Sepsis. Reliability- can we achieve it? @SepsisUK Dr Ron Daniels Chief Executive, Global Sepsis Alliance Fellow: NHS Improvement Faculty Chief Executive: United Kingdom Sepsis Trust & Chair, UK SSC RRAILS llandrindod Wells, 18 th July 2013
A U.K. Perspective
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A U.K. Perspective
Sepsis is on the up.. CDC National Center of Hospital Statistics
Why do we need to change?
Severe Sepsis Bundle 2008 Serum lactate measured Blood cultures obtained prior to antibiotic administration From the time of presentation, broad-spectrum antibiotics to be given within 1 hour Control infective source In the event of hypotension and/or lactate >4mmol/L (36mg/dl): Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent) Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/l (36 mg/dl): Achieve central venous pressure (CVP) of >8 mm Hg Achieve central venous oxygen saturation (ScvO 2 ) >70%
Severe Sepsis 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 (ScvO2)* 7) Remeasure lactate if initial lactate was elevated*
The Sepsis Six 1. Give high-flow oxygen via non-rebreathe bag 2. Take blood cultures and consider source control 3. Give IV antibiotics according to local protocol 4. Start IV fluid resuscitation Hartmann s or equivalent 5. Check lactate 6. Monitor hourly urine output consider catheterisation within one hour..plus Critical Care support to complete EGDT
Perspective Severe Sepsis Acute coronary syndrome No. cases per 100,000 per annum 240 208 NNT basic care Sepsis Six (our data) 4 First hour antibiotics 6 Clopidogrel 48 β-blockade 42 Aspirin 26 NNT invasive care EGDT (Rivers) 6 Resusc Bundle (SSC) 18 Thrombolysis 15 PCI over thrombolysis 33
First hour antibiotics in 27%...
Early, appropriate antibiotics are the key to sepsis improvement
fraction of total patients Cumulative Initiation of Effective Antimicrobial Therapy and Survival in Septic Shock 1.0 survival fraction cumulative antibiotic initiation 0.8 0.6 0.4 0.2 0.0 time from hypotension onset (hrs) Kumar et al. CCM. 2006:34:1589-96.
Running average survival in septic shock based on antibiotic delay (n=2154) For each hour s delay in administering antibiotics in septic shock, mortality increases by 7.6% Funk and Kumar Critical Care Clinics 2011 (in press)
Begin IV antibiotics as early as possible, and always within the first hour of recognising severe sepsis (1D) and septic shock. (1B) Citation: Kumar A et al. Crit Care Med 2006: 34(6) Retrospective, 15 years, 14 sites n = 2,154 median 6 h, 50% administered in 6h Only 5% first 30 minutes- survival 87% 12% first hour- survival 84%
Early antibiotics are good... Author n Setting Median time (mins) Odds Ratio for death Gaieski Crit Care Med 2010; 38:1045-53 Daniels Emerg Med J 2010; doi:10.1136 Kumar Crit Care Med 2006; 34(6):1589-1596 Appelboam Critical Care 2010; 14(Suppl 1): 50 261 ED, USA (Shock) 567 Whole hospital, UK 2154 ED, Canada (Shock) 375 Whole hospital, UK 119 0.30 (first hour vs all times) 121 0.62 (first hour vs all times) 360 0.59 (first hour vs second hour) 240 0.74 (first 3 hours vs delayed) Levy Crit Care Med 2010; 38 (2): 1-8 15022 Multi-centre 0.86 (first 3 hours vs delayed)
Running average survival in septic shock based on antibiotic delay (n=4195) 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0 10 20 30 40 50 60 70 80 90 100 Cumulative fraction of total survivors Running average survival Funk and Kumar Critical Care Clinics 2012
Retrospective, 22 hospitals, n= 4532 Bagshaw SM et al Intensive Care Med. 2009;35(5):871-81
Retrospective, 22 hospitals, n= 4532 64.4% septic shock patients developed early AKI Bagshaw SM et al Intensive Care Med. 2009;35(5):871-81
64.4% septic shock patients developed early AKI Retrospective, 22 hospitals, n= 4532 Median time shock to antibiotic = 5.5 h Bagshaw SM et al Intensive Care Med. 2009;35(5):871-81
64.4% septic shock patients developed early AKI Median time shock to antibiotic = 5.5 h Retrospective, 22 hospitals, n= 4532 OR for AKI 1.14 (1.10-1.20) P < 0.001 per hour s delay Bagshaw SM et al Intensive Care Med. 2009;35(5):871-81
How do we know which septic patient is going to get organ failure? We often don t know the source, let alone the bug... We don t adhere to guidelines, and the guidelines aren t much good We re not very good with our timing So...
Should we have, for first dose, the Sepsis Antibiotic? Pip/ taz? Meropenem? Co-amoxiclav?
How to achieve better sepsis outcomes?
2 groups with 2 sets of needs. 1. Get community-acquired sepsis patients to hospital quickly
2 groups with 2 sets of needs. 2. Recognize in-patient deterioration reliably
Inpatient deterioration Critical Care expenditure Critical Care length of stay Compared with ACS Cost per episode
Moore LJ, Jones SL, Kreiner LA, et al: Validation of a screening tool for the early identification of sepsis. J Trauma 2009; 66: 1539 1546
2 groups with 1 identical need. 3. Respond and escalate appropriately
Sepsis Six delivery
Compliance at Good Hope Hospital (%) 70 60 50 40 30 Sepsis 6 Resusc Both Mortality 20 10 0 Apr-09 Jun-09 Aug-09 Oct-09
Mortality by Sepsis Six Cohort size (%) Mortality % RRR % (NNT) Total 567 (100) 34.7 - Sepsis Six Sepsis Six 347 (61.2) 44.0 220 (38.8) 20.0 46.6 (4.16)
2 groups with 1 identical need. 4. Monitor long-term outcomes and rehab needs
Long-term cognitive impairment after sepsis Mild 3.8 7.1 Moderate-severe 6.2 16.8 0 5 10 15 20 Before sepsis After sepsis Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis. JAMA, 2010.
Incidence of PTSD (%) Fire/ natural disasters 4.5 Assault leading to injury 11.5 ITU survivors 22 War 38.8 Rape 55.5 0 10 20 30 40 50 60 Davydow DS, Gifford JM, Desai SV, et al.: Post traumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry 2008; 30: 421-434,
2 groups with 1 identical need. 5. Get the public message right
Healthcare-associated infection Urinary tract Surgical Site Infection Pneumonia Bloodstream infection 17% 18% 43% 22%
Sources of sepsis Healthcareassociated 38% Communityacquired 62%
Sources of sepsis Pneumonia Intra-abdominal UTI SSTI 7% 10% 25% 58%
Infections management is about... 1. Prevention of avoidable infection 2. Antimicrobial stewardship 3. Rapid treatment of sepsis and other severe infection
Infections management is about...
World Sepsis Day
What doing sepsis right might mean for us
Achieving 80% reliability For each year, for every 100k in the local population.. 20 lives saved 285 fewer bed days 168 fewer CC bed days Direct costs for survivors reduced by 0.25M For Wales, that s 600 lives and 7.5 million. Every year.
Summary Sepsis is a medical emergency- and a big killer Awareness and recognition are the key Early antibiotics and fluids will save more lives than Critical Care We need a whole-systems approach The public message around infections management needs to be refined To give equal weight to all important aspects
ron@sepsistrust.org @sepsisuk www.sepsistrust.org www.world-sepsis-day.org