SIRS, NICE, SOFAs and CQUINs: Challenges of changing definitions and guidelines. Dr Sian Coggle Consultant Acute Medicine and Infectious Diseases

Transcription

1 SIRS, NICE, SOFAs and CQUINs: Challenges of changing definitions and guidelines Dr Sian Coggle Consultant Acute Medicine and Infectious Diseases

2 Objectives Context Case Changing definitions Systems for recognition and management Evidence behind treatment Balances CUH work Cases/quiz

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4 123,000 cases of sepsis occur in England each year Approx. 37,000 deaths annually More than breast, bowel and prostate cancers combined Prompt recognition of sepsis and rapid intervention will help reduce the number of deaths occurring annually.

5 63 yrold P.S From wife Whole family flu-like illness PS cough for last 3 days Headache Sweaty, drowsy, not following commands

6 DH: Mirtazipine PMH: Measles aged 7 yrs Right petrousectomy 2014

7 :02 = 0 mins Minute ED action 0 T 40.4 at home, to resus 1 RR20, SpO296% (non rebreathbag), HR 99, BP 158/97, GCS 13, T 38.2 NEWS 4 3 Sepsis criteria alert triggered 6 Bloods and cultures taken 10 Lactate2.1, Ceftriaxone, Aciclovir, CT head, CXR, urine dip, ECG, fluid balance chart ordered 34 WCC 16.7, neut15, lymph 0.78, CRP 116, Cr IV ceftriaxone 2grm given 38 Hartmann s 1l over 15 mins given

8 Minute ED action Aciclovir given, lact repeated 3.0, Medical and RRT review, CXR, CT head 340 LP turbid fluid, OP 17.5 cmh2o Dexamethasone added 0.15mg/Kg 480 PMN 1060, lymph0, glucand prot pending. Gram stain difficult Discussed with microbiology and ID SpR Add Amoxicillin and Vancomycin 720 Concerns about pupils and GCS, repeat CT head on way to RRT bed on IDA

9 2001 definition Systemic inflammatory response syndrome (SIRS) requires 2 or more of the following 1. T >38 C or <36 C 2. P >90/min 3. RR >20/min or PaCO2 <32 mmhg 4. WCC >12 or >10% immature band forms Sepsis Sepsis is SIRS + confirmed or presumed infections Severe Sepsis Severe Sepsis is sepsis with organ dysfunction organ dysfunction includes: SBP <90 mmhg or MAP < 65 mmhgor lactate > 2.0 mmol/l(after initial fluid challenge) INR >1.5 or a PTT >60 s Bilirubin >34 µmol/l Urine output <0.5 ml/kg/h for 2 h Creatinine >177 µmol/l Platelets < /L SpO2 <90% on room air Septic Shock Septic shock is defined as sepsis with refractory hypotension hypotension is defined as SBP <90 mmhg or MAP <70 mmhg refractory means that hypotension persists after 30 ml/kg crystalloid; i.e.vasopressor dependence after adequate volume resuscitation

10 Definition Sepsis -3 Sepsis life-threatening organ dysfunction caused by a dysregulatedhost response to infection Septic shock a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.

11 Inclusion of organ dysfunction in the definition of sepsis, the term severe sepsis was eliminated in this new iteration European Society of Intensive Care Medicine and Society of Critical Care Medicine Third International Consensus Task Force Singer M et al. JAMA 2016 Feb 23. Seymour CW et al. JAMA 2016 Feb 23. Shankar-HariM et al. JAMA 2016 Feb 23. Abraham E. JAMA 2016 Feb 23

12 Sepsisis a life-threatening organ dysfunction due to a dysregulatedhost response to infection. Suspected sepsis is used to indicate people who might have sepsis and require face-toface assessment and consideration of urgent intervention. NICE guidelines July 2016

13 Recognising Sequential Organ Failure Assessment (SOFA) scores compared with Logistic Organ Dysfunction System (LODS) and SIRS criteria Performed same chose SOFA Suspected infection plus a change in baseline SOFA score 2 points Clinical criteria to diagnose septic shock included vasopressor use to maintain mean arterial pressure >65 mm Hg and lactate level >2 mmol/l despite adequate fluid resuscitation.

14 qsofa Limitations starting to be addressed Defining sepsis by an increase in SOFA score provided greater prognostic accuracy for inhospital mortality than either SIRS criteria or qsofa Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qsofascore for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit Raithet al JAMA. 2017;317(3):

15 8% in hospital mortality -qsofahelped predict who 3% for those with qsofaof 1, 24% for those with a qsofa 2 Adding lactate to the model did not improve the predictions Data were incomplete on 14% of patients, limiting the conclusions' strength Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department Freund et al JAMA. 2017;317(3):

16 Sensitive Specific Positive predictive value SIRS 97% 2.4% 15.9% 80% qsofa 48% 90% 42% 92% Negative predictive value Retrospective review 200 cases presenting to ED six month period who had a sepsis 6 form completed qsofais a more specific test to identify patients requiring critical care input or at risk of death. Although SIRS is more sensitive, its lack of specificity makes it a much less effective screening tool for severe sepsis TRIAGE OF SEPSIS PATIENTS: SIRS OR QSOFA WHICH IS BEST? Gunn et al emermed

17 qsofa sbp<100 Altered mental status RR > 22 >2 = 10% mortality rate

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22 Management the evidence: Early directed goal therapy: Randomized trial of 263 patients with suspected sepsis reported a lower mortality in patients when ScvO2, CVP, MAP, and urine output were used to direct therapy compared with those in whom only CVP, MAP, and urine output were targeted (31 vs47 %)

23 Both groups initiated therapy, including antibiotics, within six hours of presentation. There was a heavy emphasis on the use of red cell transfusion (for a hematocrit>30) and dobutamineto reach the ScvO2 target in this trial EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC SHOCK Emanuel Rivers et al N EnglJ Med, Vol. 345, No. 19 November 8, 2001

24 Three subsequent multicenterrandomized trials of patients with septic shock, ProCESS, ARISE and ProMISEand two meta-analyses all reported no mortality benefit (20 to 30 %), associated with an identical protocol compared with protocols that used some of these targets or usual care A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESSand ProMISeInvestigators. Intensive Care Med 2015; 41:1549. Angus DC, BarnatoAE, Bell D, et al PRISM Investigators. Early, Goal-Directed Therapy for Septic Shock -A Patient-Level Meta-Analysis. N Engl J Med 2017

25 Sepsis 6

26 Antibiotics for every hour delayed 7-8% increase in mortality Author n Setting Mediantime (mins) OddsRatio for death Gaieski CritCare Med2010; 38: Daniels EmergMed J 2010; doi: Kumar CritCare Med2006; 34(6): Appelboam Critical Care 2010; 14(Suppl 1): ED, USA (Shock) 567 Whole hospital, UK ED, Canada (Shock) 375 Wholehospital, UK (first hour vs all times) (first hour vs all times) (first hour vs second hour) (first 3 hours vs delayed) Levy CritCare Med 2010; 38 (2): 1-8 Levy NEJM 2017; /NEJMoa Multi-centre 0.86 (first 3 hours vs delayed) Multi-centre per hour ( increased odds per hour delay)

27 Retrospective cohort study of adult patients who presented to a single emergency department with severe sepsis over an 8- year period Approx patients from severe sepsis to septic shock median time to initial antimicrobial administration was significantly longer for patients who progressed to septic shock than for those who did not progress (3.77 hours vs hours) Multivariable logistic regression showed an 8% increase in the odds of progression to septic shock for each 1 hour delay in antimicrobial administration Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients. Whiles BB et al. Crit Care Med 2017 Feb 6

28 Surviving Sepsis Campaign/Society of Critical Care Medicine/European Society of Intensive Care Medicine IV antibiotics within one hour of presentation source control and antibiotic stewardship infusion of crystalloid solution at a rate at 30 ml/kg/hour within three hours for early fluid resuscitation movement away from previously recommended early goal-directed therapy targets (eg, central venous pressure) to use of dynamic predictors of fluid responsiveness, when feasible.

29 Balances Does the patient have an infection? Is it likely to be bacterial/fungal/viral? Source control achieved? Start Smart -Then Focus

30 CQUIN

31 Sepsis at CUH Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 % Sepsis Management in CUH ED % antibiotics within 60 mins % full sepsis 6 bundle in 60 mins % antibiotics within 90 mins % full sepsis 6 bundle in 90 mins

32 SEPSIS SEPSIS IS A MEDICAL EMERGENCY Does your patient have a NEWS >5 and/or look sick? Think: Could this be infection? ANY HIGH RISK CRITERIA? Mottled or blue Altered mental state Respiratory rate >25/min Increasing oxygen requirement Heart rate >130/min Systolic BP <90mmHg Urine output lower than 0.5ml/kg/hr Not passed urine for >18hrs URGENT SENIOR REVIEW NOW OPEN SEPSIS ORDER SET ON EPIC GET HELP Senior medical review within 30 mins and/or RRT if deteriorating GIVE ANTIBIOTICS WITHIN 60 MINUTES ACT FAST, SAVE LIVES Mortality increases by 8% for every hour of delay in antibiotics

33 Quiz 1 18 yrold man presents to ED on Friday night with his friends. Been on night out in town and friends concerned patient is now acutely confused. Observations: T37, HR 135, BP 110/70, sats98% OA, RR 22 What would you do next? A. Meets high risk criteria start sepsis 6 B. Obtain more history C. Give some fluids and reassess HR before considering antibiotics D. Wait for bloods including a lactate and Cr before starting any management

34 Answer 1 B obtain more history Consider if infection present before assessing for sepsis

35 Quiz 2 75 yrold on surgical ward following recent resection for bowl obstruction. HCA performs observations as part of routine rounds and patient mentions some increased redness and pain in surgical wound. Observations are: T 38.5, HR 100, BP140/70, RR 20, Sats98 % OA You are the medical SpRcovering wards what would you do next? A. Phone the surgeons and arrange CT scan B. Ensure adequate analgesia and fluid intake, then reassess observations C. Arrange an urgent set of bloods including lactate and creatinine D. Start sepsis 6 immediately

36 Answer 2 C meets criteria for intermediate risk sepsis and need urgent bloods to ensure not high risk

37 Quiz 3 61 yrold lady bed bound from MS, catheter in situ (changed yesterday) with history of recurrent UTI s. Found that morning by her carer acutely confused and now barely rousable. Observations in ED: T 37.5, HR 140, BP 90/60, sats94%oa, RR 25 What would you do next: A. This is high risk sepsis start sepsis 6 within an hour of presentation, target antibiotics to likely source B. Arrange full set of bloods and CT head as confused C. Further history D. Hold off sepsis 6 until central line in situ for monitoring

38 Answer 3 A high risk sepsis, a medical emergency

39 Quiz 4 84 yrold lady brought into ED by daughter not quite right. Had a fall last night and maybe slightly confused. Has had a cough over last few days and GP started on antibiotics. Observations: T 36.5, HR 110, BP 150/90, RR 22, Sats94 % OA Bloods back CRP 250, WCC 22, neut16, Cr 80, lact1.5 What would you do: A. Meets high risk criteria start sepsis 6 B. Measured oxygen, CXR, infection screen C. Find out baseline creatinine, if stable start antibiotics in timely manner and reassess in hour D. Reassure daughter antibiotics likely to start working soon and discharge

40 Answer 4 C meets intermediate criteria. Need to ensure not in AKI and reassess. Does require treatment for sepsis, but less urgency

41 Summary Context Case Changing definitions Systems for recognition and management Evidence behind treatment Balances CUH work Cases/quiz