Sepsis-en oppdatering
og bakgrunn for tiltakspakken!
Pasientsikkerhetsprogrammet
8 mars 2017
Hans Flaatten
KSK/Intensiv Bergen
Hvorfor?
Sepsis: et komplisert forløp
Initial håndtering
• Diagnostikk
• Start behandling: Respirasjons og sirkulasjonssvikt
Kildekontroll
• Antibiotika
• Fjerne fokus
Intensivbehandling
• Organsvikt
Rehabilitering
Tidligere definisjoner
Sitert i 7427 andre artikler!
Chest 1992
MODS & SIRS
SIRS kriteriene
?
Dårlig presisjon
N Engl J Med 2015;372:1629-38
JAMA 23 februar 2016
Prosess
• Arbeidsgruppe etablert av ESICM og SCCM (17 personer)
• Etter ferdig arbeide har forslaget vært på “høring” i en rekke
foreninger som har gitt støtte til definisjonene:
• Academy of Medical Royal Colleges (UK); American Association of Critical Care Nurses; American Thoracic
Society (endorsed August 25, 2015); Australian–New Zealand Intensive Care Society (ANZICS); Asia Pacific
Association of Critical Care Medicine; Brasilian Society of Critical Care; Central American and Caribbean
Intensive Therapy Consortium; Chinese Society of Critical Care Medicine; Chinese Society of Critical Care
Medicine–China Medical Association; Critical Care Society of South Africa; Emirates Intensive Care Society;
European Respiratory Society; European Resuscitation Council; European Society of Clinical Microbiology
and Infectious Diseases and its Study Group of Bloodstream Infections and Sepsis; European Society of
Emergency Medicine; European Society of Intensive Care Medicine; European Society of Paediatric and
Neonatal Intensive Care; German Sepsis Society; Indian Society of Critical Care Medicine; International Pan
Arabian Critical Care Medicine Society; Japanese Association for Acute Medicine; Japanese Society of
Intensive Care Medicine; Pan American/Pan Iberian Congress of Intensive Care; Red Intensiva (Sociedad
Chilena de Medicina Crítica y Urgencias); Sociedad Peruana de Medicina Critica; Shock Society; Sociedad
Argentina de Terapia Intensiva; Society of Critical Care Medicine; Surgical Infection Society; World Federation
of Pediatric Intensive and Critical Care Societies; World Federation of Critical Care Nurses; World Federation
of Societies of Intensive and Critical Care Medicine.
Hvordan skal vi forstå sepsis?
• Sepsis is defined as life-threatening organ dysfunction
caused by a dysregulated host response to infection.
• Sepsis is a syndrome shaped by pathogen factors and host
factors (eg, sex, race and other genetic determinants, age,
comorbidities, environment) with characteristics that
evolve over time.
• What differentiates sepsis from infection is an aberrant or
dysregulated host response and the presence of organ
dysfunction.
Organdysfunksjon ved sepsis
• Sepsis-induced 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 new-onset organ dysfunction. Any unexplained
organ dysfunction should thus raise the possibility of
underlying infection.
Den nye terminologien
Sepsis
Septisk
sjokk
Infeksjon
Sepsis inkluderer nå varierende grader av organdysfunksjon, og alvorlig sepsis forsvinner derfor som begrep
Kliniske kriterier: Sepsis hos kritiske syke
• Bruk av SOFA skår
• Organ dysfunction can be identified as an acute change in total SOFA
score ≥ 2 points consequent to the infection.
• A SOFA score = 2 reflects an overall mortality risk of approximately
10% in a general hospital population with suspected infection
Kliniske kriterier: pasienter med akutte
infeksjoner
• qSOFA (quick SOFA)
• 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, ie,
• alteration in mental status
• systolic blood pressure ≤ 100 mm Hg,
• or respiratory rate ≥ 22/min.
Kliniske kriterier: Septisk sjokk
• Septic shock is a subset of sepsis in which underlying circulatory and
cellular/metabolic abnormalities are profound enough to
substantially increase mortality.
• Patients with septic shock can be identified with a clinical construct of
sepsis with
• persisting hypotension requiring vasopressors to maintain MAP 65 mm Hg
AND
• having a serum lactate level >2 mmol/L (18 mg/dL) despite adequate volume
resuscitation.
• With these criteria, hospital mortality is in excess of 40%.
Pasientsikkerhetsprogrammet 2017
Tiltakene
ABCDE
• Sikre vitale funksjoner:
• Respirasjon
• Sirkulasjon
• Bevissthet
Mål: MAP ≥ 65 mmHg
Tiltakene
SOFA skår
Grad
Sirkulasjon*
Respirasjon#
Nyrefunksjon
CNS
Koagulasjon
Lever
PaO2/FiO2
ratio (kPa)
>53
39,9-53
Kreatinin/DU
μmol/l & ml
<110
110-170
GCS
0
1
MAP og bruk
av vasopressor
MAP ≥ 70
MAP < 70
15
13-14
TPK
x 103/μl
> 150
< 150
Bilirubin
μmol/l
<20
20-32
DA ≤ 5;
Dobutamin
DA > 5;
NA/A ≤ 0,1
NA/A > 0,1
26,6 – 39,8
171-299
10-12
< 100
33-101
13,3 – 26,5
300-440
< 500 ml/24t
>440
< 200 ml/24t
6-9
< 50
102-204
<6
< 20
>204
2
3
4
< 13,3
*alle doser gitt i µg/kg/min, DA= Dopamin, NA=Noradrenalin, A=Adrenalin
# 3 eller 4 poeng bare for pasienter på respirator (NIV+IPPV)
Tiltakene
JAMA. 2017;317(3):301-308.
From: Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected
Infection Presenting to the Emergency Department
JAMA. 2017;317(3):301-308. doi:10.1001/jama.2016.20329
Figure Legend:
Flow Diagram of Study to Validate qSOFA ScoringqSOFA indicates quick Sequential Organ Failure Assessment.
Date of download: 2/2/2017
Copyright © 2017 American Medical
Association. All rights reserved.
From: Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected
Infection Presenting to the Emergency Department
JAMA. 2017;317(3):301-308. doi:10.1001/jama.2016.20329
Figure Legend:
Receiver Operating Characteristic Curves for In-Hospital MortalityqSOFA indicates quick Sequential Organ Failure Assessment;
SIRS, systemic inflammatory response syndrome; and SOFA, Sequential [Sepsis-related] Organ Failure Assessment. The area
under the receiver operating characteristic curves for qSOFA is 0.80 (95% CI, 0.74-0.85); SOFA, 0.77 (95% CI, 0.71-0.82); SIRS,
0.65 (95% CI, 0.59-0.70); and severe sepsis, 0.65 (95% CI, 0.59-0.70).
Date of download: 2/2/2017
Copyright © 2017 American Medical
Association. All rights reserved.
In conclusion, qSOFA scores
were associated with
inhospital mortality, hospital
admission, ICU admission,
and hospital length of stay in
adult ED patients likely to be
admitted both with and
without suspected infection.
qSOFA is an easy tool that
can be used in the ED to
predict outcomes. Further
prospective validation of the
qSOFA is required before
widespread use.
ICD-10 koder for sepsis, endringer 2017
Endringsdokument for norsk utgave av ICD-10 2016-2017
Direktoratet for e-helse 27.09.2016
Forslag
• I tillegg tilandre sepsiskoder (eks A40 og A41) og infeksjonskoder
foreslår vi at det også brukes koden:
• R65.1 ved sepsis (ny definisjon) hvor det foreligger dokumentasjon av
organsvikt, eks ved SOFA skår økning ≥ 2 poeng
• R57.2 ved septisk sjokk (ny definisjon)
• Da vil en lettere både på egen institusjon samt fra NPR enkelt kunne
hente ut informasjon om omfanget av sepsis ved norske sykehus!
According to family
spokesman Bob
Gunnell, was "septic
shock due to
unspecified natural
causes."