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A Hospitalist’s Perspective
Claire Paris, MD
IPC Healthcare
Johnson City, TN
Disclosure Statement of Financial Interest
I, Claire Paris,
DO NOT have a financial interest,
arrangement, or affiliation with one or more
organizations that could be perceived as a
real or apparent conflict of interest in the
context of the subject of this presentation.
I, Claire Paris,
DO NOT anticipate discussing the
unapproved/investigative use of a
commercial product/device during this
activity or presentation.
Objectives
 Approach to early diagnosis & treatment of SEPSIS
 What is a Bundle?
 Fluid Resuscitation and Pressors
 Understand impact of delirium in the ICU
Sepsis
 The process by which flesh rots,
swamps generate foul airs, and
wounds fester
 Hippocrates
 Germ Theory “Blood Poisoning”
 Pasteur, Semmelweiss
 Host
Definitions- SIRS
To define a clinical response to nonspecific insult of
infectious or noninfectious origin- 2 or more:
 Fever >100.4°F or <96.8°F
 HR >90 bpm
 RR >20 or PaCO2 <32
 WBC >12,000/µL or
< 4,000/µL or
>10% bands forms
Definitions Continued
 Sepsis- inflammatory response (SIRS) + infection 1.3%
 Severe Sepsis- + organ dysfunction 9.2%
 Sepsis induced hypotension SBP <90mmHg or drop
>40 mmHg
 Septic Shock- hypotension refractory to fluid
resuscitation, +/- elevated lactate 28%
 MODS- Multiple Organ Dysfunction Syndromehomeostasis cannot be maintained without intervention
 Multihit Theory- early intervention is key
Venn Diagram
Causes of Sepsis
 Pneumonia- half of all cases
 Intra-abdominal infections
 Urinary tract infections
Comparison With
Other Major Diseases
Incidence of Severe Sepsis
AIDS* Colon Breast CHF† Severe
Cancer§
Sepsis‡
†National
Mortality
of Severe
Sepsis
Mortality
of Severe
Sepsis
AIDS*
Breast AMI†
Cancer§
Severe
Sepsis‡
Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association.
2000. ‡Angus DC et al. Crit Care Med. 2001;29(7):1303-1310.
Where’s the Beef?
Lead time to Diagnosis
Lactate
Delivery of Treatment
Bundles
Early Goal-Directed Therapy
Control
EGDT
Relative Risk
(95% Confidence
Interval)
In-Hospital
46.5
30.5
0.58
(0.38-0.87)
0.009
28-day Mortality
49.2
33.3
0.58
(0.39 – 0.87)
0.01
44.3
0.67
(0.46-0.96)
0.03
60-day Mortality
56.9
P
Rivers E. N Engl J Med. 2001;345: 1368-1377.
Why measure lactate?
 Elevated lactate >4 mg/dL in severe sepsis = tissue
hypoperfusion
 Trigger for quantitative resuscitation
What is a Bundle?
 evidence based practice of series of interventions that
when done together improve outcomes
3 Hour Bundle- Surviving Sepsis
 1) Measure Lactate Level
 2) Obtain Blood Cultures Prior to Administration of
Antibiotics (but do not delay!)
 3) Broad Spectrum Antibiotics
 4) Administer 30 mL/kg Crystalloid for Hypotension or
Lactate ≥4 mmol/L
6 Hour Bundle- Surviving Sepsis
 1) Vasopressors (for Hypotension That Does Not
Respond to Initial Fluid Resuscitation) to Maintain a
Mean Arterial Pressure (MAP) ≥65 mm Hg
 2) For Septic Shock or Initial Lactate ≥4 mmol/L:
a. Maintain Adequate Central Venous Pressure
b. Maintain Adequate Central Venous O2 Sat
 3) Remeasure Lactate If Initial Lactate Was Elevated
Blood Cultures
 At least 2 blood cultures obtained before
starting antibiotics as long as NO delay (>45
min)
 1 drawn percutaneously and 1 drawn
through each vascular access device
(placed >48 hours prior) (Grade 1C)
SCCM 2013
Guideline Recommendations
 Administration of effective IV antimicrobials within the
1st hour of recognition of septic shock (grade 1B) and
severe sepsis without septic shock (grade 1C)

Initial empiric anti-infective therapy of one or more drugs
that have activity against all likely pathogens and that
penetrate in adequate concentrations into tissues
presumed to be the source of sepsis (grade 1B)
ETC…

Evaluate risk factors for MDR/Health-care
associated pathogens
• Immunosuppression, COPD, hemodialysis,
LTCF residence

Mortality reduction
• Combination antibiotics
• Sepsis bundles and protocols
• Early, appropriate antibiotics
Initial Resuscitation
•
During the first 6 hours, the goals of initial resuscitation
of sepsis-induced hypoperfusion should include all of
the following as a part of a treatment protocol (Grade
1C):
 Central venous pressure 8-12 mm Hg
 Mean arterial pressure ≥65 mm Hg
 Urine output ≥0.5 mL/kg/h
 Central venous (superior vena cava) or mixed
venous oxygen saturation 70% or 65%, respectively
Fluid Therapy
•
•
•
Crystalloids- initial fluid of choice in the resuscitation of
severe sepsis and septic shock.(Grade 1B)
Do NOT use of hydroxy- ethyl starches for fluid
resuscitation of severe sepsis and septic shock. (Grade
1B) (increased mortality and risk of kidney injury)
Use ALBUMIN in the fluid resuscitation of severe sepsis
and septic shock when patients require repeated boluses
of crystalloids. (Grade 2C)
Vasopressor Therapy
•
•
•
Target - mean arterial pressure (MAP) of 65 mm Hg.
(Grade 1C)
Norepinephrine- the first choice vasopressor. (Grade
1B)
Epinephrine (added to and potentially substituted for
norepinephrine) when an additional agent is needed to
maintain adequate blood pressure. (Grade 2B)
Vasopressors
 In general avoid:
 Dopamine, unless
 Relative or absolute bradycardia
Renal dose
Dopamine
and low risk of tachyarrhythmias (2C)
 Phenylephrine, unless
 Norepinephrine associated with serious arrhythmias
 Cardiac output is high and blood pressure target
difficult to achieve
 As salvage therapy (1C)
Vasopressor Therapy
•
Vasopressin up to 0.03 units/minute can be added
to norepinephrine to raise MAP to target or decreasing
norepinephrine dosage.
•
Low-dose vasopressin is not recommended as the
single initial vasopressor for treatment of sepsisinduced hypotension, and vasopressin doses higher
than 0.03-0.04 units/minute should be reserved for
salvage therapy (failure to achieve adequate MAP with
other vasopressor agents).
Inotropic Therapy
•
)
Dobutamine infusion up to 20 μg/kg/min may be
administered or added to vasopressor (if in use) in the
presence of:
• myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output, or
• ongoing signs of hypoperfusion, despite achieving
adequate intravascular volume and adequate mean
arterial pressure. (Grade 1C)
ETC
 DVT prophylaxis (1B)
 Stress Ulcer Prophylaxis- H2 blocker or PPI
 Transfuse Hb <7.0 (except special circumstances)
 Nutrition
 Set Goals of Care/Prognosis with Pt/Family (1B)
 Glucose target < 180
 CAUTI / CLABSI / C.DIFF
VAP- Ventilator Associated
Pneumonia
 Leading cause of death in hosp acquired infections46% mortality
 Prolongs time on vent, adds to ICU and LOS and $$
 VENT BUNDLE Elevate head of bed 30 degrees
 Daily sedation vacation, assess for readiness to
wean
 PUD prophylaxis
 DVT prophylaxis
 Daily oral care with chlorhexidine
ICU PAD Bundle: Big Picture
1. Optimize pain management first (CPOT tool)
2. Make light sedation the norm
3. Move away from routinely using benzodiazepines ,
especially in ICU patients who are at high risk for delirium
4. Implement more effective delirium prevention and
treatment strategies using both pharmacologic and
nonpharmacologic methods
5. Use antipsychotics judiciously and be aware of clinical
effects
Cardinal Symptoms of Delirium &
Coma
60%-80% of mechanically ventilated patients
50%-70% of non-ventilated patients
Hypoactive delirium = 43.5%
Hyperactive delirium = 1.6%
Mixed delirium = 54.1%
Buffalo-Beer Theory
 “Well ya see, Norm, it's like this... A herd of buffalo can only
move as fast as the slowest buffalo. And when the herd is
hunted, it is the slowest and weakest ones at the back that are
killed first. This natural selection is good for the herd as a
whole, because the general speed and health of the whole
group keeps improving by the regular killing of the weakest
members. In much the same way, the human brain can only
operate as fast as the slowest brain cells. Excessive intake of
alcohol, as we know, kills brain cells. But naturally it attacks
the slowest and weakest brain cells first. In this way, regular
consumption of beer eliminates the weaker brain cells,
making the brain a faster and more efficient machine. That's
why you always feel smarter after a few beers.”
–Cliff Clavin ?
Delirium in the Critically Ill
Increased mortality
Prolonged hospitalization/vent duration
Increased cost
Patients suffer from concerning long-lasting and disabling aspects of
critical illness with worse consequences than in non-ICU patients
Long term cognitive impairment & decline in executive function &
memory with frontal lobe and hippocampal atrophy are being
consistently found in recent studies.
Delirium and drug exposure appear to be the most modifiable
aspects of care, with need for more studies
ICU PAD Bundle
ICU PAD Bundle: Big Picture



Optimize pain management first (CPOT tool)

Implement more effective delirium prevention and
treatment strategies using both pharmacologic and
nonpharmacologic methods

Use antipsychotics judiciously and be aware of clinical
effects


Treat withdrawal symptoms
Make light sedation the norm
Move away from routinely using benzodiazepines ,
especially in ICU patients who are at high risk for delirium
Mobilize! (even ventilated patients)
ABCDEF
 A: Awakening trials for ventilated patients.
 B: Spontaneous breathing trials.
 C: Choose light sedation. And Coordination between staff. The
combination of sedation and analgesics being used are reviewed, and
changes or reductions in the doses are considered.
 D: A standardized delirium assessment program, including treatment and
prevention options. (Pharmacologic and non-pharmacologic)
 E: Early mobilization and ambulation of critical care patients.
 F: Family engagement
Key Points:
 Use 2013 PAD Guidelines to establish an overarching protocol driven
approach to daily ICU patient management
 Assess & treat pain first (may be sufficient)
 If patient remains agitated after adequately treating pain, use prn/bolus
sedation initially, if frequent boluses (>3/hr) use continuous sedation
 Turn off sedation daily and restart only if needed at lowest dose to
maintain chosen target level of consciousness
 Deep sedation (RASS -4/-5) appears harmful; target awake/alert
 Screen for delirium (CAM-ICU or ICDSC); If delirious, first seek reversible
causes and attempt non-pharmacologic management (if not screened,
delirium missed ~75% of the time
 Use the ABCDEF to improve outcomes for your patients
2013 PAD Guidelines:
Benzodiazepines
 General Choice: non-benzodiazepine sedation
strategies preferred (propofol or dex), with
statistically shorter ICU LOS (~0.5 day, p=0.04)
 Benzos= risk factor for delirium
 Delirious ICU patients and ventilated patients at
risk for delirium use dexmedetomidine
(precedex) (alpha-2) > benzo (GABA)
Dr. Dre
Diseases-
Sepsis, COPD, CHF
Drug Removal- SATs and
stopping benzodiazepines/
narcotics
Environment- Immobilization,
sleep and day/night, hearing,
lines, foley, glasses, hearing aids
Thank You