Sepsis- an update
Dr Judith Joss MRCP, FRCA, DICM, FICM
Consultant in Anaesthesia and Intensive Care Medicine
Ninewells Hospital and Medical School, Dundee
Maternal Critical Care Symposium 2016
‘SEPSIS 3’
The Third International
Consensus Definitions for Sepsis
and Septic Shock
SCCM, ESICM taskforce
JAMA. 2016;315(8):801-810
Areas to cover
Changes in Sepsis definitions
• Old vs New
• Why?, How?
• The Implications for clinicians and healthcare systems
Brief review of the treatments
• The Surviving Sepsis Campaign guidelines and bundles
Sepsis in the Obstetric patient
• The unique challenges
• Local initiatives and successes (and a small bit about PCT)
Have we ever known what sepsis is?
“Advances in the treatment of fever … have not
kept pace with the rapid progress in our
knowledge of the etiology. In the present
condition of bacteriology we may expect great
things in the near future, but meanwhile we
jog along without any fixed aim, too often
carried away by winds of doctrines and wild
theories”.
William Osler, The study of the Fevers of the
South. JAMA 21, 999–1004 (1896)
Back in the days when we thought
knew what ‘sepsis’ was
• SCCP/SCCM consensus definitions 1991, 2001
Sepsis
SIRS +
infection
Severe
Sepsis
Sepsis +
acute organ
dysfunction
SIRS
Temp> 38 °C or < 36°C, HR>90, RR>20/min,
PaCO2 < 4.2kPa, WCC>12 or <4
Non-specific clinical response
Septic
Shock
Severe sepsis +
hypotension
Did we need a new definition?
SIRS
• Overly non specific
• 4:5 patients with
SIRS dont have
infection
• 1:8 with infection
causing organ
dysfunction dont
have SIRS
• Greater understanding
of science of infection,
New
knowledge
cell biology and organ
dysfunction
Research
• We had a research
problem!! With good
evidence of
inconsistencies in
terminology
How were the new definitions
derived?
Literature review,
SCCM and ESICM
convened a panel of 19
experts (2014)
Analysis of huge electronic
databases
Delphi process
Peer review
Endorsement by international
societies
SEPSIS 3
SEPSIS - 3
• The new definition of sepsis is:
‘Infection with an“Life threatening organ
dysfunction
caused by a
increase of two or
more
dysregulated host
SOFA points’
response to infection”
SEPSIS - 3
• The new definition of septic shock is:
“A subset of sepsis with
“Infection particularly
with hypotension
profound
requiring vasopressors
circulatory, cellular
to
and
maintain MAP
metabolic
>65mmHg
abnormalities
PLUS a Lactate
associated
of >2mmol/l”
with an increased
mortality than sepsis alone”
SOFA SCORE
Quick SOFA
Patients with suspected infection that are likely to have a prolonged ICU stay or to die in the
hospital can be promptly identified at bedside with qSOFA The qSOFA score is less robust than a
SOFA score of 2 or greater, but it does not require laboratory tests and can be assessed quickly
and repeatedly.
Comparison of terminology
SEPSIS 2
SEPSIS 3
SIRS
?
SEPSIS
SIRS plus Infection
?
SEVERE SEPSIS
SEPSIS
SEPSIS Plus Organ Dysfunction
Infection + SOFA increase 2
SEPTIC SHOCK
SEPTIC SHOCK
Vasopressor + Lactate >2
How does this work clinically?
all patients with
suspected
INFECTION
These patients are sick
They must be identified
and treatment started
SEPSIS
SOFA >2 or qSOFA≥2
(10% Mortality)
SEPTIC SHOCK
These patients are
very sick
require increased
frequency of review
And may require an
increased level of care
(40% mortality)
These patients are on
vasopressors and should
be in a critical care area
May 2016 Scottish Patient Safety Programme
consensus definition of sepsis.
Recommendations
The National Early Warning Score will continue to be the recommended method of
identifying deteriorating patients, including those with sepsis.
Early Warning Scoring System trigger points for sepsis screening and management will
continue to be locally defined. Screening for sepsis should be undertaken with the question
– ‘could this deterioration be due to infection’.
Systemic Inflammatory Response (SIRS) criteria will continue to aid in the general diagnosis
of infection.
The qSOFA criteria may be used as an adjunct to identify patients at increased risk of death
and support decisions about treatment escalation.
All monitoring and screening tools should be viewed as an adjunct to clinical judgement.
Further studies on qSOFA will inform decisions about their potential use as a screening tool
for sepsis.
SSC statement in response
to SEPSIS 3
Step 1: Screening and Management of Infection
Hospitals should continue to use signs and symptoms of infection to promote the early identification of
patients with suspected or confirmed infection.
management should begin by obtaining blood and other cultures
administering tailored antibiotics as appropriate, and simultaneously obtaining laboratory results to
Evaluate the patient for infection-related organ dysfunction.
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)
Practitioners should strongly consider closer monitoring of these at-risk patients.
If organ dysfunction is identified, ensuring that the three-hour bundle elements have been initiated continues
to be a priority.
Step 3: Identification and Management of Initial Hypotension
In those patients who have infection and hypotension or a lactate level greater than or equal to 4 mmol/L, providing 30
mL/kg crystalloid with reassessment of volume responsiveness or tissue perfusion should be implemented. The six-hour
elements of care should be completed. For the six-hour bundle, repeat lactate level is also recommended if initial lactate
level was greater than 2 mmol/L.
Note that:
qSOFA does not define sepsis (but the presence of two qSOFA criteria is a predictor of both increased mortality and ICU
stays of more than three days in non-ICU patients)
Prepare for Change
Hospitals should develop detailed plans
and educate their physician and nursing staff
hospitals should also create detailed plans and educate quality department staff to abstract charts and translate the new
nomenclature into language compatible with the national quality measure, which typically uses the older terminology.
Conclusion
Once hospitals have adequately prepared for change, sepsis team leaders should reinforce the message that the new definitions
Do not change the primary focus of early sepsis identification and initiation of timely treatment in the management of this
Vulnerable patient population
SSC Guidelines (2012)
3 Hour Target
6 Hour Target
• Lactate
• Blood Cultures
• Antibiotics
• 30ml/kg crystalloid
• If ↓BP or lactate>4
• Vasopressors for ↓BP
• MAP>65mmHg
• CVP &Scv02
Key
Supportive
Recommendations Treatments
• FLUIDS
• VASOPRESSORS
• INOTROPES
• STEROIDS
• (APC)
• ANTIBIOTICS
• PCT
• Blood
• Immunoglobulin
• Selenium
• Mechanical ventilation
• Glucose
• Sedation
• RRT
• Bicarbonate
• DVT and stress ulcer
• Nutrition
• Goal setting
CMACE EMERGENT THEME BRIEFING
#1: Genital Tract Sepsis
September 2010
SAVING MOTHERS’ LIVES 2006-08: Briefing on genital tract sepsis
During the 2006 – 2008 triennium, sepsis was the leading cause of direct
maternal deaths, accounting for 26 direct deaths and a further 3 deaths
classified as ‘Late Direct’
Whilst maternal mortality is declining overall, maternal deaths due to sepsis
have risen in recent triennia, particularly those associated with Group A
streptococcal infection (GAS)
2000-2002
2003-2005
2006-2008
Rate per 100000
maternities
0.65
0.85
1.13
Numbers (all
organisms)
13
21
29
Numbers (GAS)
3
8
13
Maternal Deaths – definitions
DIRECT
INDIRECT
•As a consequence of a disorder specific to pregnancy
(Haemorrhage, Pre eclampsia, Genital tract Sepsis)
•Deaths not directly associated with pregnancy state but may be
exacerbated by pregnancy (cardiac disease, psychiatric disease,
sepsis (pneumonia, flu etc)
COINCIDENTAL
•Incidental or accidental deaths not related to pregnancy
LATE
•Deaths occurring after 42days but before 1yr following
pregnancy
Sepsis in the Obstetric Patient
All trials
exclude
pregnancy
Is Sepsis more
challenging in the
obstetric patient?
Complex
Antenatal
decision
making
Pregnancy and
labour may make
detection more
difficult
Lack of validation of
early warning scores
National Maternity Modified SIRS
Criteria
Any 2 or more:
• - Temp < 36 or > 38 oC
• - HR > 100 bpm
• - WCC <4 or > 16 x 109/L
• - RR > 20 bpm
• - Altered mental state
Tayside
Sepsis 6: Overall Compliance
100
1 fail due to poor iv
access
60
40
highlighted to
staff
Compliance on
improvement
boards.
Midwives
trained in
obtaining blood
cultures.
Feedback to
individual staff
Failure to initiate
bundle on Datix
Positive
compliance
Continual audit
and feedback to
staff
Compliance charts
Risk management
review of missed
20
Mar 15
Jan 15
Nov 14
Sep 14
Jul 14
May 14
Mar 14
Jan 14
Nov 13
Sep 13
Jul 13
May 13
Mar 13
0
Jan 13
Percent compliance
80
Are we ‘over treating’ infection?
Not
infected
All patients
on Sepsis 6
• ‘Over’ treatment
group
• Could we safely
stop treatment?
Infection
Sepsis
• Appropriate
Treatment
• How do we
monitor for
deterioration?
• Escalation of
treatment
• Early
identification?
The role of biomarkers
Procalcitonin
• Secreted by most cells in response to bacterial Infection
• More specific than most commonly used biomarkers
• Rises rapidly (6-12hr), correlates with severity
PCT in
Ninewells
• Introduced into clinical use 2012 (ICU/sHDU)
• Evidence of decreased antibiotic duration in ICU
PCT in
Obstetrics
• No current evidence base
• Novel preliminary work being carried out
PCT Algorithm to stop Antibiotics
Summary
INFECTION
• Is still a clinical diagnosis
• We may still screen with SIRS/EWS
SEPSIS
• Is what was previously ‘severe sepsis’
• Screen with qSOFA
SEPTIC
SHOCK
• Vasopressors + Lactate >2mmol/l
• 40% mortality
Acknowledgements
Dr Pamela Johnston
Consultant Anaesthetist
Dr Pauline Lynch
Consultant Obstetrician
Dr Katy Orr
O&G registrar,
[email protected]