SEPSIS Recognition, Treatment and Referral Dr. Vida Hamilton
National Clinical Lead Sepsis
2014
The Burden
• International estimates • Sepsis: 300 per 100,000 per annum
• AMI:
208 per 100,000 per annum
• Mortality: 20 ‐ 55% Annual U
K sepsis d
eaths The Burden in Ireland
• HIPE data:
– 60% all in‐hospital deaths has a sepsis or infection diagnosis
– Number of sepsis cases =
8,770
– Number of bed days = 220,288
2013
– In‐hospital mortality
2012
2011
28.8% 31.3% 32.4%
Reality of Sepsis
2013
Without
With
ALOS Sepsis
5.59
26
ALOS Infection
5.59
10
ALOS Maternity
2.61
5.47
ALOS Paediatrics
3.08
22.19
Age standardised hospital discharge rate for medical septic shock, 2005 ‐ 2012
Age standardised hospital discharge rate for surgical
septic shock, 2005 ‐ 2012
Costs
• Sepsis consumes 30% of the UK critical care budget
• £20,000 per patient
• £2.5 billion annually
• Chronic health burden for survivors
Cognitive impairment
Iwashyna et al: Long‐term cognitive impairment & functional disability among survivors of severe sepsis. JAMA, 2010.
Issues
• 90% of cases with poor outcome in the Australian sepsis database, inadequate recognition was found to be the most common feature
An Irish Report • The categorisation of the severity of a patients illness
• The early detection of that deterioration
• The use of a standardised and structured communication tool such as ISBAR
• Early medical review that is prompted by evidence based trigger points
• A definite escalation plan that is monitored and audited on a regular basis
National Sepsis Guidelines
• Aim for mortality 20 – 30%
• Care pathway for every patient diagnosed with sepsis in Ireland
• Recognition, Resuscitation, Referral
• Education, audit
Diagnostic criteria for sepsis
SIRS
Sepsis
Severe Sepsis
•Infectious & non infectious causes
•Clinical response arising from a non specific insult
•SIRS plus
•Presumed or confirmed infection
•Sepsis plus
•Sepsis‐induced organ dysfunction or tissue hypoperfusion
Septic Shock
•Sepsis‐induced hypo‐perfusion or hypotension persisting despite 30 mls/kg fluid rescusitation
SIRS Criteria
• T > 38.3, < 36
• HR > 90
• RR > 16
• WCC > 12, < 4
• BSL > 7.7 mmol/l in non‐diabetic
• Altered mental status
SIRS criteria continued
• Other inflammatory parameters eg CRP, PCT
• Organ dysfunction parameters
– Hypoxia, Oliguria, Creatinine, Coag, Platelet, Bilirubin, Ileus
• Tissue perfusion parameters
– Mottling, capillary refill, lactate
• Haemodynamic variables
– BP <90, MAP < 70, SBP  > 40mmHg from baseline
Common sources of sepsis
• Respiratory
38%
• Urinary tract
21%
• Intra‐abdominal
16.5%
• CRBSI
2.3%
• Device
1.3%
• CNS
0.8%
• Others
11.3%
Sepsis screening
• Early recognition
• 2% of all ED referrals are due to sepsis • NSW audit of NEWS: sepsis is the cause of 30% of triggered reviews
• UK: NEWS > 5; 52% sepsis
ED vs In‐patient
ED
Ward
• Hospital acquired
• Community acquired
• Co‐morbidities
• Less co‐morbidities
• Second – Hit
• Generalised training
• Specialist training
• Mortality 20%
• Mortality ??? Higher
Sepsis 6 in the Ist hour
Give 3
Take 3
1.OXYGEN: Titrate O2 to saturations of 94 1. CULTURES: Take blood cultures before ‐98% or 88‐92% in chronic lung disease.
giving antimicrobials (if no significant delay i.e. >45 minutes) and consider source control.
2. FLUIDS: Start IV fluid resuscitation if 2.BLOODS: Check lactate & full blood evidence of hypovolaemia. 500ml bolus count.
of isotonic crystalloid over 15mins & give up to 30ml/kg, reassessing for signs of hypovolaemia, euvolaemia, or fluid overload.
3. ANTIMICROBIALS: Give IV antimicrobials according to local antimicrobial guidelines.
3. URINE OUTPUT: Assess urine output and consider urinary catheterisation for accurate measurement in patients with severe sepsis/septic shock. Management of sepsis in adult in‐patient
Prompt treatment
• Sepsis is a time‐dependent medical emergency
• Mortality increases by 7.6% for each hour delay to appropriate antibiotics (Kumar CCM 2006)
Early antibiotics are good
Author
N
Setting
Median Odds ratio time (mins) for death
Gaieski
261
ED, USA
(shock)
119
Whole hospital, UK
121
ED, Canada
(shock)
360
Whole hospital, UK
240
CCM 2010; 38;1045‐53
Daniels
567
Emerg Med J 2010; doi:10.1136
Kumar
2154
CCM 2006; 34(6): 1589‐1596
Appelboam
375
CCM 2010; 14(Suppl 1):50
Levy
CCM 2010; 38(2): 1‐
8
15022
Multi‐centre
0.30
(1st hour vs all times)
0.62
(1st hour vs all times)
0.59
(1st 3 hours vs delayed)
0.74
(1st 3 hours vs delayed)
0.86
(1st 3 hours vs delayed)
Start Smart
• 9‐fold increase in mortality with inappropriate antibiotics
• Independent risk factors
– COPD
– Immunocompromised
– Chronic dialysis
Then Focus
• Daily patient review
– Investigations
– Culture results
• Five options
– Continue current antimicrobial
– Change antimicrobial
– Change iv to oral
– Stop – OPAT
Risk stratification
Trzeciak, S et al. Int Care Med 2007; 33(6):870-7.
n-=1177
Compliance with sepsis 6
Compliance,GHH (%)
Mortality
Total
Cohort size
(%)
Mortality %
RRR %
(‘NNT’)
567 (100)
34.7
-
Sepsis Six

347 (61.2)
44.0
Sepsis Six

220 (38.8)
20.0
46.6
(4.16)
Basics limit severity
Impress Sept 2014
Mortality
US
24%
Europe
28%
Bundle compliant
20%
Non‐bundle compliant
30% p=0.026
ProCESS , ARISE
Feb 2014
•
ED Hypotension or lactate > 4
•
ProCESS
EGDT vs Simplified quantitative resus vs Usual Care
– Pre‐randomisation 30mls/kg (2l/kg)
– Study fluid 3.3, 2.8, 2.3 litres
– Mortalities 21%, 18.2%, 18.9%
•
ARISE
Sept 2014
EGDT vs Usual Care
– Pre‐randomisation
34mls/kg (2.5l)
– Study fluid 2.7 – 2.9 litres
– Mortality 18.6%, 18.8%
What about the tricky patients?
• History of congestive cardiac failure
• Dialysis patient
• Pre‐eclampsia and sepsis
• The same principles apply bolus and review
• Use smaller volumes more often • Get more senior assistance if necessary
• These patients do badly with sepsis Is that it?
• Sepsis 6 is the minimum intervention
• Sepsis is a continuum
• Source control
• Seasonal and other outbreaks, recent travel, patient at risk of MDR organisms
Referral
• Surviving sepsis campaign guidelines are critical care treatment regimes • If your patient has organ dysfunction and/ or shock that has not resolved after 30mls/kg IVT they need critical care review
“….as the physicians say it happens in hectic fever, that in the beginning of the malady it is easy to cure but difficult to detect, but in the course of time, not having been either detected or treated in the beginning, it becomes easy to detect but difficult to cure.”
NICCOLO MACHIAVELLI, THE PRINCE, 1513
Barriers to implementation
• Lack of awareness, Lack of agreement
• Lack of self‐efficacy
– Perception – Reality gap, Education, Audit
• Lack of outcome expectancy
– Audit
• Inertia of previous practice – Lactate, Audit, Discussion forums, Bottom‐up/ Top‐down
External barriers
• Guideline related
– Lack of maternity guidelines
– Poor specificity of SIRS criteria
• Patient related
– Late presentation, co‐morbidities
• Environment related
– Lack of resources
Overcoming barriers
• Education
• Audit
– HIPE, KPI, ward‐based audit
• Resourcing
Thank you
• Any questions?