The changing face of
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1 The changing face of 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 Cognitive impairment Mild Moderate-severe Before sepsis After sepsis Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis. JAMA, 2010.
7 Basics limit severity
8 The Sepsis Six 1. Give oxygen as needed 94% to target SpO 2 > 2. Take blood cultures control consider source 3. Give IV antibiotics protocol according to local 4. Start IV fluid resuscitation equivalent Hartmann s or 5. Check lactate repeat within 2h 6. Monitor..plus Critical urine Care output support to consider complete EGDT catheterisation
9 @SepsisUK NCEPOD 2015
10 54% of patients had sepsis pre-hospital 80% acquired infection in community
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13 @SepsisUK Recognition 2014
14 Infection Sepsis Severe Sepsis Septic shock Burns Burns Systemic Inflammatory Hypoperfusion Response (SIRS) Organ dysfunction
15 <1% 10% 30% 50% Infection Sepsis Severe Sepsis Septic shock Burns Burns Systemic Inflammatory Hypoperfusion Response (SIRS) Organ dysfunction
16 CVS SBP <90, MAP <70, or SBP decrease >40 SvO 2 70% or ScvO 2 <65% Cardiac index <3.5 Lmin -1 Decreased capillary refill or mottling Lactate >2 mmoll -1 RS PaO 2 /FIO 2 <300 or SpO 2 <90% Renal Urine output <0.5 mlkg -1 hr -1 for 2 hrs Creatinine >177 micromoll -1 Hepatic Bilirubin >4 mgdl-1 or >70mmolL -1 Coagulation INR >1.5 or aptt >60s Platelets <100,000 x 10 6 L -1 GI Ileus
17 Septic shock For each hour s delay in administering antibiotics, mortality increases by 7.6% Funk and Kumar Critical Care Clinics 2011 (in press)
18 Infection Sepsis Severe Sepsis Septic shock Burns Burns
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20 <1% 10% 35% 50% Severe Infection Sepsis Sepsis Septic shock Burns Burns Systemic Inflammatory Response (SIRS)
21 Recognition
22 Infection Sepsis Badness Burns Burns
23 Infection Sepsis Septic shock Badness Burns Burns
24 3. Is any RED FLAG present? Systolic B.P <90mmHg/ >40mmHg below n. Lactate > 2 mmol/l Heart rate > 130 per minute Respiratory rate > 25 per minute Oxygen saturations < 92% (unless COPD) Responds only to voice or pain/ unresponsive Purpuric rash/ mottled/ ashen/ cyanotic Not passed urine for 18 hours Y Red Flag Sepsis This is a time critical condition, immediate action is required. Assume severe sepsis present. Sepsis Six 1 High-flow oxygen. 2 Blood cultures and consider source control. 3 Intravenous antibiotics. 4 Intravenous fluid resuscitation. 5 Check haemoglobin and 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 should 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)
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27 3. Is any red flag present? Systolic B.P <90 mmhg/ MAP <65 mmhg Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice or pain/unresponsive Purpuric rash
28 3. Is any red flag present? Systolic B.P <90 mmhg/ MAP <65 mmhg Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice or pain/unresponsive Purpuric rash
29 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice or pain/unresponsive Purpuric rash
30 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice or pain/unresponsive Purpuric rash
31 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice or pain/unresponsive Purpuric rash
32 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice or pain/unresponsive Purpuric rash
33 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice or pain/unresponsive Purpuric rash
34 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO 2 >92% Responds only to voice or pain/unresponsive Purpuric rash
35 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO 2 >92% Responds only to voice or pain/unresponsive Purpuric rash
36 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO 2 >92% Responds only to voice or pain/unresponsive Purpuric rash
37 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO 2 >92% Responds only to voice or pain/unresponsive Purpuric rash/ mottled/ ashen/ cyanotic
38 3. Is any red flag present? Systolic B.P <90 mmhg/ >40mmHg below n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO 2 >92% Responds only to voice or pain/unresponsive Purpuric rash/ mottled/ ashen/ cyanotic Not passed urine for 18 hours
39 !!!!!! Sepsis Screening & Action Tool To be applied to all non-pregnant patients over 16 years who have suspected infection, for whom staff or relatives are concerned, or who have clinical observations outside normal limits.!! 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/ is escalation clinically inappropriate? Yes Initials Discontinue pathway! 1. Is NEWS 3 or above? And/or does patient looks sick? Y 2. Could this be due to an infection?! Yes, but source unclear at present! Pneumonia! Urinary Tract Infection! Abdominal pain or distension! Cellulitis/ septic arthritis/ infected wound! Device-related infection! Meningitis! Other (specify:..)! Y 3. Is any ONE red flag present? Systolic BP 90 mmhg (or drop > 40 from normal)! Lactate 2 mmol/l! Red NEWS score for Respiratory Rate (RR)! Red NEWS score for Heart Rate (HR)! Red NEWS score for conscious level! Needs oxygen to keep SpO 2 92% (88% in COPD)! Non-blanching rash, mottled/ ashen/ cyanotic! Oliguria (from history or less than 0.5 ml/kg/hr)! Recent chemotherapy! Y Tick Tick Tick Y N N N!! Low risk of sepsis! Use standard protocols, review if deteriorates! Any moderate risk criteria? Altered mentation/ acute loss of functional ability! Rigors! Immunosuppressed! Trauma, surgery or procedure in last 6 weeks! Clinical signs of wound, device or skin infection! Amber NEWS score for RR or breathing hard! Amber NEWS score for HR or new arrhythmia! Amber NEWS score for Systolic BP! Not passed urine in last hours! Temperature < 36 O C! Red Flag Sepsis. Start Sepsis 6 pathway NOW (see overleaf) This is time critical, immediate action is required.! Sepsis! Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no sepsistrust.org N Y Send bloods! To include FBC, U&Es, CRP, LFTs, clotting!! Contact ST3+ doctor to review! USE SBAR! Must review results within 1 hour!! Has clinician attended?! Time complete Is AKI present? (tick one) YES NO! Clinician to make antimicrobial! Prescribing decision within 3h!! Time complete Tick Initials Initials
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44 1. Low level awareness alert Temperature recorded/ antibiotic prescribed 2. Medium level awareness alert Temperature recorded/ antibiotic prescribed AND a risk factor
45 1. Yellow flag sepsis alert Moderate risk but no Red Flag criteria
46 1. Yellow flag sepsis alert Moderate risk but no Red Flag criteria 2. Red Flag Sepsis alert Suspected infection and any RFS criterion
47 2. Red Flag Sepsis alert Suspected infection and any RFS criterion
48 @SepsisUK Fixing the system.
49 Systems approach Rivers 2001 RCT Sebat 2005 Before-After Nguyen 2007 Complete or Not Thiel 2009 Before-After Levy 2011 Before-After Goals CVP >8 MAP > 65 ScVO2 >70% HCT >30 MAP > 70 SaO2 > 92 UOP > 30ml/h SvO2 > 60 CI > 2.5 ABX in 4 h CVP > 8, MAP > 65, ScVO2 > 70%, HCT > 30 Check Lactate Steroids Appropriate ABX in 4 h, CVP > 8, MAP > 65, ScVO2 > 70% Early ABX, Blood Cultures, Appropriate ABX, CVP > 8, MAP > 65, SvO2 > 70% Specific Interventions Fluids, Blood, Pressors ABX, Fluids Pressors ABX, Fluids, Blood, Pressors ABX, Fluids, Pressors, Steroids, Xigris, Other Supportive Care ABX, Fluids, Pressors, Steroids, Xigris, Other Supportive Care System Interventions ED-based Sepsis Team Screening, Education, Shock Team, Protocols Education, Inservices, Protocols Education, Inservices, Order Set, Protocols Screening, Education, Order Sets Absolute Change in Mortality -16% -12% -19% -16% -7%
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55 Sepsis is a condition whose time has come The same muscle and effort should be put into sepsis as for meningitis, MRSA and C Diff Now is the time not for words but for practical actions on the ground
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MAKING SENSE OF IT ALL AUGUST 17
MAKING SENSE OF IT ALL AUGUST 17 @SepsisUK Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance Special Adviser to WHO SCALE AND BURDEN @sepsisuk Dr Ron Daniels B.E.M. CEO, UK Sepsis
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