Transcript Powerpoint Sepsis 2016

SEPSIS Recognition,
Treatment and
Referral
Dr. Vida Hamilton
National Clinical Lead Sepsis
www.hse.ie/sepsis
Sepsis - 2
• A dysregulated immune response to infection
• Regulated
o Innate & Adaptive
• Cellular: Dendritic cells, T-cells, B-cells
• PAMPs that bind TLR 2,3,4, Mannin-binding lecithin
receptors
• (DAMPs)
• Molecular: complement, acute phase, cytokines
• Anti-viral: Interfon, local cellular immunity, apoptosis
Regulated?
• Local inflammation
o Vasodilation, capillary leak
• Systemic inflammation
o SIRS, CARS
Bone 1996
‘Hyperinflammatory response’
Sepsis – 1
• Control inflammation – improve outcome
• Multiple studies
o Steroids
o Anti- TNF
o Anti-IL1
o Anti-IL6
o Other monoclonal antibodies
• At best – no improvement
• Often – increased mortality
NEJM
Actors
• Micro-organism
o Virulence
o Innoculation dose
o Multi-drug resistance
• Host
o Genetic polymorphisms
o Co-morbidities
• Age
• Chronic health status
• Immuno-modulatory medications
More pathophysiology
•
Hotchkiss 2013
Dysregulated?
• Multi-organ dysfunction then failure
o Little necrosis
•
•
•
•
Apoptosis of the cellular immune system
Anti-inflammatory phase ‘ immunoparalysis’
D4 persistent lymphopenia
‘Stimulate immune system improve outcome’
Sepsis-3: A life threatening organ dysfunction
caused by a dysregulated host response to
infection
• SOFA score
o
o
o
o
o
o
Respiration: PaO2/FiO2 or SaO2/FiO2
Coagulation: Platelets
Liver: Bilirubin
Cardiovascular: Hypotension or vasopressor
CNS: GCS
Renal: Creatinine or urinary output
• qSOFA
o RR> 22, Altered Mental status, SBP <100
1o outcome: increased specificity in predicting
Mortality > 10%; ICU LOS > 3 days
The Burden
• Common
• Sepsis:
• AMI:
330 per 100,000 per annum
208 per 100,000 per annum
• Mortality: 20 - 55%
The Burden in Ireland
• HIPE data:
o 60% all in-hospital deaths has a sepsis or infection
diagnosis
o Number of sepsis cases = 8,770
o Number of bed days =
220,288
2013 2012 2011
o In-hospital mortality
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
• 25,000 euro per acute presentation
• Chronic health burden for survivors
o Anxiety, depression, post-traumatic stress
o Musculo-skeletal, immune suppression
o Shortened life expectancy
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 decrease in in-hospital mortality by
20% for severe sepsis
• Care pathway for every patient diagnosed
with sepsis in Ireland
• Recognition, Resuscitation, Referral
• Education, audit
Diagnostic criteria for sepsis
SIRS
Sepsis
Severe Sepsis
Septic Shock
•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
•Sepsis-induced
hypo-perfusion or
hypotension
persisting despite
30 mls/kg fluid
rescusitation
SIRS Criteria
•
•
•
•
•
•
T > 38.3, < 36
HR > 90
RR > 20
WCC > 12, < 4
BSL > 7.7 mmol/l in non-diabetic
Altered mental status
Common mistake - 1
• Other inflammatory parameters
o CRP, PCT
• Organ dysfunction parameters
o Hypoxia, Oliguria, Creatinine, Coag, Platelet,
Bilirubin, Ileus
• Tissue perfusion parameters
o Mottling, capillary refill, lactate
• Haemodynamic variables
o BP <90, MAP < 70, SBP  > 40mmHg from baseline
Sources of sepsis
•
•
•
•
•
•
•
Respiratory
Urinary tract
Intra-abdominal
CRBSI
Device
CNS
Others
38%
21%
16.5%
2.3%
1.3%
0.8%
11.3%
Give 3
Take 3
1.OXYGEN: Titrate O2 to saturations 1. CULTURES: Take blood cultures
of 94 -98% or 88-92% in chronic lung before giving antimicrobials (if no
disease.
significant delay i.e. >45 minutes)
and consider source control.
2. FLUIDS: Start IV fluid
resuscitation if evidence of
hypovolaemia. 500ml bolus of
isotonic crystalloid over 15mins &
give up to 30ml/kg, reassessing for
signs of hypovolaemia, euvolaemia,
or fluid overload.
2.BLOODS: Check point of care
lactate & full blood count. Other
tests and investigations as per
history and examination.
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.
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
• Community
acquired
• Less co-morbidities
• Generalised training
• Mortality 20%
Ward
•
•
•
•
•
Hospital acquired
Co-morbidities
Second – Hit
Specialist training
Mortality ??? Higher
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
CCM 2010; 38;104553
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): 18
15022
0.30
(1st hour vs all
times)
Whole hospital, 121
UK
0.62
ED, Canada
(shock)
0.59
360
(1st hour vs all
times)
(1st 3 hours vs
delayed)
Whole hospital, 240
UK
0.74
Multi-centre
0.86
(1st 3 hours vs
delayed)
(1st 3 hours vs
delayed)
Management of sepsis in
adult in-patient
Start Smart
• 9-fold increase in mortality with
inappropriate antibiotics
• Independent risk factors
o COPD
o Immunocompromised
o Chronic dialysis
Then Focus
• Daily patient review
o Investigations
o Culture results
• Five options
o
o
o
o
o
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
Fluid resuscitation and
Mortality
Figure 3. Mean hospital mortality among patients with decreased lactate within 8 hours of index test, stratified by total fluid received in increments of
7.5 ml/kg based on medication administration record.
Annals ATS, 2013
http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201304-099OC
Cultures
– common mistake 2
Compliance with sepsis 6
• Reduces the relative risk of death by 46.6%
• 1 additional life saved for every 5 care
episodes
• Mortality reduced from 44% to 20%
o Daniels et al, Emergency medicine journal 2011
Compliance with Sepsis 6
R Daniels UK Sepsis Trust 2011
Severe sepsis audit – SSC
Inital Sepsis Bundle
100
90
80
Percent in Compliance
70
60
50
40
30
20
10
0
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
Serum lactate within 3 Hrs
Blood Culture before Antibiotics
Antibiotic Compliance
Fluids for hypotension or elevated lactate
May-15
Jun-15
Fluid resuscitation trials
Antibioti PreEGDT
c
randomis
mins
ation
(mls/kg)
Usual
Care
ProCES
S
76
30
2.8
+/- 1.9
2.3
+/- 1.9
ARISE
70
34
1.96
+/-1.4
ProMis
e
70
2 litres
2.0
+/- 1.0
Protocol
Standar
dCare
Mort
28-day
Mort
90 day
(60 day in
ProCESS)
UC/EGD
UC/EGD
T
T
3.3
+/- 1.7
18.9/21/
18.2
33.7/31.9
/30.8
1.7
+/-1.4
14.8/15.9
18.6/18.8
1.78
+/- 1.0
24.5/24.8
29.2/29.5
Impress Sept 2014
Mortality
US
24%
Europe
28%
Bundle compliant
20%
Non-bundle compliant
30%
p=0.026
HIPE: Diagnosis of Sepsis, Severe Sepsis
or Septic Shock in 2015
Number of
Inpatients
Number of
Deaths
Crude
Mortality
Rate
Sepsis
9239
1756
19.0%
Severe Sepsis
111
38
34.2%
Septic Shock
509
217
42.6%
Total
9859
2011
20.4%
Diagnosis
HIPE: Inpatients with a Diagnosis of Sepsis,
Severe Sepsis or Septic Shock in 2015
Diagnosis
Sepsis
Severe Sepsis
Septic Shock
Number of
Inpatients
Number of
Deaths
Crude Mortality
Rate
Yes
2542
680
26.8%
No
6697
1076
16.1%
Total
9239
1756
19.0%
Yes
73
29
39.7%
No
38
9
23.7%
Total
111
38
34.2%
Yes
372
153
41.1%
No
137
64
46.7%
Total
509
217
42.6%
Yes
2987
862
28.9%
6872
1149
16.7%
9859
2011
20.4%
Admission to Crit
Total Sepsis, Severe
No
Sepsis & Septic Shock
Total
Hospital Inpatient Enquiry: Crude Mortality for
Inpatients with a Diagnosis of Sepsis & Admission to
Critical Care, by Age Group, 2015
50.0%
45.0%
Mortality Rate
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
0-14
Years
15-34
Years
35-44
Years
45-54
Years
55-64
Years
65-74
Years
75-84
Years
85+
Years
OECD Health Care Quality Indicators
National Healthcare Quality Reporting System
March 2015
Number per
annum
Mortality
Change in
Mortality
2004 - 2013
AMI
6125
6.4%

H. Stroke
1456
26%

I. Stroke
4485
10%

Sepsis
9859
20.4%
?
40%
13.6%
Reassess
• Is your patient responding to treatment?
• After an initial response have they deteriorated
again?
• Are they having a prolonged static period?
• Don’t forget recent travel, seasonal outbreaks, risk
factors for MDRs
Barriers to
implementation
• Lack of awareness, Lack of agreement
• Lack of self-efficacy
o Perception – Reality gap,
o Education
o Audit
Audit
• HIPE Metadatasheet
o Mortality
o ICU admission
o Median LOS
• Compliance (> 95% form in chart)
o All ED patients admitted with sepsis
o All NEWS > 4 with infection
Summary
•
•
•
•
Recognise, Resuscitate, Refer
Sepsis 6 in the 1st hour
Risk stratify and document
Review
Thank you
www.hse.ie/sepsis