SEPSIS & SEPTIC SHOCK Jaime Palomino, MD Pulmonary & Critical Care Medicine Tulane University Health Sciences Center New Orleans, Louisiana

Epidemiology  Sepsis yearly incidence  50 – 95 cases / 100,000  Increasing by 9% each year  2% hospital admissions  9% sepsis  severe sepsis  3% severe sepsis  septic shock 10% of ICU admissions 10% of ICU admissions

Annane D et al. Lancet 2005;365:63-78

Russell J. NEJM 2006;355:

Septic Shock – Treatment  Initial Resuscitation

Rivers E et al. NEJM 2001;345:

Septic Shock – Treatment  What are the recommended vasopressors in septic shock patients? MAP ≥ 65 mmHg MAP ≥ 65 mmHg Norepinephrine and Dopamine  initial vasopressors of choice Norepinephrine and Dopamine  initial vasopressors of choice Epinephrine  first alternative when BP is poorly responsive to Norepinephrine or Dopamine Epinephrine  first alternative when BP is poorly responsive to Norepinephrine or Dopamine

Annane D et al. Lancet 2007;370:676-84

Septic Shock – Treatment  Vasopressors Vasopressin Vasopressin May be subsequently added to Norepinephrine (Dose: 0.03units/min) with anticipation of an effect equivalent to Norepinephrine alone.May be subsequently added to Norepinephrine (Dose: 0.03units/min) with anticipation of an effect equivalent to Norepinephrine alone.

Russell J et al. NEJM 2008;358:

Povoa P et al. CCM 2009;37:

Septic Shock – Treatment  Vasopressors Comparison of Dopamine and Norepinephrine as the First Vasopressor Agent in the Management of Shock Comparison of Dopamine and Norepinephrine as the First Vasopressor Agent in the Management of Shock De Backer D. NCT De Backer D. NCT Primary Outcome Measures: 28 day survival Primary Outcome Measures: 28 day survival Estimated Enrollment: 1600 Estimated Enrollment: 1600 Study Start Date: December 2003 Study Start Date: December 2003 Estimated Study Completion Date: December 2010 Estimated Study Completion Date: December 2010

Septic Shock – Treatment  Steroids

Sprung et al. NEJM 2008;358:111-24

Relative Adrenal Insufficiency Diagnosis Thomas Z et al. Ann Pharmacother 2007;41:

Dellinger R et al. Crit Care Med 2008; 36:

Annane et al. JAMA 2009;301:

Septic Shock – Treatment  Glucose Control

Van Den Berghe G et al. NEJM 2001;345:

Van Den Berghe G et al. NEJM 2006;354:

Brunkhorst FM et al. NEJM 2008;358:

NEJM 2009;360:

Septic Shock– Treatment  Activated Protein C

Bernard GR et al. NEJM 2001;344:

Abraham E et al. NEJM 2005;353:

Dellinger R et al. Crit Care Med 2008; 36:

Early Versus Delayed Enteral Feeding and Omega-3 Fatty Acid/Antioxidant Supplementation for Treating People With Acute Lung Injury or Acute Respiratory Distress Syndrome (The EDEN-Omega Study)  This study has been terminated.  ( The Omega arm of this study was stopped for futility. The EDEN arm continues to recruit patients as a separate independent study. ) 

Early Versus Delayed Enteral Feeding and Omega-3 Fatty Acid/Antioxidant Supplementation for Treating People With Acute Lung Injury or Acute Respiratory Distress Syndrome (The EDEN-Omega Study)  Interim analysis: day 60: day 60: 26.6% Omega-3 Vs 16.3% Control26.6% Omega-3 Vs 16.3% Control Ventilator-Free days (within 28 days): Ventilator-Free days (within 28 days): 14.6 days Omega-3 Vs 17.4 days Control14.6 days Omega-3 Vs 17.4 days Control ICU-Free days (within 28 days): ICU-Free days (within 28 days): 13.9 days Omega-3 Vs 16.8 days Control13.9 days Omega-3 Vs 16.8 days Control Chest Physician. August Elsevier.

Septic Shock – Diagnosis  Serum Markers

Annane D et al. Lancet 2005;365:63-78

Nobre V et al. AJRCCM 2008;177:

Tang B et al. AJRCCM 2007;176:

Wurfel M et al. AJRCCM 2008;178:

Cinel I et al. CCM 2009;37:

Russell J. NEJM 2006;355:

Septic Shock – Treatment  Last but not less important… Sedation protocol Sedation protocol Sedation GoalSedation Goal Daily awakening trialsDaily awakening trials Avoid NMBAs as much as possibleAvoid NMBAs as much as possible DVT prophylaxis DVT prophylaxis Stress Ulcer (GI) prophylaxis Stress Ulcer (GI) prophylaxis Consideration for Limitation of Support Consideration for Limitation of Support