Post Sepsis Syndrome & Post Sepsis Care. Surviving Sepsis

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1 Post Sepsis Syndrome & Post Sepsis Care Jennifer Azen, MD, MPH UW Medicine Post Acute Care Service Surviving Sepsis In Hospital Mortality has declined from 35% in 2000 to 18% in 2012 Accounts for 12.2% of US hospital readmissions Worldwide, 19.4 million patients with sepsis, 14.1 million survive to hospital discharge In US, 1.3 million survivors (56% over 65) 1/2 have complete recovery 1/6 have cognitive impairment 1/3 die within a year (50% from sepsis, 50% from complications) 1

2 Post Sepsis Syndrome Similar to Post ICU Syndrome Post sepsis syndrome is a condition that affects up to 50% of sepsis survivors. They are left with physical and/or psychological long term effects, such as: Insomnia, difficulty getting to sleep or staying asleep Nightmares, vivid hallucinations and panic attacks Disabling muscle and joint pains Extreme fatigue Poor concentration Decreased mental (cognitive) functioning Loss of self esteem and self belief Post ICU Syndrome Described more extensively in literature (BRAIN ICU Study, multicenter cohort study followed pts at 3 months and 12 months) 3 components Cognitive impairment Physical impairment Psychological impairment 2

3 Quality Post Sepsis Care Reduce readmission: Reduce recurrent sepsis Carefully manage pre existing chronic disease Evaluate for post sepsis syndrome Connect patients with appropriate therapy No validated tools to determine likelihood of recovery. Your immune system on sepsis Initial response: Pro inflammatory pathways and anti inflammatory innate immune pathways Changes in the immune system response based on location, pathogen, medical events, and timing of antibiotics Resolution of the immune response is complex and prolonged with inflammatory changes and/or immune suppression. The severity of all responses is influenced by the presepsis health and quality of early treatment! 3

4 From: Enhancing Recovery From Sepsis A Review JAMA. 2018;319(1): doi: /jama , Prescott, Angus Recurrent Sepsis Immune system dysfunction Incomplete treatment or deescalating treatment Injured organ/tissue at risk for infection Catheter associated infections Healthcare associated infections 4

5 New vs Relapsed Infection Retrospective cohort study, single center Reviewed 472 readmissions within 90 days of sepsis 65% had same infection at the same site 19% had confirmed infection with same site and organism 34% unclear (initial organism not identified) 50% had new infections Post sepsis management: from head to toe Encephalopathy, prolonged delirium Visual changes Dysphagia, sinusitis Vocal cord injury/trachea abnormalities Endocrine changes, thyroid, adrenal, calcium/bone, hair Prolonged lung recovery Heart failure, higher rates of CAD Resolving hepatitis Impaired glucose control, pancreatic insufficiency Impaired glucose control, pancreatic insufficiency Adrenal insufficiency Resolving acute kidney injury Diarrhea/constipation Anemia Edema Myopathy Neuropathy Paralysis Amputation Pressure ulcers 5

6 Avoiding Chronic Disease Exacerbation Medication (pre) Medication (post) Medication (dose) Patient education Close follow up with outpatient team Clear communication Teach fluid management Signs and symptoms of sepsis When to call and who to call vaccinate Recognizing Post Sepsis Syndrome 6

7 Physical Debility Critical illness myopathy Critical illness neuropathy Cardiopulmonary limitations in mobility Functional limitations In Medicare patients, develop an average of 1 2 new limitations in ADLs Dysphagia Risk for aspiration 7

8 Cognitive Impairment Etiology multifactorial Delirium seems to be more predictive of cognitive impairment long term In Medicare patients rates of cognitive impairment rates increased from 6.1 to 16.7%, not increased in non sepsis hospitalized pts. Even with normal testing, patients report impairment. 8

9 Psychological Impairment Increase in anxiety (32%), depression (29%), and PTSD (32%) Somatic symptoms are reported higher in patients with psychologic impairment Not clear if presepsis state Quality of life reduction Often do not return home or work Identify Post Sepsis Syndrome Assess functional limitations: PT/OT referral Screen for aspiration risk Screen for depression/anxiety/ptsd encourage ICU diary Patients benefit from knowing the what happened. 9

10 Prevention of Post Sepsis Syndrome Higher quality sepsis care Manage pain, agitation, delirium Opiates preferred, minimize benzos Lighten sedation Early mobilization to reduce muscle atrophy Early therapy referrals. 10

11 More work to be done Using predictive models using SOFA Outcomes in non Medicare patients Mid German Sepsis Cohort Enrolling 3000 ICU sepsis survivors for mid and long term follow up. References Iwashyna, Wesley, et al. Long term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA. 2010; 304 (16): Prescott, Angus. Enhancing Recovery From Sepsis, A Review. JAMA. 2018; 319(1): Faheem, Khadpe, et al. Persistent organ dysfunction after severe sepsis: A systematic review. Journal of Critical Care. 2014; 29: Shen, Lu, Yang. Risk of Recurrene After Surviving Severe Sepsis: A Matched Cohort Study. Critical Care Medicine. 2016; 44 (10): Prescott, Costa. Improving Long Term Outcomes After Sepsis. Critical Care Clin. 2018; 34(1): Abu, Mizrakli, et al. Long Term Survival of Young Patients Surviving ICU Admission With Severe Sepsis. Critical Care Medicine. 2018; May 7 Jones, Fuchs, et al. Post Acute Use and Hospital Readmission after Sepsis. Ann Am Thorac Soc. 2015; 12 (6): DeMerle, Royer, et al. Readmissions for Recurrent Sepsis: New or Relapsed Infection? Critical Care Medicine. 2017; 45 (10): Guirgis, Brakenridge, et al. The long term burden of severe sepsis and septic shock: Sepsis recidivism and organ dysfunction. J Trauma Acute Care Surg; (3): Sharukh, McCague, et al. One year mortality after recovery from critical illness: A retrospective cohort study. PLOS ONE. May 11, 2018 Jackson, Pndharipande, et al. Depression, post traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN ICU study: a longitudinal cohort study. The Lancet. 2014: Vol 2: Scherag, Hartog, et al. BMJ Open :