Diagnosis and Management of Sepsis. Disclosures

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1 Diagnosis and Management of Sepsis David Shimabukuro, MDCM Medical Director, 13 ICU Physician Lead, UCSF Sepsis Bundle Compliance and Mortality Reduction I have no disclosures Disclosures 1

2 The following feature has been edited for content and to run in the allotted time Agenda Epidemiology Definitions and Diagnosis Treatment Definitive End organ support 2

3 Agenda Epidemiology Definitions and Diagnosis Treatment Definitive End organ support Epidemiology 3

4 Epidemiology Epidemiology 4

5 Death rate over time Heart Disease Malignant Neoplasms Cerebrovascular Disease Septicemia National Vital Statistics Reports, vol 6, no 4, May 08, 2013 Epidemiology Cause 8% 14% 12% 8% 20% 38% Lung Blood Skin/Soft Tissue Abdominal Genitourinary Other 5

6 Agenda Epidemiology Definitions and Diagnosis Treatment Definitive End organ support CASE Mrs. M is an 82 year old woman with a past medical history significant for Alzheimer s, hypothyroidism, and hypertension, was admitted to the floor from a skilled nursing facility with dysarthria from an acute CVA. 6

7 CASE On hospital day 2, she is quite somnolent but arouses with tactile stimulation. Her vitals are BP 120/76, HR 78, RR 30, Temp 38, and oxygen saturation 90% on 6LNC (she was on RA yesterday evening). Her WBC this morning has increased to 11.1 from 8.9. CASE 7

8 Does she have 1. Systemic inflammatory response syndrome 2. Sepsis 3. Severe Sepsis 4. Septic shock 5. None of the above 1. No 2. Yes I would order a lactate? 8

9 CASE Her lactate level returns at 4.4 mmol/l. Does she have 1. Systemic inflammatory response syndrome 2. Sepsis 3. Severe Sepsis 4. Septic shock 5. None of the above 9

10 1. No 2. Yes I would transfer her to the ICU 1. No 2. Yes I would place a central venous catheter 10

11 Sepsis Definitions SIRS Sepsis Severe Sepsis Sepsis: ACCP/SCCM Definitions SIRS Sepsis Severe Sepsis T > 38.3 C or < 36 C HR > 90 beats/min Tachypnea WBC > 12K or < 4K SIRS plus confirmed or suspected infection SEPSIS plus evidence of at least one alteration in organ perfusion SEVERE SEPSIS plus hypotension (Systolic blood pressure < 90 or Mean Arterial Blood Pressure < 65) OR Lactate > 4 11

12 Severe Sepsis Definition Crit Care Med February 2013 Volume 41 Number 2 pp

13 San Francisco Definition Sepsis is defined as a life threatening organ dysfunction due to a dysregulated host response to infection. 13

14 What is Sepsis?? A variable condition that affects each of us differently and is initiated by a known or suspected infectious insult. Is catching it earlier better?? 14

15 Sepsis Screening Crit Care Med February 2013 Volume 41 Number 2 pp Sepsis Screening Great.but when should we do it and how should it be done!!!! Crit Care Med February 2013 Volume 41 Number 2 pp

16 Sepsis Screening Sepsis Screening 16

17 Sepsis Screening Important to have one that works for your hospital Should probably do once a shift (no clear data) Screening works as a reminder for continued awareness and vigilance (Determine time of presentation) Agenda Epidemiology Definitions and Diagnosis Treatment Definitive End organ support 17

18 Antibiotics Source Control Definitive Treatment Management of Severe Sepsis and Crit Care Med February 2013 Volume 41 Number 2 pp

19 Management of Severe Sepsis and 1 Crit Care Med 2006 Vol. 34, No. 6 19

20 20

21 End organ support (by improving tissue perfusion) Management of Severe Sepsis and 21

22 Management of Severe Sepsis and Fluid Therapy Crystalloids are first choice for the overwhelming majority of patients Albumin can be used to reduce volume from crystalloids Hydroxyethyl starches should not be used Management of Severe Sepsis and Fluid Therapy WATCH OUT!!!!! Too much fluid is bad and not enough is bad 22

23 Management of Severe Sepsis and Management of Severe Sepsis and 23

24 Management of Severe Sepsis and Beyond the 6 hour resuscitation 24

25 Management of Severe Sepsis and Lung Injury All patients at risk Low tidal volume ( 6cc/kg IBW) Plateau pressure < 30 cm H 2 0 Permissive hypercapnia FIO2:PEEP strategy Management of Severe Sepsis and Corticosteroids For refractory hypotension despite fluids and vasopressors/inotropes Do not perform ACTH stimulation test Glucose Target level to less than 180 mg/dl 25

26 Management of Severe Sepsis and Blood Products HGB level g/dl after hypoperfusion has resolved FFP not to be used unless bleeding is present or for planned invasive procedure PLT to be given prophylactically when <10K in absence of bleeding Management of Severe Sepsis and 26

27 EGDT Management of Severe Sepsis and Does this bundle actually work?? 27

28 Management of Severe Sepsis and yes no Management of Severe Sepsis and Crit Care Med 2010 Vol 38 No 2 pp

29 Management of Severe Sepsis and Management of Severe Sepsis and 29

30 Management of Severe Sepsis and Management of Severe Sepsis and 30

31 Original Article A Randomized Trial of Protocol-Based Care for Early The ProCESS Investigators N Engl J Med Volume 370(18): May 1, 2014 Cumulative Mortality. The ProCESS Investigators. N Engl J Med 2014;370:

32 Conclusions In a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes. Original Article Goal-Directed Resuscitation for Patients with Early The ARISE Investigators and the ANZICS Clinical Trials Group N Engl J Med Volume 371(16): October 16,

33 Probability of Survival and Subgroup Analyses of the Risk of Death at 90 Days. The ARISE Investigators and the ANZICS Clinical Trials Group. N Engl J Med 2014;371: Conclusions In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days. 33

34 Original Article Trial of Early, Goal-Directed Resuscitation for Paul R. Mouncey, M.Sc., Tiffany M. Osborn, M.D., G. Sarah Power, M.Sc., David A. Harrison, Ph.D., M. Zia Sadique, Ph.D., Richard D. Grieve, Ph.D., Rahi Jahan, B.A., Sheila E. Harvey, Ph.D., Derek Bell, M.D., Julian F. Bion, M.D., Timothy J. Coats, M.D., Mervyn Singer, M.D., J. Duncan Young, D.M., Kathryn M. Rowan, Ph.D., for the ProMISe Trial Investigators N Engl J Med Volume 372(14): April 2, 2015 Kaplan Meier Survival Estimates. Mouncey PR et al. N Engl J Med 2015;372:

35 Conclusions In patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome. Changes 35

36 Surviving Sepsis Campaign Bundle Revision 2015 Surviving Sepsis Campaign Bundle Revision

37 Summary Avery heterogeneous disease that is difficult to diagnose in its early stages and difficult to treat in its later stages. Routine screening can allow for earlier identification Early intervention can attenuate its course Summary Definitive treatment involves rapid appropriate antibiotic administration and source control Supportive care for end organ dysfunction is the mainstay of treatment Management bundle continues to evolve 37

38 UCSF Experience Leveraging data in the EMR Vital signs/assessments Laboratory values Problem list Medication list 38

39 Leveraging data in the EMR 6 different algorithms based on patient location ED Medical/Surgical ward Medical/Surgical ICU Hematology/Oncology CVT ward CVT ICU 39

40 Code Sepsis UCSF Sepsis Bundle UHC Sepsis Mortality Index 8 0 Sepsis Updates 10/26/

41 41

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