The Sepsis Timebomb. James Wigfull Critical Care and Anaesthesia Sheffield Teaching Hospitals

Transcription

1 The Sepsis Timebomb James Wigfull Critical Care and Anaesthesia Sheffield Teaching Hospitals

2 Relationship of SIRS, Sepsis and Infection BACTEREMIA PANCREATITIS INFECTION FUNGEMIA PARASITEMIA VIREMIA SEPSIS SIRS POST-PUMP SYNDROME TRAUMA BURNS OTHER OTHER The ACCP/SCCM consensus Conference Committee, Chest 1992;101:

3 Sepsis and mortality Vallés et al. Chest 2003;123:

4 Sepsis and Septic Shock: An Intensivist s Immunologic View Antimicrobials Infection CARS SIRS Organ Injury Antiinflammatory (endogenous) Time RECOVERY van der Poll T, van Deventer SJH. Infect Dis Clin N Am

5 Sepsis and Septic Shock: An ID View Cellular dysfunction/tissue injury Inflammatory response Shock Threshold Toxic burden Microbial load TIME

6 An Injury Paradigm of Sepsis and Septic Shock Prof A Kumar, University of Manitoba Antimicrobial therapy Cellular dysfunction/tissue injury Inflammatory response Shock Threshold Toxic burden Microbial load TIME

7 An Injury Paradigm of Sepsis and Septic Shock Prof A Kumar, University of Manitoba earlier antimicrobial therapy Cellular dysfunction/tissue injury Shock Threshold Inflammatory response Toxic burden Microbial load TIME

8 An Injury Paradigm of Sepsis and Septic Shock Prof A Kumar, University of Manitoba Antimicrobial therapy + Source control Cellular dysfunction/tissue injury Shock Threshold Inflammatory response Toxic burden Microbial load TIME

9 fraction of total patients Cumulative Initiation of Effective Antimicrobial Therapy and Survival in Septic Shock 1.0 survival fraction cumulative antibiotic initiation time from hypotension onset (hrs) Kumar et al. CCM. 2006:34:

10 Odds Ratio of Death (95% Confidence Interval) Mortality Risk with Increasing Delays in Initiation of Effective Antimicrobial Therapy Kumar et al, CCM. 2006:34: Time (hrs)

11 Comparison with other time dependent interventions NNT NNT MI 30 CVA Trauma 30 Severe sepsis Septic shock 6-8 Easy diagnosis Clear onset Presents to A&E Not recognized early Insidious onset Often develops on wards

12 Door to balloon time and mortality in AMI Adapted from Cannon et al. JAMA 2000; 283:

13 "Preventable" deaths per year Door to balloon time and mortality in AMI By getting door-to-balloon times of 1000 <2h for ALL STEMI patients, 800 we would save lives per year h >2-3h >3-4h >4-6h >6-12h >12h "Preventable deaths" Adapted from Cannon et al. JAMA 2000; 283:

14 Percentage of patients Shock to effective antibiotic time and mortality in septic shock h >2-3h >3-4h >4-6h >6-12h >12h %Mortality % of patients Adapted from Kumar et al. Crit Care Med 2006; 34:

15 "Preventable" deaths per year Shock to effective antibiotic time and mortality in septic shock By getting shock-to-antibiotic times of <2h for ALL septic shock patients, we would save 32,360 lives per year h >2-3h >3-4h >4-6h >6-12h >12h "Preventable" Deaths Adapted from Kumar et al. Crit Care Med 2006; 34:

16 Ab s given

17 Effect of Failure to Implement Source Control if Required % total patients % survival Source Control Implemented Source Control Not Implemented

18 fraction of total patients Cumulative Source Control Implementation and Survival in Septic Shock 1.0 survival fraction cumulative source control implementation time from hypotension onset (hrs)

19 Source Control/Antimicrobial Interaction and Survival in Septic Shock Antimicrobial Initiation Post-Shock < 3 h 3-6 h > 6 h < 6 h 92% (n=75) 70.3% (n=37) 44.4% (n=63) Source Control Initiation Post-Shock 6-24 h 80.0% (n=60) 46.0% (n=50) 19.0% (n=94) > 24 h 69.0% (n=29) 36.0% (n=25) 13.0% (n=100)

20 % Ab s given Source control

21 hours Audit of Event timing from SHEWS 2 to theatre for the deteriorating colorectal patient at NGH from October 2009 to March A B C D E F A: SHEWS 2 to SpR review B: SpR review to Antibiotics C: CT booking to scan D: CTscan to report E: Scan to theatre booking F: Booking to arrival

22 Audit of Event timing from SHEWS 2 to theatre for the deteriorating colorectal patient at NGH from October 2009 to March Total time from trigger to theatre 0 Survivors Nonsurvivors

23 The Size Of The Problem patients per year in the UK receive higher risk emergency general surgery will develop significant complications Resulting in deaths

24 Number of ITU beds by country Germany Belgium Croatia USA Canada France Netherlands Spain Australia New Zealand China UK Series1 Series2 ITU beds per population ITU beds per 100 acute hospital beds

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27 Key recommendations

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30 Key recommendations

31 Key recommendations

32 Key recommendations

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34 Key recommendations

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37 The National Emergency Laparotomy Audit Dave Murray National Clinical Lead

38 Audit against standards

39 Key Recommendations: Delivery of Care Patient Pathway: Clear diagnostic and monitoring plans Adoption of escalation strategy with early involvement of senior staff Timing of diagnostic tests / timing of surgery Adequate emergency theatre access with appropriate prioritisation Post-operative location Risk of death estimated and documented: prior to surgery to ensure adjustments made in urgency of care and seniority of staff involved at end of surgery to determine optimal location for post-operative care

40 Key Recommendations: Individualised care High risk patients 10% 30d mortality Two consultants in theatre (surgeon and anaesthetist) Post-op Critical Care Unit Elderly patients Specialist input pre- and post-op Nutrition

41 The role of Outcome Measures in improving quality of care 30-day mortality Risk adjusted via P-POSSUM Unplanned return to theatre escalation of care 30-day readmission

42 The role of Process Measures in improving quality of care Admission to first dose of antibiotics Time from decision to theatre Pre-op CT scan Objective assessment of risk of death High risk patients directly admitted to critical care post-op Key Standards of Care relate to patient s predicted risk of death

43 Conclusions With the onset of shock the mortality clock starts ticking! Timely delivery of appropriate antibiotics is everybody s responsibility deal with it if it hasn t already happened Source control the mortality clock does not wait for a convenient theatre slot