to publish a complete set of guidelines in subsequent years.
Early Goal Directed Therapy (EGDT), developed at Henry Ford Hospital by E. Rivers, MD, is a systematic approach to resuscitation that has been validated in the treatment of severe sepsis and septic shock. It is meant to be started in the Emergency Department. The theory is that one should use a step-wise approach, having the patient meet physiologic goals, to optimize cardiac preload, afterload, and contractility, thus optimizing oxygen delivery to the tissues.[2] More recently, the GENESIS Project has validated this approach.[3]
In EGDT:
- fluids are administered until the central venous pressure (CVP), as measured by a central venous catheter reaches 8-12 cm of water (or 10-15 cm of water in mechanically ventilated patients).
- If the mean arterial pressure is less than 65 mmHg or greater than 90 mmHg, vasopressors or vasodilators are given as needed to reach the goal. Then,
- The central venous saturation (ScvO2), i.e. the oxygen saturation of venous blood as it returns to the heart as measured at the superior vena cava, is optimized. If the ScvO2 is less than 70%, blood is given to reach a hemoglobin of 10 g/dl and then inotropes are added until the ScvO2 is optimized. Elective intubation may be performed to reduce oxygen demand if the ScvO2 remains low despite optimization of hemodynamics.
Urine output is also monitored, with a goal of 0.5 ml/kg/h. In the original trial, mortality was cut from 46.5% in the control group to 30.5% in the intervention group.[2] The Surviving Sepsis Campaign guidelines recommends EGDT for the initial resuscitation of the septic patient with a level B strength of evidence (single randomized control trial).[1]
The protocol per the GENESIS Project is:the GENESIS Project has validated this approach.[3]
- Measure serum lactate
- Obtain blood cultures and administer broad-spectrum antibiotic within 3 hours of emergency department admission
- If hypotensive or serum lactate 4 mmol/L
- 20 mL/kg of crystalloid
- If needed, add vasopressors to keep mean arterial pressure >65 mm Hg
- If needed, aim for central venous pressure 8 mm Hg
- If needed, aim for central venous oxygen saturation 70%
Most therapies aimed at the inflammatory process itself have failed to improve outcome, however drotrecogin alfa (activated protein C, one of the coagulation factors) has been shown to decrease mortality from about 31% to about 25% in severe sepsis. To qualify for drotrecogin alfa, a patient must have severe sepsis or septic shock with an APACHE II score of 25 or greater and a low risk of bleeding.[4] Low dose hydrocortisone treatment has shown promise for septic shock patients with relative adrenal insufficiency as defined by ACTH stimulation testing.[5]
Standard treatment of infants with suspected sepsis consists of supportive care, maintaining fluid status with intravenous fluids, and the combination of a beta-lactam antibiotic (such as ampicillin) with an aminoglycoside such as gentamicin.
References
- ↑ 1.0 1.1 Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM; Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004 Mar;32(3):858-73. Erratum in: Crit Care Med. 2004 Jun;32(6):1448. Correction of dosage error in text. Crit Care Med. 2004 Oct;32(10):2169-70. PMID 15090974.
- ↑ 2.0 2.1 Rivers E, Nguyen B, Havstad S; et al. (2001). "Early goal-directed therapy in the treatment of severe sepsis and septic shock". N. Engl. J. Med. 345 (19): 1368–77. PMID 11794169.
- ↑ 3.0 3.1 Cannon CM, Holthaus CV, Zubrow MT, Posa P, Gunaga S, Kella V; et al. (2012). "The GENESIS Project (GENeralized Early Sepsis Intervention Strategies): A Multicenter Quality Improvement Collaborative". J Intensive Care Med. doi:10.1177/0885066612453025. PMID 22902347.
- ↑ Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8;344(10):699-709. PMID 11236773 Full Text.
- ↑ Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21;288(7):862-71. PMID 12186604.