Emanuel P. Rivers, MD, MPH, IOM Vice Chair and Research Director Senior Staff in Emergency Medicine and Critical Care Henry Ford Hospital Clinical Professor, Wayne State University Detroit, Michigan Early Goal Directed Therapy in Severe Sepsis and Septic Shock: Where are we 10 years later
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Emanuel P. Rivers, MD, MPH, IOM
Vice Chair and Research Director
Senior Staff in Emergency Medicine and Critical Care
Henry Ford Hospital
Clinical Professor, Wayne State University
Detroit, Michigan
Early Goal Directed Therapy inSevere Sepsis and Septic Shock:
Where are we 10 years later
Why Should You Botherwith Early Sepsis Intervention?
Time Sensitive DiseasesChanging the Paradigm of Practice
< 5%
Trauma
7%
Stroke
< 10%
AMI
Acute MyocardialInfarction Mortality - 10%
Liver TransplantMortality - 5%
Trauma Mortality - 5% Cardiac Surgery Mortality - 5%
Septic Shock Mortality– 50-55%
10% of Hospital Admissions – 40% of Hospital Deaths
$100 million in total hospital costs per year
HealthGrades analyzed over 5 million Medicarerecords of patients admitted through the emergencydepartment at 4,907 hospitals from 2006 through2008, to identify the top 5% of the best-performinghospitals in emergency medicine.
InflammationMicrocirculation
Early Goal DirectedHemodynamic Optimization
Organ Dysfunction
Decrease Mortality
Decrease Health Care ResourceConsumption
Early Detection of HighRisk Patients
AppropriateDisposition
ICU
ER
Collaboration is Fun
The Lecture Goals
The First Step:Understanding the Pathogenesis and
Expanding theLandscape of Sepsis
Global TissueHypoxia and
OrganDysfunction
Organism
Multiple OrganDysfunction and
Refractory Hypotension
Diffuse endothelialdisruption and
microcirculation defects
Systemic Inflammationor Inflammatory
Response
Septic Shock
Sepsis: A Complex and Dynamic Landscape
Severe Sepsis
EmergencyDepartment
Intensive CareUnit
Out PatientSetting
At Home orResidence
SepsisSource
Systemic Inflammatory Response Syndrome (SIRS)A clinical response arising from a nonspecific insult,including 2 of the following:
• Temperature ≥38oC or ≤36oC
• HR ≥90 beats/min
• Respirations ≥20/min
• WBC count ≥12,000/mm3 or≤4,000/mm3 or >10% bands
• PaCO2 < 32mmHg
General PracticeFloors
ORand Recovery
• 115 million visits/year.• 2.9% of hospital admits are
severe sepsis and septic shock.– 600,000 admissions per
year through the ED.• ED waiting times (5-6 hours)
approaching 24 hours.
• After ICU Admission:
– > 6 hour total delay forhemodynamic optimization.
• 62 year presents with sepsis after a prostate biopsy.• He also complains of SIRS, SOB and disorientation.• WBC of 25,000 and Lactate of 9 mM/L• Blood cultures and Antibiotics• 7 liters of fluid
May, 2006
7 liters of fluids in first6 hours and offvasopressors
Before Surgery
Day 2 – Extubated in theRecovery Room
10 liters of fluid in10 hours
Day 3 –Mobilization
93 years old Perforated Ulcer
Levophed – 10 ug/min
Although no difference in mortality at 60 days between the twotreatment groups, patients treated according to a conservativestrategy of fluid management (47 hours after ICU adm) had:
1. Significantly improved lung function and centralnervous system function
2. Decreased need for sedation, mechanicalventilation, and intensive care.
3. A small (0.3 day) increase in the number ofcardiovascular-failure–free days during the first 7 dayswith the liberal strategy.
These salutary effects were achieved without an increase in thefrequency of non-pulmonary organ failure or shock.