Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Psychoneuroimmunology wikipedia , lookup
Inflammation wikipedia , lookup
Hygiene hypothesis wikipedia , lookup
Urinary tract infection wikipedia , lookup
Carbapenem-resistant enterobacteriaceae wikipedia , lookup
Acute pancreatitis wikipedia , lookup
Infection control wikipedia , lookup
Hospital-acquired infection wikipedia , lookup
SEPSIS Recognition, Treatment and Referral Dr. Vida Hamilton National Clinical Lead Sepsis www.hse.ie/sepsis Sepsis - 2 • A dysregulated immune response to infection • Regulated o Innate & Adaptive • Cellular: Dendritic cells, T-cells, B-cells • PAMPs that bind TLR 2,3,4, Mannin-binding lecithin receptors • (DAMPs) • Molecular: complement, acute phase, cytokines • Anti-viral: Interfon, local cellular immunity, apoptosis Regulated? • Local inflammation o Vasodilation, capillary leak • Systemic inflammation o SIRS, CARS Bone 1996 ‘Hyperinflammatory response’ Sepsis – 1 • Control inflammation – improve outcome • Multiple studies o Steroids o Anti- TNF o Anti-IL1 o Anti-IL6 o Other monoclonal antibodies • At best – no improvement • Often – increased mortality NEJM Actors • Micro-organism o Virulence o Innoculation dose o Multi-drug resistance • Host o Genetic polymorphisms o Co-morbidities • Age • Chronic health status • Immuno-modulatory medications More pathophysiology • Hotchkiss 2013 Dysregulated? • Multi-organ dysfunction then failure o Little necrosis • • • • Apoptosis of the cellular immune system Anti-inflammatory phase ‘ immunoparalysis’ D4 persistent lymphopenia ‘Stimulate immune system improve outcome’ Sepsis-3: A life threatening organ dysfunction caused by a dysregulated host response to infection • SOFA score o o o o o o Respiration: PaO2/FiO2 or SaO2/FiO2 Coagulation: Platelets Liver: Bilirubin Cardiovascular: Hypotension or vasopressor CNS: GCS Renal: Creatinine or urinary output • qSOFA o RR> 22, Altered Mental status, SBP <100 1o outcome: increased specificity in predicting Mortality > 10%; ICU LOS > 3 days The Burden • Common • Sepsis: • AMI: 330 per 100,000 per annum 208 per 100,000 per annum • Mortality: 20 - 55% The Burden in Ireland • HIPE data: o 60% all in-hospital deaths has a sepsis or infection diagnosis o Number of sepsis cases = 8,770 o Number of bed days = 220,288 2013 2012 2011 o In-hospital mortality 28.8% 31.3% 32.4% Reality of Sepsis 2013 Without With ALOS Sepsis 5.59 26 ALOS Infection 5.59 10 ALOS Maternity 2.61 5.47 ALOS Paediatrics 3.08 22.19 Age standardised hospital discharge rate for medical septic shock, 2005 - 2012 Age standardised hospital discharge rate for surgical septic shock, 2005 - 2012 Costs • 25,000 euro per acute presentation • Chronic health burden for survivors o Anxiety, depression, post-traumatic stress o Musculo-skeletal, immune suppression o Shortened life expectancy Cognitive impairment Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis. JAMA, 2010. Issues • 90% of cases with poor outcome in the Australian sepsis database, inadequate recognition was found to be the most common feature An Irish Report • The categorisation of the severity of a patients illness • The early detection of that deterioration • The use of a standardised and structured communication tool such as ISBAR • Early medical review that is prompted by evidence based trigger points • A definite escalation plan that is monitored and audited on a regular basis National Sepsis Guidelines • Aim for decrease in in-hospital mortality by 20% for severe sepsis • Care pathway for every patient diagnosed with sepsis in Ireland • Recognition, Resuscitation, Referral • Education, audit Diagnostic criteria for sepsis SIRS Sepsis Severe Sepsis Septic Shock •Infectious & non infectious causes •Clinical response arising from a non specific insult •SIRS plus •Presumed or confirmed infection •Sepsis plus •Sepsis-induced organ dysfunction or tissue hypoperfusion •Sepsis-induced hypo-perfusion or hypotension persisting despite 30 mls/kg fluid rescusitation SIRS Criteria • • • • • • T > 38.3, < 36 HR > 90 RR > 20 WCC > 12, < 4 BSL > 7.7 mmol/l in non-diabetic Altered mental status Common mistake - 1 • Other inflammatory parameters o CRP, PCT • Organ dysfunction parameters o Hypoxia, Oliguria, Creatinine, Coag, Platelet, Bilirubin, Ileus • Tissue perfusion parameters o Mottling, capillary refill, lactate • Haemodynamic variables o BP <90, MAP < 70, SBP > 40mmHg from baseline Sources of sepsis • • • • • • • Respiratory Urinary tract Intra-abdominal CRBSI Device CNS Others 38% 21% 16.5% 2.3% 1.3% 0.8% 11.3% Give 3 Take 3 1.OXYGEN: Titrate O2 to saturations 1. CULTURES: Take blood cultures of 94 -98% or 88-92% in chronic lung before giving antimicrobials (if no disease. significant delay i.e. >45 minutes) and consider source control. 2. FLUIDS: Start IV fluid resuscitation if evidence of hypovolaemia. 500ml bolus of isotonic crystalloid over 15mins & give up to 30ml/kg, reassessing for signs of hypovolaemia, euvolaemia, or fluid overload. 2.BLOODS: Check point of care lactate & full blood count. Other tests and investigations as per history and examination. 3. ANTIMICROBIALS: Give IV antimicrobials according to local antimicrobial guidelines. 3. URINE OUTPUT: Assess urine output and consider urinary catheterisation for accurate measurement in patients with severe sepsis/septic shock. Sepsis screening • Early recognition • 2% of all ED referrals are due to sepsis • NSW audit of NEWS: sepsis is the cause of 30% of triggered reviews • UK: NEWS > 5; 52% sepsis ED vs In-patient ED • Community acquired • Less co-morbidities • Generalised training • Mortality 20% Ward • • • • • Hospital acquired Co-morbidities Second – Hit Specialist training Mortality ??? Higher Prompt treatment • Sepsis is a time-dependent medical emergency • Mortality increases by 7.6% for each hour delay to appropriate antibiotics (Kumar CCM 2006) Early antibiotics are good Author N Setting Median Odds ratio time (mins) for death Gaieski 261 ED, USA (shock) 119 CCM 2010; 38;104553 Daniels 567 Emerg Med J 2010; doi:10.1136 Kumar 2154 CCM 2006; 34(6): 1589-1596 Appelboam 375 CCM 2010; 14(Suppl 1):50 Levy CCM 2010; 38(2): 18 15022 0.30 (1st hour vs all times) Whole hospital, 121 UK 0.62 ED, Canada (shock) 0.59 360 (1st hour vs all times) (1st 3 hours vs delayed) Whole hospital, 240 UK 0.74 Multi-centre 0.86 (1st 3 hours vs delayed) (1st 3 hours vs delayed) Management of sepsis in adult in-patient Start Smart • 9-fold increase in mortality with inappropriate antibiotics • Independent risk factors o COPD o Immunocompromised o Chronic dialysis Then Focus • Daily patient review o Investigations o Culture results • Five options o o o o o Continue current antimicrobial Change antimicrobial Change iv to oral Stop OPAT Risk stratification Trzeciak, S et al. Int Care Med 2007; 33(6):870-7. n-=1177 Fluid resuscitation and Mortality Figure 3. Mean hospital mortality among patients with decreased lactate within 8 hours of index test, stratified by total fluid received in increments of 7.5 ml/kg based on medication administration record. Annals ATS, 2013 http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201304-099OC Cultures – common mistake 2 Compliance with sepsis 6 • Reduces the relative risk of death by 46.6% • 1 additional life saved for every 5 care episodes • Mortality reduced from 44% to 20% o Daniels et al, Emergency medicine journal 2011 Compliance with Sepsis 6 R Daniels UK Sepsis Trust 2011 Severe sepsis audit – SSC Inital Sepsis Bundle 100 90 80 Percent in Compliance 70 60 50 40 30 20 10 0 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 Serum lactate within 3 Hrs Blood Culture before Antibiotics Antibiotic Compliance Fluids for hypotension or elevated lactate May-15 Jun-15 Fluid resuscitation trials Antibioti PreEGDT c randomis mins ation (mls/kg) Usual Care ProCES S 76 30 2.8 +/- 1.9 2.3 +/- 1.9 ARISE 70 34 1.96 +/-1.4 ProMis e 70 2 litres 2.0 +/- 1.0 Protocol Standar dCare Mort 28-day Mort 90 day (60 day in ProCESS) UC/EGD UC/EGD T T 3.3 +/- 1.7 18.9/21/ 18.2 33.7/31.9 /30.8 1.7 +/-1.4 14.8/15.9 18.6/18.8 1.78 +/- 1.0 24.5/24.8 29.2/29.5 Impress Sept 2014 Mortality US 24% Europe 28% Bundle compliant 20% Non-bundle compliant 30% p=0.026 HIPE: Diagnosis of Sepsis, Severe Sepsis or Septic Shock in 2015 Number of Inpatients Number of Deaths Crude Mortality Rate Sepsis 9239 1756 19.0% Severe Sepsis 111 38 34.2% Septic Shock 509 217 42.6% Total 9859 2011 20.4% Diagnosis HIPE: Inpatients with a Diagnosis of Sepsis, Severe Sepsis or Septic Shock in 2015 Diagnosis Sepsis Severe Sepsis Septic Shock Number of Inpatients Number of Deaths Crude Mortality Rate Yes 2542 680 26.8% No 6697 1076 16.1% Total 9239 1756 19.0% Yes 73 29 39.7% No 38 9 23.7% Total 111 38 34.2% Yes 372 153 41.1% No 137 64 46.7% Total 509 217 42.6% Yes 2987 862 28.9% 6872 1149 16.7% 9859 2011 20.4% Admission to Crit Total Sepsis, Severe No Sepsis & Septic Shock Total Hospital Inpatient Enquiry: Crude Mortality for Inpatients with a Diagnosis of Sepsis & Admission to Critical Care, by Age Group, 2015 50.0% 45.0% Mortality Rate 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 0-14 Years 15-34 Years 35-44 Years 45-54 Years 55-64 Years 65-74 Years 75-84 Years 85+ Years OECD Health Care Quality Indicators National Healthcare Quality Reporting System March 2015 Number per annum Mortality Change in Mortality 2004 - 2013 AMI 6125 6.4% H. Stroke 1456 26% I. Stroke 4485 10% Sepsis 9859 20.4% ? 40% 13.6% Reassess • Is your patient responding to treatment? • After an initial response have they deteriorated again? • Are they having a prolonged static period? • Don’t forget recent travel, seasonal outbreaks, risk factors for MDRs Barriers to implementation • Lack of awareness, Lack of agreement • Lack of self-efficacy o Perception – Reality gap, o Education o Audit Audit • HIPE Metadatasheet o Mortality o ICU admission o Median LOS • Compliance (> 95% form in chart) o All ED patients admitted with sepsis o All NEWS > 4 with infection Summary • • • • Recognise, Resuscitate, Refer Sepsis 6 in the 1st hour Risk stratify and document Review Thank you www.hse.ie/sepsis