Update in Critical Care Medicine

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Update in Critical Care Medicine

• Ann Intern Med 2007147412-416

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Sepsis ManagementHow much do we really know?

• Intensive Insulin
• Steroids
• rhAPC
• Vasopressin
• Dobutamine
• Swan-Ganz Catheters

• Early Dialysis
• ScvO2 Monitoring
• EGDT
• Nutritional Support
• Transfusion Targets
• Quantitative BAL

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• The study was terminated early because mortality
  in the intensive care unit in the group assigned
  to intensive insulin therapy was significantly
  lower than that in the group assigned to
  conventional therapy (4.6 vs. 8.0 ).

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Intensive Care Intensive Insulin?Van den
Berghe, NEJM 2006354449-61

• 1200 pts in medical ICUs expected to stay 3 or
  more days
• Randomized to a target BG between
• 80-110 (Intensive Insulin Therapy - IIT), vs.
• 180-200
• Results
• Overall
• NO difference in mortality
• MORE hypoglycemia in the IIT group
• With trend towards higher mortality (67 vs 46,
  p0.1)
• However, if actually did stay 3 days or more,
  IIT
• Decreased mortality
• Accelerated weaning, ICU d/c, and hospital d/c

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Intensive Care Intensive Insulin?Van den
Berghe, NEJM 2006354449-61

• Conclusion
• IIT decreases morbidity but has no effect on
  mortality.
• Comments
• IIT seems to harm early and help late.
• Reasonable Goal
• lt150 for the first three days then 80-100
• Demonstrates the phenomenon of exaggeration of
  results when trials are stopped early.

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Red States or Blue StatesARDSnet, NEJM
20063542564-75

• Question
• How should fluids be managed in pts with ALI?
• 1000 pts randomized to
• Conservative I O over 7 days
• Liberal I gt O by 7 liters over 7 days
• Results
• Equal 60 day mortality
• Conservative
• Better oxygenation
• More vent-free days (14.6 vs 12.1)
• More days not in the ICU (13.4 vs 11.2)
• NO increase in shock or HD

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Red States or Blue StatesARDSnet, NEJM
20063542564-75

• Conclusion
• In pts with ALI, a conservative fluid strategy,
  IO, helps wean pts from mechanical ventilation.

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PAC or CVC, that is the questionARDSnet, NEJM
20063542213-24

• Question
• Do outcomes differ for patients with ALI if PACs
  or CVCs are used?
• 1000 pts randomized to PAC or CVC
• Results
• Equal 60 day mortality
• PACs
• No difference in lung function, kidney function,
  hypotension, ventilator settings, use of
  dialysis, or use of vasopressors
• BUT more total catheters (2.47 vs 1.64) and twice
  the number of catheter-related complication
  (mainly arrhythmias)

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PAC or CVC, that is the questionARDSnet, NEJM
20063542213-24

• Conclusion
• PAC-guided therapy did not improve survival or
  organ function and was associated with more
  complications.
• Commentary
• Arrhythmia might have been due to the catheters
  but could also have been due to an increased use
  of vasopressors
• Bottom Line
• PACs should NOT be routinely used to manage ALI.

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VAP DiagnosisCanadian Crit Care Group, NEJM
20063552619-30

• Question
• BAL vs Endotracheal Aspiration
• 740 pts randomized to
• BAL with Quantitative Culture
• Endotracheal Aspiration with routine culture
• Results
• NO difference in mortality, ICU LOS, receipt of
  targeted therapy, days alive without abx, or
  maximum organ dysfunction score

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Septic Shock how soon to start AbxKumar, Crit
Care Med 2006341589-96

• Question
• Is delay in initiation of abx after onset of
  hypotension in septic shock associated with an
  increase in mortality.
• Retrospective Cohort Study
• 2154 pts with septic shock who started abx after
  onset of hypotension
• Findings
• Median time to effective antimicrobial therapy
  was 6 hrs
• If given abx in first hour, 79.9 survival
• Each hr delay, over the next 6 hrs, decreased
  survival rate by 7.6

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Septic Shock how soon to start AbxKumar, Crit
Care Med 2006341589-96

• Supports Surviving Sepsis Campaign Recs

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Bundles

• A group of interventions related to a disease
  that when performed together result in better
  outcome than when individually done.
• It increases the use of evidence-based science
  in clinical practice and provides a mechanism to
  enforce teamwork.
• A bundle is not guidelines, but a method to
  implement the guidelines.

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BundlesThe Good, the Bad, and the Ugly?

• Ventilator Bundle
• Sepsis Resuscitation Bundle
• Sepsis Management Bundle

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BundlesReasonable?

• Ventilator Bundle
• DVT Prophylaxis
• Peptic Ulcer Disease Prophylaxis
• Elevation of the Head of the Bed
• Sedation Vacation

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BundlesLactate? ScvO2?

• Sepsis Resuscitation Bundle
• Measure Serum Lactate
• Blood Cultures before abx
• Prompt Abx (3 hrs Ed 1 hr non-ED)
• If hypotensive or lactate gt 4
• 20 ml/kg crystalloid
• Vasopressors to achieve MAP gt 65 mmHg
• If persistent hypotension or elevated lactate
• Assure CVP gt 8
• Achieve ScvO2 gt 70 or SmvO2 gt 65

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BundlesrhAPC????

• Sepsis Management Bundle
• Low-dose steroids
• Drotrecogin alfa (activated)
• Glucose control maintained
• gt lower limit of normal, but lt 150 mg/dl
• Plateau pressures maintained lt 30 cm H2O

Surviving Sepsis Campaign supported by Ely
Lilly. rhAPC made by Ely Lilly.
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Sepsis ManagementHow much do we really know?

• Intensive Insulin
• Steroids
• rhAPC
• Vasopressin
• Dobutamine
• Swan-Ganz Catheters

• Early Dialysis
• ScvO2 Monitoring
• EGDT
• Nutritional Support
• Transfusion Targets
• Quantitative BAL