La gestione della paziente settica: Diagnosi & Monitoraggio.

Transcript

1 La gestione della paziente settica: Diagnosi & Monitoraggio

2 ENTITA DEL FENOMENO Ospedalizzazione per Sepsi e IM Circa casi/anno

3 Causes of maternal death

4 Causes of maternal death

5 PROBLEM EXTENT

6 ICU ( ) severe sepsis/septic shock MORTALITY (f) BUNDLES WHY BUNDLES? Girardis et al. Cri Care 2009

7 GENERALI: Temperatura: > 38 C o < 36 C INCIDENZA Infezione MORTALITA Frequenza Cardiaca: > 90 bpm o > 2 DS valore normale età Tachipnea Iperglicemia in assenza diabete Edema significativo o bilancio fluidico positivo (>20 ml/kg 24 ore) SIRS VARIABILI INFIAMMATORIE: Proteina C-Reattiva > 2 DS Procalcitonina > 2 DS Sepsi ALTRE SvO2 > 70% (?) Indice Cardiaco > 3.5 L/min*m2 Sepsi severa Evoluzione clinica LEUCOCITI > /µl o < 4.000/µl o >10% forme immature Sepsi 7-13% Sepsi severa 28-50% Shock Settico 45-80% Shock settico 7

8 DEFINITIONS Why SIRS concept should be not necessarily indicate a dysregulated, life-threatening criteria are present in many hospitalized patients, including those who never develop infection and never incur adverse in 8 (14%) patients admitted to ICU with infection and new organ failure did not have the requisite minimum of 2 SIRS criteria to fulfill the definition of sepsis VERY LOW predictive positive value LOW predictive negative value

9 2015 DEFINITIONS NEW is defined as life-threatening organ dysfunction caused by a dysregulated host response to dysfunction can be identified as an acute change in total SOFA score 2 points consequent to the shock clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP 65mmHg and having a serum lactate level >2 mmol/l (18mg/dL) despite adequate volume In lay terms, sepsis is a life-threatening condition that arises when the body s response to an infection injures its own tissues and organs.

10 SIRS Infection Organ Dysfunction Infection Sepsis Organ Dysfunction Severe Sepsis Vasoactive drugs Septic Shock Sepsis Vasoactive drugs [La]b 2mM Septic Shock

11 organ dysfunction may be occult; therefore, its presence should be considered in any patient presenting with infection. Conversely, unrecognized infection may be the cause of newonset organ dysfunction. Any unexplained organ dysfunction should thus raise the possibility of underlying The clinical and biological phenotype of sepsis can be modified by preexisting acute illness, long-standing comorbidities, medication, and interventions.

12 Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside with qsofa ( 2) 1. alteration in mental status, 2. systolic blood pressure 100mmHg, 3. respiratory rate Organ dysfunction can be identified as an acute change in total SOFA score 2 points consequent to the infection.

13 IDENTIFICATION

14 IDENTIFICATION

15 2015 DEFINITIONS Implications of the New Definitions for Screening and Management For hospitals who have prepared for the transition, screening for early identification and treatment of patients with sepsis (formerly called severe sepsis) should continue essentially as has been previously recommended by SSC. Step 1: Screening and Management of Infection The appropriate first step in screening should be identification of infection. Hospitals should continue to use signs and symptoms of infection to promote the early identification of patients with suspected or confirmed infection Step 2: Screening for Organ Dysfunction and Management of Sepsis (formerly called Severe Sepsis) Patients with sepsis (formerly called severe sepsis) should still be identified by the same organ dysfunction criteria (including lactate level greater than 2 mmol/l). Organ dysfunction may also be identified in the future using the quick Sepsis-Related Organ Failure Assessment (qsofa) Importantly, evidence of two out of three qsofa elements in patients who have screened positive for infection may be used as a secondary screen to identify patients at risk for clinical deterioration.

16 EARLY IDENTIFICATION OUTPATIENT SETTING BAS Systolic BP < 90 mmhg RR >30 b/min SpO2< 90 %

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19 WHICH SEPSIS BIOMARKER? (1,2,3,4,5,6,n,n+1,n+2 ) 178 biomarkers evaluated in 3,370 studies linked to Cytokines and Cellular Receptors Coagulation Biomarkers linked to injury of endothelial Biomarkers linked to Biomarkers linked to organ Acute phase response And many others. -

20 DIAGNOSIS of Infection Yes/No PCT -

21 DIAGNOSIS of Infection Yes/No PCT -

22 DIAGNOSIS Type of infection PCT and Surgery PCR PCT + SIRS -

23 ANTIBIOTIC STEWARDSHIP -

24 TAKE HOME CALL ASAP SEPSIS/OUTREACH TEAM & ID SPECIALIST

25 PROBLEM EXTENT Arise Impress Promise?

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27 DEFINITIONS

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31 DEFINITIONS

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36 THINK SEPSIS Lessons from the Confidential Enquiries

37 Think Sepsis

38 2/05 5:30 Vignette: sepsis M. aveva appena partorito un maschietto con un parto vaginale senza problemi. Due ore dopo il parto cominciò a sentirsi male nel puerperio. Diceva che si sentiva svenire. La sua saturazione era 65% e la pressione sistolica appena percepibile (68/ ) ed era molto tachicardica (150).? 65? 150 Venne subito rivisitata dal giovane medico di turno che riscontrò un moderato sanguinamento vaginale. Venne posta diagnosi di emorragia critica e iniziarono l infusione di fluidi. La sua pressione però non migliorava, allora venne portata in sala operatoria per una isterectomia in emergenza, ma lì si verificò un arresto cardiaco. Ogni tentativo di rianimazione fallì. 68 x

39 Il riscontro autoptico evidenziò un esteso arrossamento cutaneo, un edema dei genitali esterni e una coagulazione intravasale disseminata, tutti risultato di una sepsi da Streptococco di Gruppo A. Allerta il TEAM SEPSI 5067

40 Influenza

41 Universal lessons

42 Summary

43 Grazie per l attenzione!