The New Paradigm: Goal-Directed Therapy for Severe Sepsis and Septic Shock Jamie Cowan April 25, 2006 Emergency Medicine Clerkship

Patient Scenario 45 yo male CC “Not feeling well” Known alcoholic w/cirrhosis Temp 96.2 BP 100/65 HR 100 RR 18

SIRS – System Inflammatory Response Syndrome Criteria: 2 or more of the following –Temp > 38C or < 36 C –HR > 90 –RR > 20 –PaCO2 < 32 –WBC > 12,000 or < 4,000 –Bands > 10%

Patient History and Exam Patient looks ill Known alcoholic with acute/chronic pancreatitis Says he had an operation to remove dead pancreas 7 days ago Started feeling bad 2 days ago, felt much worse last night, developed N/V/D Complains of severe abdominal and back pain

Labs Na – 141 K – 4.2 Cl – 100 Cr – 1.8 Glucose – 191 WBC – 13 with 15% bands Lactate 4.1

Definition Sepsis Sepsis –SIRS + probable site of infection Severe Sepsis –Organ Dysfunction (Oliguria, INR, Cr) –Hypotension –Hypoperfusion Delta MS Lactate Septic Shock –Sepsis induced Hypotension with perfusion abnormalities despite fluid resuscitation Multiple Organ System Failure (MOSF or MODS) –Shock, ARDS, ARF, DIC, Liver Failure, Hyperglycemia

Sepsis Epidemiology Estimated 750,000 severe sepsis cases in USA per year –387,000 initially present to ED Mortality rate ranges from 23-46% 500 deaths per day Estimated annual cost is $16.7 billion Global estimates range from cases per 100,000

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock NEJM, Nov 2001 Rivers EP et al.

Please see the following tables and figures from this article: –Figure 2 –Table 2 –Table 3 –Table 4 Pubmed link: Rivers et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med Nov 8;345(19): PMID:

Key points from article Goal-oriented therapy for sepsis –Balancing oxygen therapy and demand by managing preload, afterload, and contractility –Primary focus of ICU management –Study examined role of goal-oriented therapy in ED setting and effects on mortality and organ dysfunction Goal directed therapy in the ED setting was associated with: –Decreased in-hospital mortality than standard therapy (72 hour comparison) –Less severe organ dysfunction (APACHE II scores)

Key points Fluid resuscitation –Monitor MAP, CVP –Tx = Crystalloid/colloid, vasopressors, ionotropes Estimate total body ischemia –Monitor lactate and SvO2 –Tx = PRBC transfusions