Sepsis PPT | Sepsis Diagnosis | Sepsis Surviving Campaign | Sepsis Symptoms | Surviving Sepsis Campaign Guidelines | Surviving Sepsis Campaign Guidelines For Management Of Severe | Surviving Sepsis Campaign International : Slideworld Medical PPT Search Engine

Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

Rating :

Rate It:

Send This

Download

Comment

Favourite

more

Post To:

Facebook

Twitter

Digg

Delicious

more share options

ricci on Sep 27, 2009 Says :

Very interesting. Thank

Post a comment

Post Comment on Twitter Post Comment on SlideWorld

Comments:

Subscribe to follow-up comments

Notes

Show Notes

Slide 1 :

Comment on “Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 (Dellinger et al Intensive Care Medicine 2008; 34: 17-60) AME Spoelstra – de Man, ARJ Girbes

Slide 2 :

Severe sepsis and septic shock

Slide 3 :

Severe sepsis and septic shock Millions of individuals around the world each year Killing one in four Increasing in incidence Speed and appropriateness of initial therapy is crucial

Slide 4 :

2004: International group of experts, representing 11 organisations, published 46 guidelines to improve outcome 2008: Revision of these guidelines Use of GRADE system to classify strength of recommendations -> large improvement guidelines

Slide 5 :

GRADE system Recommendations Grade 1: strong Grade 2: weak Quality of evidence: Grade A: high Grade B: moderate Grade C: low Grade D: very low

Slide 6 :

However……… Several guidelines certainly not adjusted according to available current literature!!!

Slide 7 :

First of all: SDD! Absence of a recommendation regarding selective digestive tract decontamination (SDD)! Guidelines group was evenly split, equal numbers in favor and against recommendation of SDD

Slide 8 :

SDD One of the best ever evaluated therapy in intensive care medicine. More than 50 RCT’s, 10 meta-analyses. Overall conclusion: SDD reduces pneumonia by 65% and mortality by 22%, without emerging of antimicrobial resistance.

Slide 9 :

Cochrane reviewComparison topical plus systemic vs no prophylaxis (Liberati et al, Cochrane Database Syst Rev CD000022; 2004)

Slide 10 :

Arguments in SSC guidelines against SDD 1. No studies focused on septic patients ? however, nor did the studies regarding: stress ulcer prophylaxis deep venous thrombosis prophylaxis glucose control bicarbonate therapy.

Slide 11 :

2. Preference of authors SSC for non-antimicrobial interventions as ventilator bundles ? should therefore a therapy with proven high efficiency be withhold?

Slide 12 :

Main argument against SDD 3. Persistent concern regarding emergence of antimicrobial resistance in critically ill patients ? in 10 studies monitoring resistance for 2 – 9 years, this was not a clinical problem. ? SDD even seemed to reduce resistance of aerobic Gram-negative bacilli, the target micro-organisms of SDD (Bonten et al. Lancet; 2003: 362: 2118-9)

Slide 13 :

Special concern about emergence of resistant Gram-positive infections due to use of enteral vancomycin as a component of SDD ? Vancomycin-resistant enterococci did not emerge in any of the studies and there was no evidence that SDD promoted infection due to Gram positive bacteria. de Jonge Lancet 2003; 362: 1011-6. Korinek Crit Care Med 1993; 21: 1466-73. Schardey 1997; 225: 172-80. Bergmans 2001: 164: 382-8.

Slide 14 :

On the contrary! The continued use of only systemic antibiotics may lead to a further rise in drug-resistant Gram-positive bacteria.

Slide 15 :

Second: stress ulcer prophylaxis Strong recommendation in favour of the use of stress ulcer prophylaxis! Recommendation based on ancient studies performed in the 1980s a meta-analysis from 1991 a large trial in 1998 without control arm.

Slide 16 :

Most recent meta-analysis(Messori et al BMJ 2000; 321: 1103-6) ? no reduction of clinical important bleeding but is somehow completely ignored!

Slide 17 :

Messori et al BMJ 2000; 321: 1103-6

Slide 18 :

Results of ancient trials ? these results may not be applicable nowadays, because the incidence of stress ulcer-related bleeding has significantly decreased over recent decades due to improved ICU treatment

Slide 19 :

Incidence gastro-intestinal bleeding 1977: MacDougall Lancet; 1 : 617-9 1985: Puera Ann Intern Med; 103: 173-7 1987: Shuman Ann Intern Med; 106: 562-7 1994: Zandstra Intensive Care Med; 20: 335-40 Incidence (%)

Slide 20 :

This affects balance between benefit of prevention of gastro-intestinal bleeding and the increased risk of VAP due to higher stomach pH. (Kahn Intensive Care Med 2006; 32: 1151-8)

Slide 21 :

Recent trials Comparable rates of bleeding and endoscopic evidence of stress-related injury between treatment and placebo groups Ben Menachem Ann Intern Med 1994; 121: 568-75. Misra J Neurol Sci 2005; 239: 5-10. Reusser Crit Care Med 1990; 18: 270-4. Kantorova 2004; 51: 757-61. Pathophysiologically plausible, since stress ulcera are not caused by increased secretion of gastric acid, but by splachnic hypoperfusion. Unfortunately, most recent trials do not have a placebo group

Slide 22 :

Altogether A strong recommendation not to use stress ulcer prophylaxis would be more appropriate!

Slide 23 :

Third: glucose control Strong recommendation to reduce blood glucose levels in patients with severe sepsis!

Slide 24 :

However The beneficial effect of intensive insulin therapy has only been demonstrated in surgical patients, not in septic patients. The benefit versus harm balance of intensive insulin therapy may be quite different for septic patients as compared to surgical patients

Slide 25 :

Septic patients may be more at risk for hypoglycaemia, because sepsis may be associated with a deficiency of counter regulatory hormones.

Slide 26 :

Causes of hypoglycaemia in sepsis (E.D. Crouser et al Clinics in chest medicine 1996; 17: 249-61)

Slide 27 :

In 3 studies (medical patients of van den Berghe, VISEP and glucontrol), the risk of hypoglycaemia was significant increased, and hypoglycaemia was an independent risk factor for mortality.

Slide 28 :

Intensive insulin therapyPercentage hypoglycaemia Hypoglycaemia (%)

Slide 29 :

None of these studies followed up the patients with hypoglycaemia for neurocognitive impairment

Slide 30 :

The target glucose level of < 150 mg/dl recommended in the guidelines is based solely on expert opinion However, in septic patients, low and high glucose concentrations can result in a higher mortality.

Slide 31 :

J-curve J-curve of mortality in relation to the target glucose concentration.

Slide 32 :

Therefore The beneficial effect, the harmlessness, and the target glucose level of intensive insulin therapy remains to be demonstrated in septic patients.

Slide 33 :

In conclusion A strong recommendation in favour of the use of SDD should have been implemented The strong recommendation to use stress ulcer prophylaxis should be a strong recommendation not to use it. The strong recommendation to reduce blood glucose levels in septic patients should be at most a weak recommendation.

	aspoelstra@tergooiziekenhuizen.nl 1 Years ago. Category: Internal Medicine

Tags:	Internal Medicine

Embed:
4272 Views, 1 favourite
PowerPoint Presentation on Surviving Sepsis Campaign: International guidelines for management of se more PowerPoint Presentation on Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 or PowerPoint Presentation on less

SWINE Flu

Why do women live longer then men? Humor

History of Medicine

Yoga and Medicine

How to be a Successful Interventional Fellow size 50 MB

Cardiac Pathology

Hypertension: New Concepts, Guidelines, and Clinical Management

Diabetes Pathology

Medical Powerpoint Templates
(20% Dicsount For Student/Faculty)