Management of Sepsis in Combat Injury Patients In

MANAGEMENT OF SEPSIS IN COMBAT INJURY PATIENTS IN I.C.U R.S.P.A.D Chris A JohannesHead of Intensive Care Unit Central Army Hospital Gatot Subroto JAKARTA

ACCP/SCCM Consensus DefinitionsInfectionInflammatory response to microorganisms, orInvasion of normally sterile tissuesSystemic Inflammatory Response Syndrome (SIRS)Systemic response to a variety of processesSepsisInfection plus2 SIRS criteria

Severe SepsisSepsisOrgan dysfunctionSeptic shockSepsisHypotension despite fluid resuscitationMultiple Organ Dysfunction Syndrome (MODS)Altered organ function in an acutely ill patientHomeostasis cannot be maintained without intervention

Bone RC et al. Chest. 1992;101:1644-55.

The interrelationship between SIRS, sepsis, and infectionChest 1992;101:1645

Sepsis: A Complex DiseaseThis Venn diagram provides a conceptual framework to view the relationships between various components of sepsis.The inflammatory changes of sepsis are tightly linked to disturbed hemostasis.Adapted from: Bone RC et al. Chest. 1992;101:1644-55.Opal SM et al. Crit Care Med. 2000;28:S81-2.

SIRS: More Than Just a Systemic Inflammatory ResponseSIRS: A clinical response arising from a nonspecific insult manifested by 2 of the following:Temperature 38C or 36CHR 90 beats/minRespirations 20/minWBC count 12,000/mL or 4,000/mL or >10% immature neutrophilsRecent evidence indicates that hemostatic changes are also involvedAdapted from: Bone RC et al. Chest. 1992;101:1644-55.Opal SM et al. Crit Care Med. 2000;28:S81-2.

Sepsis: More Than Just InflammationSepsis:Known or suspected infectionTwo or more SIRS criteriaA significant link to disordered hemostasisAdapted from: Bone RC et al. Chest. 1992;101:1644-55.

Severe Sepsis: Acute Organ Dysfunction and Disordered HemostasisSevere Sepsis: Sepsis with signs of organ dysfunction in 1 of the following systems: CardiovascularRenalRespiratoryHepaticHemostasisCNSUnexplained metabolic acidosis

Adapted from: Bone RC et al. Chest. 1992;101:1644-55.

Angus DC et al. Crit Care Med. 2001; (In Press).Zeni F et al. Crit Care Med. 1997;25:1095-100.Wheeler AP et al. N Engl J Med. 1999;340:207-14.Severe Sepsis: A Complex and Unpredictable Clinical SyndromeHigh mortality rate (28%-50%)Heterogeneous patient populationUnpredictable disease progressionUnclear etiology and pathogenesisSystemic InflammationImpaired FibrinolysisCoagulation

Sepsis: Defining a Disease ContinuumBone et al. Chest. 1992;101:1644; Wheeler and Bernard. N Engl J Med. 1999;340:207. SepsisSIRSInsultSevere SepsisSepsis with 1 sign of organ failureCardiovascular (refractory hypotension)RenalRespiratoryHepaticHematologicCNSMetabolic acidosis

Effective Therapy in Sepsis ?One Therapy for All Menu of therapyPresence of inflammatory, severity of diseaseCorticosteroid th/, enteral feeding, type of iv solution, low tidal volume in ARDS, protein C, hemoperfusion column, early goals directed th/, tight control blood sugar, anti endotoxins, anti inflammatory th/ etc

Initial ResuscitationDiagnosisAntibiotic therapySource ControlFluid therapyVasopressorsInotropic TherapySteroidsRecombinant Human Activated Protein C (rhAPC) [drotrecogin alfa (activated)]

Blood Product AdministrationMechanical Ventilation Sedation, Analgesia, and Neuromuscular Blockade in SepsisGlucose ControlRenal ReplacementBicarbonate TherapyDeep Vein Thrombosis ProphylaxisStress Ulcer ProphylaxisLimitation of Support

IndexDellinger, et. al. Crit Care Med 2004, 32: 858-873.

Does appropriate antimicrobial therapy improve the outcome of patients with bloodstream infections and severe sepsis or septic shock in patients with Gram-positive bacteriemia ?Antibiotics in sepsis; Intensive Care Med (2001) 27: S33-S48YES

Antibiotics in sepsis; Intensive Care Med (2001) 27: S33-S48The mortality directly attributable to infection was lower in the AB group (25%) than in the control group (40%), suggesting that appropriate antibiotics reduced mortality (p=0,27)

Antibiotics in sepsis; Intensive Care Med (2001) 27: S33-S48Are there clinical conditions justifying the use of empirical anti-Gram-positive therapy in patients with severe sepsis ?YES

Causes of Nosocomial Bacteremia(M.B Edmond, et al, 1999 , SCOPE Project)Microorganism%

Gram-positive organism64,4Gram-negative organism27,0Fungi8,4

Immunoglobulin in Sepsis21 patients received Pentaglobin (IgM enriched immunoglobulin) for 3 daysNo change in organ dysfunction, septic shock or mortality in sepsis patients

Critical Care 2002;6:357-362

IVIG in SepsisMeta analysis (N=91) from Cochran review group concluded that polyclonal immunoglobulin results in improved mortality (relative risk 0.3 (CI 0.9 to 0.99)Results less clear for monoclonal immunoglobulin

Alejandria et al Cochrane Database Rev 2002

IVIG in SepsisRendomized, Double Blind, Control Study ( N= 56 ) set in medical/surgical ICUs of seven teaching hospital, Pt with severe sepsis and septic shock of intra Abdominal Origin admitted to the ICU within 24 h after the onset of symptoms were included in the study. Intra venous polyclonal immunolobulin ( IVIG ) at a dosage of 7 ml/kg/day , and equal amount of 5% human albumin ( Control Group ) was randomized Shock : Volume 23(4) April 2005 pp 298 - 304

IVIG in SepsisThe overall mortality rate was 37, 5%. Twenty pts had shock and 36 pts had severe sepsis ( the mortality rate was 55% and 25%). In the intent to treat analysis, the mortality rate was reduced from from 48.1% in pts treated with ATB plus albumin to 27,5% ( p = 0.06% ) for pts with ATB plus IVIG.

Shock: Volume 23(4) April 2005 pp 298 - 304

IVIG in SepsisConclusion: IVIG administration when use in combination with ATB, improved the survival of surgical ICU patients with intra Abdominal sepsis.

Shock: Volume 23(4) April 2005 pp 298 -304

CASE REPORTDuring January July 2005.12 young men pts ( 23 38 years old ) were evacuated to ICU RSPAD from the conflict area.They admitted to ICU because of severe sepsis and septic shock e.c. gun shoot.

Location of gun shoot N--------------------------------------------------------------- 1. Abdomen 6 2. Thorax 2 3. Thoraco Abdominal 1 4. Head 2 5. Musculosceletal 1 -------------------------------------------------------------- Total 12

Clasification of Sepsis N--------------------------------------------------------------- 1. Sepsis 3 2. Severe Sepsis 4 3. Septic Shock 5 -------------------------------------------------------------- Total 12

Isolated micro organism from blood 1. Klebsiella sp ( 4 pts ) 2. Enterobacter sp ( 2 pts ) 3. Pseudomonas aerogenosa ( 2 pts ) 4, Escheria coli ( 1 pts )

On Ventilator : 8 pts. ( e.c. ARDS ) All pts we give Fluid. ( Crystalloid an Colloid)Antibiotic : Meropenem CefipimeSource Control Glucocorticoid if there any indication.Glucose ControlNutrition Therapy

Polyclonal IVIGTight Monitoring. - Hemodynamic monitoring. - SaO2 - BGA - Blood Glucose. - Urine Output

RESULT 8 pts ( 66,6 % ) survived 4 pts ( 33,3 % ) died.

CONCLUSIONIF WE USE THE GUIDELINES FROM SURVIVING SEPSIS CAMPAIGN, THE MORTALITY IN SEPSIS COULD BE DECREASED.

THANK YOU ( [email protected] )

*The American College of Chest Physicians (ACCP) and Society of Critical Care Medicine (SCCM) held a consensus conference in August 1991 to agree on a set of definitions that could be applied to patients with sepsis and organ dysfunction. The consensus panel also recommended the use of severity scoring methods to characterize the disease and develop a comprehensive model for the syndrome.This slide provides a brief definition of the various components of the sepsis syndrome. Notably, this is a non-linear process rather than a continuum and the presence of organ dysfunction identifies a population with a significant risk of mortality.

Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992;101:1644-55.*This conceptual framework shows the interrelationships between infection, non-infectious disorders, SIRS, sepsis, and severe sepsis. Components of the process not discussed on the following slides include:Infection: a microbial phenomenon characterized by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by those organismsBacteremia: the presence of viable bacteria in the blood streamSeptic shock: sepsis-induced hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status Multiple organ dysfunction syndrome (MODS): presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without interventionInflammation and hemostasis are tightly linked. Therefore, although not shown on this slide, sepsis and severe sepsis lie on a background of disturbed hemostasis.

Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992;101:1644-55.Opal SM, Thijs L, Cavaillon JM, et al. Relationships between coagulation and inflammatory processes. Crit Care Med. 2000;28:S81-2.*The systemic inflammatory response syndrome (SIRS) is a clinical response arising from a nonspecific insult manifested by two or more of the following:Fever or hypothermiaTachycardiaTachypneaLeukocytosis, leukopenia, or a left-shift (increase in immature neutrophilic leukocytes in the blood)Recent evidence indicates that hemostatic changes play a significant role in many SIRS-linked disorders.

Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992;101:1644-55.Opal SM, Thijs L, Cavaillon JM, et al. Relationships between coagulation and inflammatory processes. Crit Care Med. 2000; 28:S81-2.*The original ACCP/SCCM criteria for the diagnosis of sepsis required the presence of known or suspected infection plus two or more SIRS criteria.Climbing a flight of stairs can produce two SIRS criteria (tachypnea, tachycardia) in a normal sedentary individual. Thus, clinical studies of sepsis generally require at least three SIRS criteria plus known or suspected infection for entry.

Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992;101:1644-55.*Severe sepsis is sepsis plus signs and symptoms of acute organ dysfunction, hypoperfusion, or hypotension. Hypoperfusion and perfusion abnormalities may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status.As shown on the next slide, organ dysfunction may involve any of the following alone or in combination:Cardiovascular systemKidneyRespiratory systemLiverHematologic (blood, coagulation)Central nervous systemPresence of an otherwise unexplained metabolic acidosis

Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992;101:1644-55.*Following identification of a patient with sepsis, the clinician must assess the patient for the presence of acute organ dysfunction (severe sepsis). The presence of acute organ dysfunction is often recognized clinically by the patients presenting signs and symptoms. However, in some instances laboratory data or results of invasive monitoring will confirm the diagnosis of organ dysfunction.The illustration of the patient on this slide has arrows pointing to various organs that might provide clues to the presence of organ dysfunction. Indications of organ dysfunction include:Central nervous system: altered consciousness, confusion, psychosis, deliriumRespiratory system: tachypnea, hypoxemia, oxygen saturation