Sepsis

Dr. Max Jonas, Expert Anaesthetics Consultant introduces the challenges with sepsis as well as highlighting the role of hemodynamic monitoring within this key clinical area.

“I use the LiDCO rapid because I can use it with an existing radial arterial line, it is easy to set up and use, and it is reliable in unstable patients.”

Patients with sepsis often present with a low blood pressure. This can be difficult to manage because it is now recognised that only 50% of these patients respond when fluid is given.

It is, therefore, crucial that we not only recognise sepsis early but we also correctly monitor the patient early to optimally manage fluid and drug therapies.

Recent guidelines published by a Task Force of the ESICM and by the Surviving Sepsis Campaign highlight a need for continuous advanced haemodynamic measurements to guide fluid and drug management.

The main initial role of hemodynamic monitoring is to establish whether the patient is fluid responsive.

Either passive leg raise or stroke volume/pulse pressure variation should be used to see if the patient is fluid responsive or not. The CVP cannot determine this.

A fluid challenge guided by the response in the stroke volume should be used when fluids are given to prevent overfilling the patient.

If the patient is unresponsive to fluids with a low blood pressure then the appropriate drug can be used.

I use the LiDCO rapid because I can use it with an existing radial arterial line, it is easy to set up and use, and it is reliable in unstable patients.

Download the Sepsis infographic visualising clinical outcomes when using LiDCO hemodynamic monitoring

Sepsis | Reduced mortality with noninvasive hemodynamic monitoring of shock

Sepsis | Reduced mortality with noninvasive hemodynamic monitoring of shock

Patient Population
ICU shock patients.

LiDCO Monitor
LiDCOplus.

Trial Design
Observational study comparing no hemodynamic monitoring vs pulmonary artery vs LiDCOplus managed shock patients.

Outcome Impact
Treatment of patients using the LiDCOplus monitor significantly reduced the observed mortality rate to 13% against 32% and 20% in the invasively monitored and 37% in the unmonitored patient groups.

PURPOSE
This study compared clinical outcomes associated with exposure to pulmonary artery catheters (PACs), central venous catheters (CVCs), arterial pressure waveform analysis for cardiac output (APCO), or no central monitoring (NCM) in patients with shock.

MATERIALS AND METHODS
We assessed 6,929 consecutive patients from 2003 to 2006 within a surgical intensive care unit of a university hospital, identifying 237 mechanically ventilated patients with shock.

RESULTS
Adjusted for severity of illness, use of APCO monitoring, compared with other options, was associated with reduced intensive care unit mortality (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.18-0.77) and 28-day mortality (OR, 0.43; 95% CI, 0.22-0.85). Other monitors were not associated with changes of 28-day mortality (CVC: OR, 0.63; 95% CI, 0.34-1.17; PAC: OR, 0.78; 95% CI, 0.36-1.69) or were associated with increased risk (NCM: OR, 2.29; 95% CI, 1.14-4.61). There were significant differences in the fluid and vasoactive drug prescriptions among the groups.

CONCLUSIONS
This study supports an association between the use of APCO monitoring and reduction in mortality in shock compared with traditional methods of monitoring. Although it is impossible to exclude the role of unrecognized/unrecorded differences among the groups, these findings may result from differences in supportive care, directed by monitor technology.

Hata J, Stotts C, Shelsky C, Bayman E, Frazier A, Wang J, Nickel E. Reduced mortality with noninvasive hemodynamic monitoring of shock. J Crit Care. 2011;26(2):224.E1-8.

Treatment of patients using the LiDCOplus monitor significantly reduced the observed mortality rate to 13% against 32% and 20% in the invasively monitored and 37% in the unmonitored patient groups

Consensus on circulatory shock and hemodynamic monitoring

Consensus on circulatory shock and hemodynamic monitoring

Consensus
Circulatory shock and hemodynamic monitoring.

Purpose
The purpose of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock.

 

 

AIM
The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock.

METHODS

The European Society of Intensive Care Medicine (ESICM) formed a task force of 12 experts.

RESULTS

44 consensus statements that can be used at the bedside to diagnose, treat and monitor patients with shock.

 

Surviving Sepsis campaign | 2016

Surviving Sepsis campaign | 2016

Guidelines
Management of sepsis and septic shock.

Purpose
To provide an update to the Surviving Sepsis Campaign guidelines for Management of Sepsis and Septic Shock: 2012.

Appendices
Appendix 1. Recommendations and Best Practice Statement
Appendix 2. Comparison of Recommendations from 2012 to 2016

PURPOSE
To provide an update to the Surviving Sepsis Campaign guidelines for Management of Sepsis and Septic Shock: 2012.

METHODS

A consensus committee of 55 international experts representing 25 international organisations. The panel consisted of 5 sections: hemodynamics, infection, adjunctive therapies, metabolic and ventilation.

RESULTS

The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Of these, 32 are supported by strong recommendations, 39 with weak recommendation and 18 best-practice statements (BPS).

FLUID THERAPY F1

“We recommend that a fluid challenge technique be applied where fluid administration is continued as long as hemodynamic factors continue to improve (BPS).”

Rhodes A, Evans LE, Alhazzni W, Levy MM, et al.  Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486-552. 

“Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.”

A rational approach to fluid therapy in sepsis

A rational approach to fluid therapy in sepsis

Patient population
Severe sepsis and septic shock.

Purpose
The purpose of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock.

 

 

PURPOSE
The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock.

METHODS

The European Society of Intensive Care Medicine (ESICM) formed a task force of 12 experts.

RESULTS

44 consensus statements that can be used at the bedside to diagnose, treat and monitor patients with shock.

CONCLUSIONS

“An emerging body of basic science and clinical studies supports the concept of a hemodynamically-guided, restricted fluid resuscitation strategy in patients with severe sepsis and septic shock.”

Marik P, Bellomo R. A rational approach to fluid therapy in sepsis. Br J Anaesth. 2016;116(3):339-49. 

“These data suggest that a physiologic, haemodynamically guided conservative approach to fluid therapy in patients with sepsis would be prudent and would likely reduce the mortality and improve the outcome of this disease.”

Updated Surviving Sepsis Guidelines

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World Sepsis Day

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“Treatment of patients using the LiDCOplus monitor significantly reduced the observed mortality rate to 13% against 32% and 20% in the invasively monitored and 37% in the unmonitored patient groups.”
Hata et al. 2011

“An emerging body of basic science and clinical studies supports the concept of a haemodynamically-guided, restricted fluid resuscitation strategy in patients with severe sepsis and septic shock.”
Marik et al. 2015

The LiDCOunity monitor is a single platform which combines both the LiDCOplus and LiDCOrapid functions. This provides a single solution to monitoring needs throughout the hospital. The clinician can choose which mode is most appropriate to the clinical situation. The LiDCOunity can be used non-invasively, minimally invasively with a radial arterial line and can be calibrated with the lithium dilution technique.  Find out more

The LiDCOplus hemodynamic monitor provides a continuous, reliable and accurate assessment of the hemodynamic status of critical care and surgery patients.  The LiDCOplus is comprised of two technologies: a continuous arterial waveform analysis system (PulseCO™) coupled to a single point lithium indicator dilution calibration system.  Find out more

The LiDCOrapid monitor analyses the blood pressure waveform to provide more information in high-risk surgical and critically ill patients to help with fluid and drug management.  The LiDCOrapid uses the PulseCO™ algorithm which converts blood pressure to its constituent parts of flow (CO, SV) and resistance (SVR). The PulseCO™ algorithm is scaled to each patient with a nomogram using age, height, and weight.  Find out more