Toward achieving reliable sepsis care
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Transcript of Toward achieving reliable sepsis care
Toward achieving reliable sepsis care
Dr Ron Daniels FFICM FRCA FRCPEdChair, UK Sepsis Trust
CEO, Global Sepsis Alliance@SepsisUK
Breast cancer
Breast cancer
Bowel cancer Breast cancer
Bowel cancer Breast cancer
Annual UK sepsis deaths
What is sepsis?
Sepsis, Septic Shock,SIRS (systemic inflammatory response
syndrome),SSI (signs and symptoms of infection),Septicaemia, Bacteraemia, Toxic Shock Syndrome, Bloodstream infection etc, etc….
What is sepsis?
Infection– Inflammatory response
to microorganisms, or– Invasion of normally
sterile tissues Systemic Inflammatory
Response Syndrome (SIRS)– Systemic response to a
variety of processes Sepsis
– Infection plus– 2 SIRS criteria
Severe Sepsis– Sepsis– Organ dysfunction
Septic shock– Sepsis– Hypotension despite fluid
resuscitation
Bone RC et al. Chest. 1992;101:1644-55.
ACCP/SCCM defs
Burns
Trauma
Other
Infection SIRS Virus
Fungi
Parasite
Pancreatitis
Bacteria
Sepsis
SEVERE
SEPSIS
Burns
Are any 2 of the following SIRS criteria present and new to your patient?
Obs: Temperature >38.3 or <36 0C Respiratory rate >20 min-1
Heart rate >90 bpm Acutely altered mental state
Bloods: White cells <4x109/l or >12x109/l Glucose>7.7mmol/l (if patient is not diabetic)
If yes, patient has SIRS
Screening tool
Is this likely to be due to an infection?For example
Cough/ sputum/ chest pain Dysuria
Abdo pain/ diarrhoea/ distension Headache with neck stiffness
Line infection Cellulitis/wound infection/septic arthritis
Endocarditis
If yes, patient has SEPSIS
Start SEPSIS SIX
What is shock?
Tissue perfusion is not adequate for the tissues’ metabolic requirements
Septic Shock
Shock secondary to systemic
inflammatory response to a new
infection
Types of ShockCardiogenic Neurogenic
Hypovolaemic
Anaphylactic and…
What is shock?
Tissue perfusion is not adequate for the tissues’ metabolic requirements
For sepsis, shock is one of:
SBP < 90 mmHgMBP < 65 mmHg after IV fluidsDrop of < 40 mmHg
Lactate > 4 mmol/l
What is shock?
Severe Sepsis: Ensure Outreach and Senior Doctor attend NOW!
BP Syst < 90 / Mean < 65(after initial fluid challenge)
Lactate > 2 mmol/l
Urine output < 0.5 ml/kg/hr for 2 hrs
Clotting INR > 1.5 or aPTT > 60 s
Bilirubin > 34 μmol/l
O2 Nec. to keep SpO2 > 90%
Platelets < 100 x 109/l
Creatinine > 177 μmol/l
UO < 0.5 ml/kg/hr
• Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs.
• Sepsis leads to shock, multiple organ failure and death especially if not recognized early and treated promptly.
• Sepsis remains the primary cause of death from infection despite advances in modern medicine, including vaccines, antibiotics and acute care.
• Millions of people die of sepsis every year worldwide
Merinoff definition
Why do we need to change??
Serum lactate measured
Blood cultures obtained prior to antibiotic administration
From the time of presentation, broad-spectrum antibiotics to be given within 1 hour
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 mean arterial 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%
SSC Bundle 2008
To be completed within 3?? hours:1) Measure lactate level2) Obtain blood cultures prior to administration of antibiotics3) Administer broad spectrum antibiotics4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
To be completed within 6 hours:5) Apply vasopressors for hypotension that does not respond to initial fluid
resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg)6) In the event of persistent arterial hypotension despite volume resuscitation
(septic shock) or initial lactate 4 mmol/L (36 mg/dL):- Measure central venous pressure (CVP)*- Measure central venous oxygen saturation (ScvO2)*
7) Remeasure lactate if initial lactate was elevated*
SSC Bundle 2012
Severe Sepsis Acute coronary syndrome
No. cases per 100,000 per annum
337 200
NNT ‘basic’ care Sepsis Six (our data) 6 First hour antibiotics 5
Clopidogrel 48 β-blockade 42 Aspirin 26
NNT invasive care EGDT (Rivers) 6
Resusc Bundle (SSC) 18
Thrombolysis 15
PCI over thrombolysis 33
Perspective
Perspective
Available at sepsistrust.org
The Sepsis Six
The Sepsis Six
1. Give high-flow oxygen via non-rebreathe bag
2. Take blood cultures and consider source control
3. Give IV antibiotics according to local protocol
4. Start IV fluid resuscitation Hartmann’s or equivalent
5. Check lactate
6. Monitor hourly urine output consider catheterisation
within one hour..plus Critical Care support to complete EGDT
Aim to give 100% initially
In practice you can’t!NRB with reservoir: 60-98%
Needs regular review
After initial resusc target SpO2 > 94%
Septic patients exempt from BTS guidelines
May still be appropriate in COPD!!Monitor carefully
Step 1: Oxygen
Before starting antibiotics, at least one blood culture:
PercutaneouslyAND at least one from each vascular access device (if > 48 hrs)
Other cultures
urine, CSF, wounds, sputum, other fluids
Consider NOW diagnostic support such as imaging
1. Weinstein, MP Rev Infect Dis 1983; 5: 35 – 532. Blot F. J Clinical Microbiol 1999; 36; 105 -109
Step 2: Cultures
Reassess antimicrobial regimen daily to optimise efficacy, prevent resistance, avoid toxicity & minimise costs. (1C)
Do we practice de-escalation?As few as 23% of opportunities
Step 2: Cultures
Alvarez-Lerma F, Alvarez B, Ruiz F et al for the ADANN Study Group. Crit Care 2006; 10: R 78
Start therapy as soon as possible and certainly in the first hour...
...preferably after taking blood cultures!!
Choice should include one or more with activity against likely pathogen
Penetration of presumed sourceGuided by local pathogensGive broad spectrum until defined
Step 3: Antibiotics
Early, appropriate antibiotics are the key to improved
outcomes
First hour antibiotics in 27%...
Kumar et al. CCM. 2006:34:1589-96.
time from hypotension onset (hrs)
0-0.50.5-1
1-2 2-3 3-4 4-5 5-6 6-9 9-1212-24
24-3636+
frac
tion
of to
tal p
atien
ts
0.0
0.2
0.4
0.6
0.8
1.0 survival fraction
cumulative antibiotic initiation
Effective Antimicrobial Therapy &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 sites n = 2,154 median 6 h, 50% administered in 6h Only 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 abx are good.
0 10 20 30 40 50 60 70 80 90100
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Cumulative fraction of total survivors
Running average survival
Survival in septic shock based on antibiotic delay (n=4195)
Funk and Kumar
Critical Care Clinics 2012
Retrospective, 22 hospitals, n= 4532
Bagshaw SM et al Intensive Care Med. 2009;35(5):871-81
Retrospective, 22 hospitals, n= 4532
Bagshaw SM et al Intensive Care Med. 2009;35(5):871-81
64.4% septic shock patients developed early AKI
Retrospective, 22 hospitals, n= 4532
Bagshaw SM et al Intensive Care Med. 2009;35(5):871-81
64.4% septic shock patients developed early AKI
Median time shock to antibiotic = 5.5 h
Retrospective, 22 hospitals, n= 4532
Bagshaw SM et al Intensive Care Med. 2009;35(5):871-81
64.4% septic shock patients developed early AKI
Median time shock to antibiotic = 5.5 h
OR for AKI1.14 (1.10-1.20) P < 0.001
per hour’s delay
Why?
To reduce organ dysfunction and multi-organ failure
By optimising tissue oxygen delivery
By increasing organ perfusion
Step 4: Fluids
DO2 = Oxygen delivery to the tissue
CaO2 = Amount of O2 in arterial blood
Fluid therapy improves cardiac output by increasing venous return to the heart
CaO2 = ([Hb] x SaO2 x 1.34) + (PaO2 x 0.0225)
DO2 = CaO2 x CO
Step 4: Fluids
DO2 = Oxygen delivery to the tissue
CaO2 = Amount of O2 in arterial blood
Fluid therapy improves cardiac output by increasing venous return to the heart
CaO2 = ([Hb] x SaO2
DO2 = CaO2 x CO
Optimizing DO2
Judicious fluid challengesUp to 30ml/kg in divided boluses (min. 20ml/kg in shock)
Crystalloid (500ml boluses)Colloid (250-300ml boluses)
Reassess for effect after each challengeHR, BP, capillary refill, urine output, RR
In patients with cardiac diseaseUse smaller volumesMore frequent assessmentEarly CVC
Fluid resuscitation
High lactate identifies tissue hypoperfusion in patients at risk who are not hypotensive
‘Cryptic shock’
Gives an overview of current tissue oxygen delivery
The GoalLactate to improve
as resuscitation progresses
Step 5: Lactate
0
5
10
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20
25
30
35
40
% i
n h
osp
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Mo
rtal
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Lactate threshold
Low (0 - 2.0)
Intermediate ( 2.1 - 3.9)
Severe (>4.0)
Trzeciak, S et al , Acad Emerg Med; 13, 1150-1151. n-=1613
Risk stratification
Accurate hourly urine output monitoring
(for many, this will mean catheterisation)
The Goal> 0.5 ml/kg/hr
> 40 ml/hour in the average adult
Step 6: Urine output
In health, kidneys autoregulate, so UO is independent of BP over a wide range
In sepsis, this is lost and UO will fall as BP falls
However RBF is directly proportional to cardiac output
Renal blood flow
2 groups with 2 sets of needs
1. Get patients with community-acquired sepsis to hospital
quickly
2 groups with 2 sets of needs
2. Recognise inpatient deterioration reliably
Inpatient deterioration
Critical Care expenditure
Critical Care length of stay
Compared with ACS
Cost per episode
Sepsis
Screen!!
1c reco
mmendation 2013
Moore LJ, Jones SL, Kreiner LA, et al: Validation of a screening tool for the early identification of sepsis. J Trauma 2009; 66: 1539–1546
2 groups with 1 identical need
3. Respond and escalate appropriately
Sepsis Six delivery
39904 39965 40026 400870
10
20
30
40
50
60
70
Sepsis 6
Resusc
Both
Mortality
Compliance,GHH (%)
Mortality
Cohort size (%)
Mortality % RRR %(‘NNT’)
Total 567 (100) 34.7 -
Sepsis Six 347 (61.2) 44.0
Sepsis Six 220 (38.8) 20.0 46.6(4.16)
What does ‘doing sepsis right’ look like?
For each year, for every 100k in the local population..
20 lives saved285 fewer bed days168 fewer CC bed days
Direct costs for survivors reduced by £0.25M
For UK, that’s 12,500 lives and £156 million. Every year.
[email protected] @SepsisUK
www.sepsistrust.orgwww.world-sepsis-day.org