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1 MAKING SENSE OF IT ALL AUGUST Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance Special Adviser to WHO

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3 SCALE AND Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance Special Adviser (maternal sepsis) to WHO

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6 GLOBAL SEPSIS MORTALITY Sepsis 6M * Ischaemic Heart Disease 7.2M (CDC 2015) Cancer 8.2M (WHO 2015)) Tobacco 6M (WHO 2016) Malaria 0.44M (WHO 2015) Fleischman C, Scherag A, Adhikari N et al

7 SEQUELAE- COGNITION Mild Moderate-severe Before sepsis After sepsis Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis. JAMA, 2010

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12 WHAT IS Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance Special Adviser (maternal sepsis) to WHO

13 SEPSIS IS. a life-threatening condition arising when the body s dysregulated response to infection causes injury to its tissues and organs

14 UK SOURCES Pneumonia UTI Abdominal SSTI

15 Infection Sepsis Severe Sepsis Septic shock

16 <1% 10% 30% 50% Infection Sepsis Severe Sepsis Septic shock

17 Septic shock For each hour s delay in administering antibiotics, mortality increases by 7.6%

18 Infection Sepsis

19 Infection Sepsis Badness

20 3. Is any RED FLAG present? Systolic B.P <90 mmhg Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds to voice/ pain/unresponsive Purpuric rash Y Red Flag Sepsis This is a time critical condition, immediate action is required. Assume sepsis present. Sepsis Six 1 Oxygen to maintain Sats > 94% 2 Blood cultures and consider source control 3 Intravenous antibiotics 4 Intravenous fluid resuscitation 5 Check serial lactates 6 Hourly urine output measurement Record the time each of these actions is completed. All actions should be completed as soon as possible but always within 60 minutes. Communication: Inform senior clinician (e.g. registrar or above). Additional: Bloods to include: FBC, U/E s, LFT s, clotting profile. Observations should be taken every 30 mins Lactate should be repeated within 2 hours. Perform a CXR and Urinalysis Consider source control ( e.g. surgical intervention)

21 SEPSIS-3

22 3 GREAT THINGS! 1. NARRATIVE- organ dysfunction 2. Delta-SOFA 3. Lose SIRS

23 Singer M, JAMA 2016

24 q SOFA CRASHES & BURNS??

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26 NEWS & SEPSIS n=21,000 NEWS Age Mortality % and lactate < and lactate and lactate >4 32.5

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28 3. Is any Red Flag present? Systolic B.P <90 mmhg/ drop of 40 mmhg Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep saturations <92% Responds to V/P/U or acute confusion Purpuric rash/ mottled/ ashen/ pale Not passed urine for 18 hours

29 Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance Special Adviser (maternal sepsis) to WHO

30 !!!! Your logo! ED/ AMU Sepsis Screening & Action Tool To be applied to all non-pregnant adults and young people over 12 years with fever (or recent fever) symptoms, or who are clearly unwell with any abnormal observations!! Patient details (affix label):!...!!!!! Staff member completing form:! Date: (DD/MM/YY):! Name (print):! Designation:! Signature:!...!!!! Important: Is an end of life pathway in place? Yes Is escalation clinically inappropriate? Yes Initials Discontinue pathway!!! 1. Could this be sepsis? Patient looks sick! Patient, carer or relative very worried! NEWS (or similar) triggering! Risk factors present! e.g. age over 75, recent surgery, trauma or invasive procedure,! immunosuppressed, indwelling device or skin integrity breached! Y 2. Could this be due to an infection?! Tick Yes, source unclear Pneumonia! Urinary Tract Infection Joint or skin infection Meningitis! Y 3. Is any ONE red flag present? AVPU= V, P or U (if changed from normal)! Acute confusion! Respiratory rate 25 per minute! Needs oxygen to keep SpO 2 92% (88% in COPD)! Heart rate > 130 per minute! Systolic B.P 90 mmhg (or drop > 40 from normal)! Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr! Non-blanching rash, mottled/ ashen/ cyanotic! Recent chemotherapy (last 6 weeks)! Abdo. pain/ distension! Device-related infection! Other (specify: ) Tick Tick Low risk of sepsis: Use standard protocols, consider discharge (approved by senior decision maker) with safety netting! 4. Any Amber Flag criteria? Relatives concerned about mental status! Acute deterioration in functional ability! Immunosuppressed! Trauma/ surgery/ procedure in last 6 weeks! Respiratory rate 21-24! Systolic B.P mmhg! Heart rate OR new dysrhythmia! Not passed urine in last hours! Temperature < 36 O C! Clinical signs of wound, device or skin infection! Y Y Red Flag Sepsis. Start Sepsis 6 pathway NOW (see overleaf) This is time critical, immediate action is required.! N N N Time complete Initials Send bloods if 2 criteria present, consider if 1! Include LACTATE,FBC, U&E, CRP, LFT, clotting!! Ensure urgent senior review! Must review with results within 1 hour! Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no sepsistrust.org! N Is AKI present OR is lactate > 2? (tick) YES NO! Y Clinician to make antimicrobial! prescribing decision within 3h!! If senior clinician happy, may discharge! with appropriate safety netting!!! Discharged? Tick Time complete Initials Initials

31 !!!! Your logo! ED/ AMU Sepsis Screening & Action Tool To be applied to all non-pregnant adults and young people over 12 years with fever (or recent fever) symptoms, or who are clearly unwell with any abnormal observations!! Patient details (affix label):!...!!!!! Staff member completing form:! Date: (DD/MM/YY):! Name (print):! Designation:! Signature:!...!!!! Important: Is an end of life pathway in place? Yes Is escalation clinically inappropriate? Yes Initials Discontinue pathway!!! 1. Could this be sepsis? Patient looks sick! Patient, carer or relative very worried! NEWS (or similar) triggering! Risk factors present! e.g. age over 75, recent surgery, trauma or invasive procedure,! immunosuppressed, indwelling device or skin integrity breached! Y 2. Could this be due to an infection?! Tick Yes, source unclear Pneumonia! Urinary Tract Infection Joint or skin infection Meningitis! Y 3. Is any ONE red flag present? AVPU= V, P or U (if changed from normal)! Acute confusion! Respiratory rate 25 per minute! Needs oxygen to keep SpO 2 92% (88% in COPD)! Heart rate > 130 per minute! Systolic B.P 90 mmhg (or drop > 40 from normal)! Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr! Non-blanching rash, mottled/ ashen/ cyanotic! Recent chemotherapy (last 6 weeks)! Abdo. pain/ distension! Device-related infection! Other (specify: ) Tick Tick Low risk of sepsis: Use standard protocols, consider discharge (approved by senior decision maker) with safety netting! 4. Any Amber Flag criteria? Relatives concerned about mental status! Acute deterioration in functional ability! Immunosuppressed! Trauma/ surgery/ procedure in last 6 weeks! Respiratory rate 21-24! Systolic B.P mmhg! Heart rate OR new dysrhythmia! Not passed urine in last hours! Temperature < 36 O C! Clinical signs of wound, device or skin infection! Y Y Red Flag Sepsis. Start Sepsis 6 pathway NOW (see overleaf) This is time critical, immediate action is required.! N N N Time complete Initials Send bloods if 2 criteria present, consider if 1! Include LACTATE,FBC, U&E, CRP, LFT, clotting!! Ensure urgent senior review! Must review with results within 1 hour! Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no sepsistrust.org! N Is AKI present OR is lactate > 2? (tick) YES NO! Y Clinician to make antimicrobial! prescribing decision within 3h!! If senior clinician happy, may discharge! with appropriate safety netting!!! Discharged? Tick Time complete Initials Initials

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35 Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance Special Adviser (maternal sepsis) to WHO

36 SSC 2016

37 SSC BUNDLE 2012 To be completed within 3 hours: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L To be completed within 6 hours: 5) Apply vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (ScvO 2 )* 7) Remeasure lactate if initial lactate was elevated*

38 SSC BUNDLE 2012 To be completed within 3 hours: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L To be completed within 6 hours: 5) Apply vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (ScvO 2 )* 7) Remeasure lactate if initial lactate was elevated*

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42 COMPLIANCE AT GOOD HOPE (%) 70 Sepsis 6 Resusc Both Mortality Apr-09 Jun-09 Aug-09 Oct-09

43 OUTCOMES COHORT SIZE (%) MORTALITY (%) RRR (%) Total 567 (100) No Sepsis Six 347 (61.2) 44.0 Sepsis Six 220 (38.8) (4.16)

44 EARLY ANTIBIOTICS? AUTHOR N SETTING MEDIAN, min OR (DEATH) Gaieski Crit Care Med 2010 Daniels Emerg Med J 2011 Kumar Crit Care Med 2006 Appelboam Critical Care 2010 Levy Crit Care Med ED, USA (Shock) (hour 1 v any) 567 Pan-hospital, UK (hour 1 v any) 2154 ED, Canada (Shock) (hour 1 v hr 2) 375 Whole hospital, UK (hour 3 v any) Multi-centre 0.86 (hour 3 v any)

45 IT S NOT JUST Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance Special Adviser (maternal sepsis) to WHO

46 NCEPOD STATUS IN ED Sepsis status Number of patients % Infection only Sepsis Severe sepsis Septic shock Subtotal 298 No evidence of infection prior to admission 73

47 NCEPOD 2015 Reason for delay Number of patients % Didn t ask for help GP Admitting hospital ED Other hospital MIU/ED Urgent Care Centre

48 FIXING THE Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance Special Adviser (maternal sepsis) to WHO

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50 The same muscle and effort should be put into sepsis as for meningitis, MRSA and C Diff

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58 MORTALITY (ICNARC) UK 2014 Have you ever heard of sepsis? 60% NO 40% YES 39.8%

59 MORTALITY (ICNARC) UK 2014 How would you act if someone had sepsis? 60% Not sure 40% Emergency 39.8%

60 MORTALITY (NCEPOD) UK 2016 Have you ever heard of sepsis? 33% NO 67% YES 30%

61 UK 2017 Have you ever heard of sepsis? 27% NO 73% YES

62 MORTALITY (HES) UK 2017 How would you act if someone had sepsis? 25% GP 75% Emergency 18%

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