Treating Severe Sepsis Patients Through Early Recognition and Treatment
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This document describes the results of a trial involving over 15,000 severe sepsis patients across 60 hospitals. It shows that implementing interventions for early recognition and treatment of severe sepsis, including lactate screening, antibiotics, fluids, vasopressors and source control, led to a significant decrease in in-patient mortality rates from 41% to 19% over time. While some interventions like early goal-directed therapy have been debated, the key is focusing initial treatment on the basics of recognizing severe sepsis early, treating infections with antibiotics, and supporting circulation with fluids and vasopressors when needed.
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Treating Severe Sepsis Patients Through Early Recognition and Treatment
- 5. 60 Hospitals
- 7. 0% 10% 20% 30% 40% 50% Jan-‐11 Feb-‐11 Mar-‐11 Apr-‐11 May-‐11 Jun-‐11 Jul-‐11 Aug-‐11 Sep-‐11 Oct-‐11 Nov-‐11 Dec-‐11 Jan-‐12 Feb-‐12 Mar-‐12 Apr-‐12 May-‐12 Jun-‐12 Jul-‐12 Aug-‐12 Sep-‐12 * N = 9,133 January 2011 41% September2012 19% January 2012 27% 22% ARR of In-Patient Mortality
- 10. Ok there was some of stuff…
- 17. Triage Screen
- 18. Lactate
- 21. Panic Value if ≥ 4
- 22. Why are more lactates a good thing?
- 23. How do Severe Sepsis Patients Die? Time Stability
- 25. Pneumonia 14% Severe Sepsis 40% Pre-Lactate Screen
- 26. Pneumonia 8% Severe Sepsis 30% Post-Lactate Screen
- 27. What did they do after they found them?
- 29. Treat the Source Perfuse the Tissues
- 31. Early Abx Source Control Don’t box ‘em with the tube A Wee bit of Fluid Pressors
- 32. Early Antibiotics Kumar et al.& Gaieski et al.
- 36. Source Control
- 37. “He’s too sick to intervene”
- 39. How not to kill septic patients while intubating
- 45. 2nd Lactate?
- 47. 0% 10% 20% 30% 40% 50% Jan-‐11 Feb-‐11 Mar-‐11 Apr-‐11 May-‐11 Jun-‐11 Jul-‐11 Aug-‐11 Sep-‐11 Oct-‐11 Nov-‐11 Dec-‐11 Jan-‐12 Feb-‐12 Mar-‐12 Apr-‐12 May-‐12 Jun-‐12 Jul-‐12 Aug-‐12 Sep-‐12 * N = 9,133 January 2011 41% September2012 19% January 2012 27% 22% ARR of In-Patient Mortality
- 49. Gain from Sepsis Interventions Easy Crap Mental Masturbation 95% 5%
- 50. 5%
- 51. FOAMcc
- 53. Hemodynamics
- 56. EGDT
- 58. Fluids
- 59. Debate
- 60. Give everyone two liters of…
- 61. Balanced Crystalloid Ann Surg. 2012 May;255(5):821-9 JAMA. 2012 Oct 17;308(15):1566-72)
- 62. HIP
- 64. Give 1 (or max 2) liter(s) more
- 65. Tense the Tank
- 67. Critical Care 2007,11(Suppl 2):P37 Crit Care Med 2011;39(4):689-94 Critical Care 2010,14:R142 Crit Care Med. 2012;40(12):3146-3153 Crit Care Med.2013 Jan;41(1):143-50
- 68. Peripheral Pressor Administration Crit Care Med.2013 Sep;41(9):2108-15
- 69. First 24 hrs: Think you Need Additional Fluid?
- 71. After First 24 hrs: Better have a think about it
- 74. Glycocalyx ?
- 75. Goals
- 76. MAP > 65 CI > 2.2 (2.5) Microcirc Goals?
- 77. ScvO2
- 78. 2nd Lactate?
- 79. Lack of Prognostic Value of Lactate Clearance in a Center with a Severe Sepsis Protocol
- 80. 199 patients received aggressive monitored severe sepsis care. 39 patients expired during their hospital course (18% mortality) The mean arrival lactate was 4.8 (± 3.0) in the survivors compared to 7.3 (± 4.4) in those patients who died (p<0.0001). Lactates ≥4 were significantly associated with increased mortality (p<0.05). However, the patients who achieved lactate clearance did not have significantly improved survival when compared to those patients in whom clearance was not achieved (p=.60). In addition, patients with rebound in lactate ≥4, after initial clearance, showed a 10-fold increase in mortality (p<.05).
- 81. If you are already doing the good stuff, clearance doesn’t matter--unless they rebound…
- 82. May not be applicable to places without a team that wants to care about these patients
- 83. emcrit.org/smacc
- 84. The old days…
- 85. Gain from Sepsis Interventions Easy Crap Mental Masturbation 95% 5%
- 86. 5%
- 88. You don’t need to do a whole lot of
- 89. You just need to give a