BGS Falls Sepsis in Hip Fracture Care. Dr Iain Wilkinson

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1 Sepsis in Hip Fracture Care Dr Iain Wilkinson Consultant Orthogeriatirican Surrey and Sussex Healthcare NHS Trust, Clinical lead KSS AHSN hip fracture programme

2 The plan Hip fractures Sepsis 2.0 Audit on sepsis > Risk factors for sepsis Sepsis specifics in older people Sepsis 3.0 Cases for discussion

$Hip fractures Around 65,000 hip fractures per year in the UK Likely to increase This one injury carries a total cost equivalent to about 1% of the whole NHS budget The typical patient presenting with$

3 Hip fractures Around 65,000 hip fractures per year in the UK Likely to increase This one injury carries a total cost equivalent to about 1% of the whole NHS budget The typical patient presenting with a hip fracture is an 83-yearold woman with at least one significant problem with her physical or mental health. Mortality 1/3 in a year NHFD report

4 NHFD success National launch of the NHFD 12.2% 11.1% 10.0% 9.1% 8.2% 7.4% Slide curtsey of Chris Boulton - NHFD Notes: Y axis is on log scale, labelled on natural scale. The log rate was fitted as linear function of continuous time measured in 3-month intervals. An interaction term was included to test for a change in slope comparing to Adjustment made for age and sex.

5 SIRS HR > 90 WBC >12 or <4 RR > 20 Temp >38 or <36

6 SIRS > Sepsis and beyond SIRS SIRS positive Sepsis + source of infection Severe sepsis Reversible organ hypoperfusion Septic Shock Irreversible organ perfusion

hierarchy from SIRS, sepsis, severe sepsis, and septic shock: 7%, 16%, 20%, and 46%, The median interval from SIRS to sepsis

7 SIRS SIRS may be the precursor of further deterioration One US study of patients in ITU and general wards 2 26% developed sepsis, 18% developed severe sepsis, 4% developed septic shock There were also stepwise increases in mortality rates in the hierarchy from SIRS, sepsis, severe sepsis, and septic shock: 7%, 16%, 20%, and 46%, The median interval from SIRS to sepsis was inversely correlated with the number of SIRS criteria (two, three, or all four) that the patients met. JAMA. 1995;273(2):

8 SIRS > Sepsis and beyond SIRS > severe sepsis and septic shock A myriad of pathogenic changes, including circulatory abnormalities All result in global tissue hypoxia Rivers study The incidence of death due to sudden cardiovascular collapse in the standardtherapy group was approximately double that in the early goal-directed therapy group suggesting that an abrupt transition to severe disease is an important cause of early death. Rivers et al. N Engl J Med 2001; 345:

9 From: Insights into Severe Sepsis in Older Patients: From Epidemiology to Evidence-Based Management Clin Infect Dis. 2005;40(5): doi: / Clin Infect Dis 2005 by the Infectious Diseases Society of America

10 Sepsis and older people The incidence of sepsis is disproportionately increased in elderly adults, and age is an independent predictor of mortality 1. Compared with younger sepsis patients older people die sooner following sepsis 1. Hence, early aggressive care to recognize and manage severe sepsis is required to improve outcome Crit Care Med 2006 Jan;34(1): J Intensive Care Med May-Jun;27(3):

11 Age changes Coagulation An aging led increase in plasma levels of fibrinogen, factor VII, factor VIII, factor IX, and other clotting factors There is also an increased rate of the generation of plasminogen activator inhibitor type 1 in the aged, which contributes to poor clearance of fibrin from the circulation of elderly patients Explains the increased risk of thrombosis and thromboembolism seen in the elderly. Cytokine There is also an abnormal cytokine response in the elderly There is a shift from the production of type 1 cytokines [interleukin (IL)-2, tumor necrosis factor (TNF)-α] to type 2 cytokines (IL-4, IL-10) This predisposes the elderly to systemic infection by microbial pathogens and a generally more prolonged proinflammatory response compared to younger patients. World J Crit Care Med Feb 4; 1(1):

12 Pathogenesis of sepsis in older people Decline of immune function that accompanies aging (1). Marked decline in cell-mediated immune function and reduced humoral immune function. Age-dependent defects in T and B cell function are readily demonstrable in elderly patients, yet the essential elements of innate immunity are remarkably well preserved. The induction of proinflammatory cytokines after septic stimuli is not adequately controlled by antiinflammatory mechanisms in elderly persons. This immune dysregulation is accompanied by a more pronounced procoagulant state in older patients. These molecular events function in concert to render elderly patients at excess risk for mortality from severe sepsis and septic shock. The initial clinical picture of sepsis in the elderly may be ambiguous but the specific pathopysiological changes of aging increase the risk of a sudden deterioration to severe sepsis with the development of a serious cardiovascular dysfunction (2). The reduced stress tolerance characteristic of aged tissues explains the high incidence of multiorgan failure in such patients. 1) 2)

13 From: Insights into Severe Sepsis in Older Patients: From Epidemiology to Evidence-Based Management Clin Infect Dis. 2005;40(5): doi: / Clin Infect Dis 2005 by the Infectious Diseases Society of America

14 17 Problems with using SIRS ls In one study, fever was absent in 13% of patients with bacteremia who were 65 years of age, compared with only 4% <65 years of age (P <.01) Another study found that one-half of the elderly patients studied had a blunted fever response to infection (temperature, <38.3 C); however one-quarter of these patients had a significant change in temperature above a low temperature at baseline Fa l 20 Fever may be blunted or absent in older patients with infection. Non-specific responses to infections also in older people S Altered physiology reduced max HR etc just not right Delirium, etc. May be difficult hx also BG Clin Infect Dis. 2005;40(5):

15 East Surrey Hip fracture sepsis audit

16 Audit of sepsis (infection) Standards Audit standards were: (1) 100% of patients with SIRS from a known or suspected infection should be diagnosed as septic and (2) 100% of septic patients should receive all steps of the resuscitation management bundle. Phase 1 data collection (Dec 15 - Feb 16) Interventions: introduction of a new post-operative proforma and erecting posters throughout the orthogeriatric ward to improve awareness of sepsis identification and management. Phase 2 data collection Feb - April 2016 Many thanks to Hanni Wolfenden - BSMS

17 Results Incidence of sepsis was 28.6% in phase 1 and 9.1% in phase 2. Appropriate identification occurred in 35.7% of septic patients in phase 1 improving to 50% in phase 2. Patients who were not identified as septic subsequently received poorer management. Number of participants Number with sepsis Phase Phase Gender 30 female 19 male 31 female 13 male Age (mean years)

19 Septic 85.8 ± 5.9 Non-septic 85.0 ± 8.5 α- level of significance Age (Years mean ± SD) Female : Male ratio Days between admission and operation 9: ± 52: ± ( Duration of surgery (hours mean ± SD) 1.55 ± Units of blood post operation ( 0.33 ± Mg Opiates post-op (median ± IQR) 40.0 ± Catheter present > 48 hours (%) Number of medications (mean ± SD) ± Mobilised day 1 post-op (%) Nottingham Hip Fracture Score Charlson Comorbidity Index (median) Sernbo score (median ± IQR) ASA Score (median ± IQR) Abbreviated mental test score ± 1.0 ± 12.5 ± 3.0 ± 5.0 ± ± 0.33 ± 80.0 ± ± ± 1.0 ± 14.0 ± 3.0 ± 9.0 ± *

20 Risk factors for infection Timing of surgery Backed up by another recent study Catheter In elderly patients with hip fractures, early surgery within 24 hours of admission is independently associated with less pulmonary complications including pneumonia, failure to extubate, and reintubation, as well as shorter LOS 1. Aims to reduce risk of urinary retention - which has been shown to increase the likelihood of a postoperative urinary tract infection 2. Extended use of indwelling urinary catheters postoperatively is associated with poor outcomes Bone Joint J 2017;99-B: JAAOS (1) Med Care Oct;43(10):

21 A new dawn

23 3 rd International consensus on sepsis JAMA Feb 23;315(8):801-10

24 Sepsis 3.0 Sepsis is the primary cause of death from infection, especially if not recognized and treated promptly. Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection Organ dysfunction assessed with a sore (SOFA) Sequential Organ Failure Assessment score of 2 points or more Septic shock should be defined as a subset of sepsis and is associated with a greater risk of mortality than with sepsis alone.

25 Suspected infection? qsofa > 2? Assess for evidence of organ dysfunction SOFA > 2 SEPSIS No No Sepsis still suspected? Monitor clinical condition No Monitor clinical condition

26 qsofa Bedside calculation of organ dysfunction Altered Mental state RR > 22 qsofa SBP <100mmHG

27 SOFA score older patients The SOFA score, a user-friendly tool used in intensive care units to estimate prognosis, is able to predict 1-month mortality also in patients admitted to an acute geriatric setting. The Journals of Gerontology: Series A, Volume 68, Issue 10, 1 October 2013, Pages

29 Cases for discussion

30 Case 1 87 yrs old male Tripped on step > #NOF PMH: HTN Indpamide, Lacidipine OAB Mirebegnon? TIA Aspirin SH Lives with wife in WCF Mobile with stick O/e AMTS 9/10 RR 22, SO2 100% on r/a Clear chest and otherwise normal examination Long term catheter WBC 14.6 Hb 133 U/E s normal

31 Case 1 (contd) OG review 1) Accidental Fall 2) HTN Hold rx for 3 days 3) LTC stop mirabegnon 4) NOF # - surgical fixation for secondary osteoporosis screen Day 1 Post cemented hemi 4AT = 1 RR 14, So2 96% on r/a, BP 103/61, HR 60, T 36.2c Chest clear, abdomen soft and no-tender

32 Day 3 Unwell, Progressive hypoxia So2 mid 70s on r/a and on 60%O2 = 88% Confused BP 120/80, Hr 80 RR 24 CXR bilateral LZ pneumonia CRP >350, Lac 0.9 qsofa = 2 (RR, mental state)

33 Suspected infection? qsofa > 2? Assess for evidence of organ dysfunction SOFA > 2 SEPSIS No No Sepsis still suspected? Monitor clinical condition No Monitor clinical condition

34 Day 3 Unwell, Progressive hypoxia So2 mid 70s on r/a and on 60%O2 = 88% Confused BP 120/80, Hr 80 RR 24 CXR bilateral LZ pneumonia CRP >350, Lac 0.9 qsofa = 2 (RR, mental state) SOFA = 5 (Resp = 4, renal =1) Dx Sepsis secondary to respiratory infection

35 Suspected infection? qsofa > 2? Assess for evidence of organ dysfunction SOFA > 2 SEPSIS No No Sepsis still suspected? Monitor clinical condition No Monitor clinical condition

36 Case 2 Patient from the weekend 89 Female, Admitted following an accidental sounding fall. PMH Recurrent falls, Dementia (AD), IHD (stents 15yrs ago), HTN DH - Aspirin, Ramipril, Amlodipine SH Lives in RH usually mobile with a frame independently Ix ECG SR 70bpm CXR clear Bloods WCC 12.1, Hb 131, U/e s normal Pelvic XR IC displaced NOF#

37 Case 2 (contd) For surgery Hemiarthoplasty performed mid morning. Seen post op by oncall medical consultant 5pm (in theatre during morning WR) Unwell, confused HR RR 25, BP 95/45 So2 92% on 2L O2 via nc CRP 39, WBC 11.7, Lactate 3.0 O.e unwell, weak pulse, crackles to chest R>l qsofa score = 3 Rx started for perioperative pneumonia

38 Suspected infection? qsofa > 2? Assess for evidence of organ dysfunction SOFA > 2 SEPSIS No No Sepsis still suspected? Monitor clinical condition No Monitor clinical condition

39 Case 2 (contd) Further Hx During op BP and HR dropped post cement. Needed vasopressors CXR -? Consolidation at right base Later became more agitated and more hypoxic with worsening type 1 respiratory failure Became more unwell and passed away that night. Dx- not sepsis! Bone cement implantation syndrome

40 Suspected infection? qsofa > 2? Assess for evidence of organ dysfunction SOFA > 2 SEPSIS No No Sepsis still suspected? Monitor clinical condition No Monitor clinical condition

41 Case 3 92 yr old female Fall in her RH whilst going to the bathroom at night PMH o/e C-diff colonisation, HTN, Dementia, DM, CKD (3) Normal other than? irregular pulse SH RH, mobile with stick but forgets Ix ECG SR with ectopics Hb 105, Cr 120 Subtrochenteric # For IM nail of subtrochenteric femoral #

42 Case 3 (contd) In recovery O/e OG team called as unwell recovery team concerned re.? Aspiration JVP raised, basal crackles to chest, alert and orientated HR 78 (had been raised intra op.), RR 25, SO2 100% on 2L o2 BP 86/39, Lactate 3.5 Hb 88, CRP 105 qsofa = 2 (RR and BP) SOFA = 1

43 Suspected infection? qsofa > 2? Assess for evidence of organ dysfunction SOFA > 2 SEPSIS No No Sepsis still suspected? Monitor clinical condition No Monitor clinical condition

44 Case 3 (contd) ECG showed inverted septal t waves Troponin raised Dx Peri-operative type 2 MI - secondary to anaemia and tachycardia.

45 Case 4 84 female Sitting on the edge of the bed, slipped down to the floor hip pain. PMH AF, PE > Pul HTN + IHD > CCF, Ca Colon with hemi colectomy, Mild cognitive impairment, OA DH Spironolactone, Ramipril, Clopidogrel, Bumetanide, Ranitidine, warfarin, aspirin, Oxycodone SH Lives alone, stair lift, mobile with 2 sticks, full time carer, daughter nearby Ix IC # NOF ECG AF with LAD CXR no focal consolidation Bloods: CRP 111, WBC 19.2, Hb 110, INR 2.4 Recent CT chest some basal atelectasis and enlarged right heart Echo LVH, well maintained LV function, raised PASP, moderate MR

46 Case 4 (contd) Day 2 WBC 16.8, CRP 180 RR 18, HR 115, BP 95/53, not confused O/e Crepitation to the right base qsofa = 1 SOFA = 1 (MAP = 67) Dx Post operative pneumonia (infection not sepsis)

47 Suspected infection? qsofa > 2? Assess for evidence of organ dysfunction SOFA > 2 SEPSIS No No Sepsis still suspected? Monitor clinical condition No Monitor clinical condition

48 Conclusions Infection following hip fracture surgery is relatively common The incidence of true sepsis following hip fracture surgery is unknown Following surgery there area number of conditions that may mimic organ dysfunction from sepsis. Sepsis 3.0 focuses on organ dysfunction and the SOFA score

SEPSIS & SEPTIC SHOCK

SEPSIS & SEPTIC SHOCK DISCLOSURE Relevant relationships with commercial entities none Potential for conflicts of interest within this presentation none Steps taken to review and mitigate potential bias