striking a balance - BSACbsac.org.uk/wp-content/uploads/2012/02/Sepsis-Ron-Daniels.pdf · (To be...

www.globalsepsisalliance.org

Sepsis...striking a balance

Dr Ron DanielsFellow: NHS Improvement Faculty

Chair: United Kingdom Sepsis Group, Sepsis Trust & UK SSC

Sepsis as a Global Emergency Committee, Global Sepsis Alliance

Midland Hotel Manchester, 15th November 2011


Sepsis is under‐appreciated.

Sepsis is under‐funded.

We (us doctors) over‐complicate sepsis care.

I have less to offer septic patients once they’re in my ICU.

It is inevitable that we will get our act together.


Sepsis is under‐appreciated.

Sepsis is under‐funded.

We (us doctors) over‐complicate sepsis care.

I have less to offer septic patients once they’re in my ICU.

It is inevitable that we will get our act together.

Only question is, how many of our patients will die first?


How to achieve the balance?


Media pressuresEvent reduction targets

Over‐controlEvangelism

Informed patientsLack of availability

Withhold Give antimicrobials antimicrobials


Lazy or no stewardshipNaive patientsLazy clinicians

Sepsis evangelismSepsis/SSI etc targetsResultant public panic



Reduce injudicious use

Promote rapid response when appropriate



1. Work out why ideal sepsis care continues to elude us2. Move from “recognizing” sepsis to “suspecting” it3. Make the case for simplifying sepsis care4. Establish sepsis as a medical emergency

And not forgetting…

What we need to do


A U.K. Perspective


A U.K. Perspective

North Stand


A U.K. Perspective

Breast cancer


A U.K. Perspective


Lung1 Colon2 Breast3 Sepsis41,2,3 www.statistics.gov.uk,

4 Intensive Care National Audit Research Centre (2006)

0

20

30

40

10


Why do we need to simplify sepsis care?


Standards currently achieved for ~14% of UK

patients

39% in my hospitalHow many in yours???

Source: UK SSC data


Comparison with ACS


75% in 30 mins

Comparison with ACS80%


PerspectiveSevere Sepsis Acute coronary syndrome

No. cases per 100,000 per annum

127 200

NNT ‘basic’ careSepsis Six (our data) 6

First hour antibiotics 5

Clopidogrel 48

β‐blockade 42

Aspirin 26

NNT invasive careEGDT (Rivers) 6

Resusc Bundle (SSC) 18

Thrombolysis 15

PCI over thrombolysis 33


Stroke67,000 deaths per yearFAST CampaignNational Stroke AssociationTarget: Specialist assessment in 60 min

40% mortality reduction

Myocardial infarction/ ACS89,000 deaths per yearNational Infarct Angioplasty ProjectTarget: Call‐to‐needle 60 min

Door‐to‐needle 20 min

Sepsis37,000 (+) deaths per year...........


Are antibiotics the equivalent of PCI for sepsis?


SSC‐ antibiotics

• Begin IV antibiotics as early as possible, and always within the first hour of recognising severe sepsis (1D) and septic shock. (1B)

• Broad‐spectrum: one or more agents active against likely bacterial/ fungal pathogens and with good penetration into presumed source. (1B)

• Reassess antimicrobial regimen daily to optimise efficacy, prevent resistance, avoid toxicity & minimise costs. (1C)


Kumar et al. CCM. 2006:34:1589‐96.

time from hypotension onset (hrs)

fractio

n of to

tal patients

0.0

0.2

0.4

0.6

0.8

1.0 survival fraction

cumulative antibiotic initiation

Cumulative Initiation of Effective Antimicrobial Therapy and Survival in Septic Shock


Funk and Kumar

Critical Care Clinics 2011 (in press)

Running average survival in septic shock based on antibiotic delay (n=2154)

For each hour’s delay in administering antibiotics in septic shock, mortality increases by 7.6%


Begin IV antibiotics as early as possible, and always within the first hour of recognising severe sepsis (1D) and septic shock. (1B)

Citation: Kumar A et al. Crit Care Med 2006: 34(6)Retrospective, 15 years, 14 sitesn = 2,154median 6 h, 50% administered in 6hOnly 5% first 30 minutes‐ survival 87%12% first hour‐ survival 84%


Author n Setting Median time (mins)

Odds Ratio for death

GaieskiCrit Care Med 2010; 38:1045‐53

261 ED, USA(Shock)

119 0.30(first hour vs all times)

DanielsEmerg Med J 2010; doi:10.1136

567 Whole hospital, UK

121 0.62(first hour vs all times)

KumarCrit Care Med 2006; 34(6):1589-1596

2154 ED, Canada(Shock)

360 0.59(first hour vs second hour)

AppelboamCritical Care 2010; 14(Suppl 1): 50

375 Whole hospital, UK

240 0.74(first 3 hours vs delayed)

LevyCrit Care Med 2010; 38 (2): 1‐8

15022 Multi‐centre 0.86(first 3 hours vs delayed)

Early antibiotics are good...


Running Average Survival in Septic ShockBased on Antibiotic Delay (n=4195)

AbRx Delay (hrs)0 20 40 60 80 100

fract

ion

0.0

0.2

0.4

0.6

0.8

1.0

running average survivalcumulative fraction of total survivors

Funk and Kumar

Critical Care Clinics 2011 (in press)

Running average survival in septic shock based on antibiotic delay (n=4195)


CARS

SIRS

Organ dysfunction

Time

Infective insult

Antimicrobials

Will antibiotics prevent sepsis?


Shock threshold

Acknowledgement to Anand Kumar

Septic shock: the golden hour


Shock threshold

Acknowledgement to Anand Kumar

Antimicrobials

Septic shock: the golden hour


Adequacy of initial spectrum and timing of first delivery and achievement of MIC are

collectively the keyReduce microbial and toxic load

...so hit hard and hit fast

.... BUT....


How do we know which ‘septic’ patient is going to organ failure?

We often don’t know the source, let alone the bug....

We don’t adhere to guidelines, and the guidelines aren’t much good

We’re not very good with our timing

So...


SSC Results: Critical Care Medicine 2010; 38(2): 1‐8


Should we have, for first dose, the

‘Sepsis Antibiotic?

Pip/ taz?Meropenem?Linezolid?Forget severe sepsis??


How to simplify sepsis care..where to start?


Serum lactate measured

Blood cultures obtained prior to antibiotic administration

From the time of presentation, broad‐spectrum antibiotics to be given within 1hour

Control infective source

In the event of hypotension and/or lactate >4mmol/L (36mg/dl):

Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)

Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain meanarterial pressure (MAP) > 65 mm Hg.

In the event of persistent arterial hypotension despite volume resuscitation(septic shock) and/or initial lactate >4 mmol/l (36 mg/dl):

Achieve central venous pressure (CVP) of >8 mm Hg

Achieve central venous oxygen saturation (ScvO2) >70%

Sepsis Resuscitation Bundle (To be started immediately and completed within 6 hours)


Sepsis as a CQUIN measure


Unfortunately, only 30% will have severe sepsis in ED…

Median time to ‘worst’ obs over 2.5 hoursRange 71‐284 minutes

Nelson JL, Smith BL, Jared JD et al. Prospective trial of real‐time electronic surveillance toexpedite early care of severe sepsis. Annals of Emergency Medicine 2011; 57: 500‐4

Where to start?


Resuscitation bundle item Achieved %

Failed %

2005 Data%

Blood cultures taken 94 6 91

Antibiotics as per guidelines in <1hr 28 72 28

Lactate measured 48 52 59

Adequate fluid resuscitation 69 31 57

Know your reliability


Onset of Severe Sepsis

Seen by first doctor

Blood Culture taken

Discussed with Senior Doctor

Antibiotics given

Radiology

Seen by Senior Doctor

Seen by Critical Care Specialist

Arrive Critical Care

CVP line placed

12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00

Know your processes


0

10

20

30

40

50

60

70

Apr-09 Jun-09 Aug-09 Oct-09

Sepsis 6ResuscBoth

Compliance at Good Hope Hospital (%)


0

10

20

30

40

50

60

70

Apr-09 Jun-09 Aug-09 Oct-09

Sepsis 6ResuscBothMortality

Compliance at Good Hope Hospital (%)


Cohort size Mortality % RRR

Total 567 34.7

‘Sepsis Six’ : Oxygen therapyBlood cultureAntibiotic administrationFluid challengesLactate and haemoglobin measurementUrine output monitoring…. within one hour

Mortality by Sepsis Six


Cohort size (%)

Mortality % RRR %(NNT)

Total 567 (100) 34.7 -

Sepsis Six 220 (38.8) 20.0

Sepsis Six 347 (61.2) 44.0 46.6(4.16)

Mortality by Sepsis Six


Cohort size Mortality % RRR %(NNT)

Total 567 (100%) 34.7 -

Delayed Antibiotics

217 (38.4%) 45.4

Antibiotics within 1 h

350 (61.6%) 28.1 38.1(5.77)

Mortality by antibiotics


Cohort size Mortality % RRR %(NNT)

Total 567 (100%) 34.7 -

No fluids in 1h 183 (32.3%) 44.8

Fluids in 1h 384 (67.7%) 30.0 33.0(6.73)

Mortality by fluid challenges


2.0 fewer Critical Care bed days3.4 fewer hospital bed days

Compared with other survivors

Equates to c. £5,000 cost ‘saving’

For patients receiving the Sepsis Six


The clincher


For each year, for every 500 beds..

62 lives saved883 fewer bed days520 fewer CC bed days

Direct costs for survivors reduced by £0.78M

Achieving 80% reliability


Behind the scenes of UKSG


Response to National Outcomes Framework Consultation

Response to NHS CE Innovation callLobbying of NQBLobbying of NCDsSuccessful engagement of

• Health Foundation• QIPP• NHS Institute• Patient Safety Forum• Media!


Sepsis is a medical emergency‐ and a big killerAwareness and recognition are the key

Early antibiotics and fluids will save more lives than Critical Care

Pre‐hospital recognition may improve the reliability of basic interventions

We need to get the balance right, together

Summary


Sepsis should be afforded the same import as ACS and stroke

Increasing public and media expectations and Department of Health attention will drive higher standards

We will be the ones ultimately responsible for delivering those standards and for driving change

Reliable delivery of early basic care depends on a seamless care process from home to specialist care: just like for ACS and stroke


Declaration of interests

Within the last 24 months, I have received travel expenses and honoraria to deliver two U.K lectures from Astra Zeneca, manufacturers of the antibiotic

Meropenem. I have also received consultancy fees from CareFusion, manufacturers of the antiseptic preparation ChloraPrep

[email protected]

@sepsisukwww.uksepsis.org

www.survivesepsis.org

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