Updates On Sepsis Updates based on 2016 updates on sepsis from The International Surviving Sepsis Campaign

Transcription

1 Updates On Sepsis Updates based on 2016 updates on sepsis from The International Surviving Sepsis Campaign Dr. Joseph K Erbe, DO Medical Director Hospitalist Division of Medicine

2 Objectives 1. Review the new definition of sepsis and explore the impact of this disease process. 2. Review guidelines from the surviving sepsis campaign from 2016 relevant to our practice. 3. Provide an update on early goal directed therapy at Dixie Regional Medical Center and its impact on mortality.

3 Sepsis Definition Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. No mention of early or severe Infection vs. Sepsis No mention of SIRS Sepsis is characterized by the presence of organ dysfunction

4 Diagnosis Infection or suspected infection with: Evidence of organ dysfunction Bedside qsofa score of 2 or more predicting organ dysfunction

5 Quick Sepsis-Related Organ Failure Assessment (qsofa) qsofa is a bedside tool for identifying patients at risk of sepsis with a higher risk of hospital death or prolonged intensive care unit RR greater than 22 Alteration on mental status(gcs<13) Systolic Blood pressure less than or more is a strong predictor of poor outcomes

6 A score of two or more predicts qsofa Outcomes ICU stay of 3 or more days Mortality greater than 40%

7 Septic Shock Septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality Despite adequate fluid resuscitation: *Lactate greater than 2.0 *The use of vasopressors to maintain MAP > 65

8 Diagnosis in thousands Incidence Of Sepsis Years Series 1

9 50.0% 45.0% 40.0% Hospital Inpatient Enquiry: Crude Mortality for Inpatients with a Diagnosis of Sepsis & Admission to Critical Care, by Age Group, 2015 Mortality Rate 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 0-14 Years Years Years Years Years Years Years 85+ Years

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11 Early Goal Directed Therapy(EGDT) Identification of high risk patients Control the source of infection Blood cultures Early broad spectrum antibiotics Evaluation of hemodynamics and ongoing resuscitation

12 TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics *As early as possible. Goal less than 1 hour 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L

13 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 hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was 4 mmol/l, re-assess volume status and tissue perfusion and document findings. 7. Re-measure lactate if initial lactate elevated.

14 DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH: Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings. OR TWO OF THE FOLLOWING: Measure CVP Measure ScvO2 Bedside cardiovascular ultrasound Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

15 Sepsis Diagnosed at DRMC Series Series 1

16 Sepsis Compliance and Mortality DRMC 60% 50% 40% Percentage 30% 20% Series 1 Series 2 10% 0%

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18 Summary 1. Sepsis is an increasing clinical syndrome with high mortality characterized by an abnormal response to an infection resulting in organ failure. 2. The qsofa is a useful bedside tool for assessing severity. 3. Early identification and treatment improves outcomes. 4. Locally we have seen improved outcomes with increased recognition and early goal directed therapy.

19 Free app under: Questions??? Sepsis guide: Surviving Sepsis Quick Reference

20 References 1. Elixhauser A, Friedman B, Stranges E. Septicemia in U.S. Hospitals, Agency for Healthcare Research and Quality, Rockville, MD. (Accessed on February 15, 2013). 2. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315: Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, et al. Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8): doi: /jama qsofa KPNC, VA, KC (Seattle) EMS, ALERTS (Germany) 6. Kumar A. et al., Crit Care Med 2006, 34:1286

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