Controvèrsies en el maneig de la sèpsia greu

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Joaquín Ortega Romero
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1 Controvèrsies en el maneig de la sèpsia greu Nous estudis PROCESS i ARISE. Rivers encara és viu? Ricard Ferrer Intensive Care Department Mutua Terrassa University Hospital Barcelona. SPAIN

2 SEVERE ANTI-INFLAMMATORY RESPONSE: HARMFUL MODERATED ANTI-INFLAMMATORY RESPONSE:BENEFITIAL Immuno-paralysis Apoptosis ANTI-INFLAMMATORY CYTOKINES IL-10, IL-11 MACROPHAGE ENDOTOXIN (PAMP) TLR-4 (PRR) LYMPHOCYTES Treg % PAF LIPID MEDIATOR FACTORS PG, LEUCOTRIENS TISSUE FACTOR PRO-INFLAMMATORY CYTOKINES (IL-1, IL-6, TNFα) HMGB1 COMPLEMENT ACTIVATION CORTISOL CATECHOLAMINES VASOPRESSIN GLUCAGON VO 2 DO 2 PLATELET AGGREGATION PAI-1 FIBRINOLISIS DIC COAGULOPATHY MICROVASCULAR DYSFUNCTION THROMBIN COAGULATION NITRIC OXIDE ENDOTHELIUM CAPILARY LEAK INTERSTICIAL EDEMA NEUTROPHILS ANTINFECTIOUS RESPONSE VASODILATATION HYPOTENSION MYOCARDIAL DYSFUNCTION DO 2 VO 2, Cell Death, Multi-organ failure MODERATED PRO-INFLAMMATORY RESPONSE: BENEFICIAL SEVERE PRO-INFLAMMATORY RESPONSE: SEPTIC SHOCK

3 Tissue dysoxia Oxygen Consumption (VO 2 ): O 2 extracted by the tissues. The rate (ml/min) at which O 2 dissociates from hemoglobin in the microcirculation and moves into the tissues.

4 O2 extraction needed to maintain VO2

5 CCM 1999

6 The biphasic VO 2 DO 2 model VO2 Critical point: DO 2 crit VO 2 and impaired OER Dependence zone: Max O 2 ER Independence zone: Variable O 2 Extraction Ratio Sepsis Normal 10 ml/min kg 15 ml/min kg DO2

7 VO 2 DO 2 model: O 2 Debt VO 2 O 2 Debt= O 2 Deficit x Time Dependence zone Independence zone Sepsis O 2 Deficit & Anaerobic Metabolism Lactate DO 2

8 28-Day Mortality (%) Serum Lactate and Mortality in Severe Sepsis Initial serum lactate evaluated in 839 adults admitted with severe High sepsis. initial serum lactate associated with mortality regardless of presence of shock (hypotension despite fluid resuscitation) p < p = Low Int High p = p = Low Int High Non-Shock Shock Mikkelsen ME, Miltiades AN, Gaieski DF et al. Crit Care Med. 2009;37:

9 VO 2 and alteration of microvascular flow Principal mechanisms implicated in the development of microcirculatory alterations Capillary density number of stopped-flow and intermittent-flow capillaries surface for O 2 exchange De Backer et al. Annals of Intensive Care 2011

11 Treatment strategies: balanced DO2/VO2

12 Decrease VO 2 VO 2 1 Septic Shock 2 Balanced DO 2 /VO 2 1 Sepsis O 2 Deficit & Anaerobic Metabolism 2 Lactate DO 2

13 Decrease VO 2 Analgesia Normotermia (or hipotermia) Mechanical Ventilation. Infection control: Adequate empirical antibiotics and Source Control. Titrate minimun dose of Termogenic drugs like inotropes.

14 Increase DO 2 VO2 1 Septic Shock 2 Resuscitated Shock Restored VO 2 3 Supranormal Resuscitation DO 2 > 600 ml/min m Sepsis 1 Lactate DO2

15 DO 2 = CO x CaO 2 TREATMENTS Fluids Inotropes Vasopressors CaO 2 Hb x 1.34 x SaO 2 /100 O 2 PRBC

16 End-Points of Resuscitation Treatments Fluids Vasopressors Inotropes PRBC Transfusion Protocol with Goals Outcomes Mortality Morbidity Other TTMs not included

17 Cardiac Index Group: CI > 4.5 L/min m 2 SvO 2 Group: SvO 2 > 70% RCT, 250 patients/group Critically ill patients

20 n= 263; 1 ED First 6 hours Control: Usual care ED + ICU TTM: Protocol in the ED, later transfer to ICU. Continuous ScvO 2 ScvO 2 goal Rivers et al. N Engl J Med 2001; 345:

21 Early goal directed therapy EGDT involves: Identification of high risk patients. Monitoring: central venous catheter with continuous oxymetry. 6h of protocolized resuscitation with fluids and vasopressors. Additional protocol for ScvO 2 : inotropes and PRBC.

22 EGDT: Treatments PROTOCOL GOAL GOAL

23 EGDT: Goals PROTOCOL GOAL BOTH

24 Early goal-directed therapy EGDT in patients with septic shock or lactate > 4 T C RRR NNT p Hospital mortality 31% 47% 34% d mortality 44% 57% 22% EGDT in patients with lactate >4 and no hypotension (cryptic shock) T C RRR NNT p Hospital mortality 20% 60,9% 67%

25 Quantitative Resuscitation in sepsis: Meta analysis Early quantitative resuscitation with different Goals Jones A et al. Crit Care Med 2008; 36:

26 Quantitative Resuscitation in sepsis: Meta analysis Jones A et al. Crit Care Med 2008; 36:

27 n= 300; 3 ED Early Septic Shock Different Goals. In both arms: All patients treated in ED. ICU was blinded. Same catheter inserted. Same protocol. Same treatments: Fluids Vasopressors Inotropes PRBC Jones A et al. JAMA 2010;303(8):739-46

28 Different Goals, same administered treatments Jones A et al. JAMA 2010;303(8):739-46

29 Different Goals, same morbidity and mortality Jones A et al. JAMA 2010;303(8):739-46

31 Limitations of the Rivers study Concerns about the use of dobutamine. Concerns about administering PRBC to keep hgb>10 mg/dl. Uncertainty about the external validity of the EGDT trial. Uncertainty about the internal validity of the EGDT trial. Lack of uptake of EGDT

32 NEJM 2014 First 6H RCT, 450 patients/group Early Septic Shock Protocol Based EGDT: Requires Continous Central Venous Monitoring Indications to DO 2 if ScvO 2 < 70% Protocol similar to Rivers Protocol Based Standard Therapy: Protocolized resuscitation without CV monitoring No special indications to DO 2 Usual care

34 If Hgb < 7.5, transfuse PRBC Lactate > 4, oliguria, mottled skin

35 Monitorization

36 Treatments

37 Outcome

38 First 6H RCT, 800 patients/group Early Septic Shock Protocol Based EGDT: Requires Continous Central Venous Monitoring Indications to DO 2 if ScvO 2 < 70% Protocol similar to Rivers Usual care ScvO 2 measurement was not permitted

42 Comments Early recognition of hypotension or tissue hypoperfusion in all trials. Patients were resuscitated with at least 20 ml/kg before inclusion. Less severe patients than in Rivers study. Sepsis protocols based in SSC guidelines in most of the centers. Aprox 60% of patients have a central line in place in usual care.

46 NEJM 2014

48 L. Gattinoni, SCCM 2015

49 Conclusions La resucitació del pacient amb sèpsia consta de 3 fases: Fase 1: 1H Reconeixement inmediat de la hipotensió i la hipoperfusió refractaria a fluids (aprox 20 ml/kg). Determinació de Lactat Fase 2: 6H La resucitació precoç (< 6 hores) és un dels pilars del tractament de la sèpsia. Cal fer-ho conjuntament amb la resta de mesures: antibiòtic i control del focus. Les mesures de disminució del VO2 formen part de l algoritme.

50 Conclusions Fase 2: La inserció de una via central en aquesta fase és molt freqüent als estudis i pot ser necessari en molts pacients. La EGDT és segura però utilitza més fluids, vasoactius i transfusions sense un clar benefici. Aquest ús esta induït per la utilització de la PVC i la SvO2 per guiar la resucitació no esta clara Administrar fluids i vasopresors per TAM 65 mmhg.

51 Conclusions Fase 2: La administració de CH en pacients amb HGB > 7 s ha de individualitzar: hipoperfusió sostinguda, isquemia coronaria, etc. La administració de DBT sense monitorizació avançada és qüestionable. Cal identificar els malalts que mantenen la hipòxia tissular: 2º lactat, SvO2, oliguria, livideses. Fase 3: El pacient que no respon a la resucitació inicial, cal que ingressi a UCI per continuar la resucitació amb monitorització avançada.

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