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Sepsis 3.0 Revised Sepsis Guidelines and the Impact on Practice Objectives • Consider the impact of sepsis, emphasizing the importance of early recognition & treatment • Review the current sepsis definitions and discuss the proposed changes • Examine key elements of the Surviving Sepsis Guidelines Cleveland Clinic—Fairview Hospital Cleveland, Ohio Disclosures • I have no financial disclosures • http://www.sepsisalliance.org/ Sepsis • Sepein – Greek, to rot • Septikos – Greek, characterized by putrefaction • Septicus – Latin, of or pertaining to putrefaction http://www.montereybayaquarium.org/animal-guide/octopuses-and-kin/common-cuttlefish What percentage of the general public has even heard of sepsis? A. 19% B. 31% C. 43% D. 55% E. 67% However, most people could not place the correct context Sepsis • “Septicemia is a state of microbial invasion from a portal of entry into the bloodstream which causes signs of illness.“ » Schottmueller, 1914 Sepsis • Admissions for sepsis in 2000 621,000 • Admissions for sepsis in 2008 1,141,000 • Mortality rate of 28-50% – http://www.cdc.gov/sepsis/basic/qa.html Sepsis • Contributed to 1 in every 2 to 3 hospital deaths, and most of these patients were admitted with sepsis » JAMA July 2, 2014 Volume 312, Number 1, Page 90 • The most expensive hospital condition, costing over $24 billion per year » Statistical Brief #204, May, 2016 » Healthcare Cost and Utilization Project Sepsis • 40% of total ICU expenditure – Davies, et al. 14th Annual Congress of the European Society of Intensive Care Medicine 2001 • The number of sepsis patients is projected to increase by 1.5% per year – Angus, et al. Crit Care Med 2001 Hospital Readmissions • Patients who survived sepsis to be discharged from the hospital • More than 40% were readmitted within 90 days • Half of these readmissions were deemed possibly preventable – JAMA March 10, 2015 Volume 313, Number 10 Hospital Readmissions • Patients who survived sepsis to be discharged from the hospital – The majority of unplanned hospital readmissions after sepsis are due to an infection and identified that many rehospitalized survivors present through the ED with recurrent sepsis – Crit Care Med March 2016 • Volume 44 • Number 3 – Sepsis is a leading contributor to excess healthcare costs due to hospital readmissions – Crit Care Med October 2015 • Volume 43 • Number 10 Hospital Readmissions • Index admission for heart failure – Pneumonia & sepsis are frequent reasons for readmission • Index admission for acute myocardial infarction – Pneumonia & sepsis • Index admission for pneumonia – Recurrent pneumonia, sepsis, C. diff infection – JAMA January 23/30, 2013—Vol 309, No. 4 Mortality • • • • • • • • • MI All cancers combined Sepsis Stroke COPD Alzheimer’s Motor vehicle crashes Prescription drug overdose Firearm deaths ~610,000 deaths/year ~600,000 ~300,000 ~140,000 ~135,000 ~85,000 ~35,000 ~35,000 ~35,000 How many deaths could be prevented each year if optimal care is provided to every septic patient? A. 22,000 B. 37,000 C. 62,000 D. 77,000 E. 92,000 Crit Care Med 2007;35(5):1257 Definitions • Systemic inflammatory response syndrome (SIRS) • Two or more of the following variables: – Temperature greater than 38°C or less than 36°C – Heart rate greater than 90 beats per minute – Respiratory rate greater than 20 breaths per minute or a PaCO2 level of less than 32 mm Hg – Abnormal white blood cell count (>12,000/mL or <4,000/mL or >10% bands) Definitions • Sepsis – SIRS + infection • Severe sepsis ICD-10-CM A41.9 – SIRS + infection + new organ dysfunction • Septic shock ICD-10-CM R65.21 – Impaired perfusion despite adequate fluid resuscitation Organ Dysfunction Increased thrombosis & decreased fibrinolysis Microvascular thrombosis Decreased microvascular flow Ischemia Organ Dysfunction Capillary leak Hypovolemia Decreased cardiac output Hypovolemic shock Increased interstitial fluid Edema Acute lung injury Decreased cardiac compliance Organ Dysfunction Increase in nitric oxide production Vasodilation Oxidative injury Hypotension Distributive shock Direct cellular damage Impaired mitochondrial function Organ Dysfunction • Damaged cell membranes • Impaired cardiac output – Hypovolemic – Distributive – Cardiogenic • Blockage of microvascular flow • Disordered oxygen metabolism Organ Dysfunction • • • • • • • • • • Altered mental status Acute kidney injury Acute lung injury Decreased cardiac output Insulin resistance Acid-base derangement Thrombocytopenia Ileus Coagulopathy Adrenal insufficiency Sepsis can be diagnosed by: A. Positive blood cultures B. Elevated C-reactive protein C. Elevated lactic acid D. Elevated procalcitonin E. All of the above F. None of the above Surviving Sepsis • Surviving Sepsis Campaign (2002) – Society of Critical Care Medicine – European Society of Intensive Care Medicine – International Sepsis Forum • Surviving Sepsis Guidelines – http://www.survivingsepsis.org/ Surviving Sepsis • Routine screening of at-risk patients • Obtain appropriate cultures & imaging • The administration of effective intravenous antimicrobials within the first hour of recognition • Source Control • Initial Resuscitation Lactate • “Measuring lactate levels can risk stratify patients with suspected sepsis, to prompt aggressive early treatment, and help monitor the impact of therapy” – Chee C et al. Crit Care Med 2015 Lactate • “The prognostic value of lactate levels exceeds that of blood pressure.” • “Many studies have confirmed the association between initial serum lactate level and mortality independently of clinical signs of organ dysfunction” – Cecconi M, et al. Intensive Care Med 2014;40:1795 • “In this multicenter, openlabel randomized controlled study, lactate monitoring during the first 8 hours of ICU admission, aimed at reducing lactate levels by at least 20% per 2 hours, significantly reduced ICU length of stay and also ICU and hospital mortality” – Jansen TC, et al. Am J Respir Crit Care Med 2010;182:752 Initial Resuscitation • “We recommend the protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion” – Surviving Sepsis Guidelines Initial Resuscitation • “We suggest targeting resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion” – Surviving Sepsis Guidelines Surviving Sepsis • TIME SENSITIVE! – Identify patients early in their course – Administer antibiotics promptly – Fluid resuscitation—fast & furious The minimum volume of the initial fluid resuscitation for the septic patient is: A. 250 ml B. 500 ml C. 1000 ml D. 10 ml/kg E. 30 ml/kg Surviving Sepsis 3-hour bundle • Measure lactate level • Draw blood cultures • Administer broad spectrum antibiotics • Administer 30 ml/kg crystalloid fluid bolus 6-hour bundle • If persistent hypotension after initial fluid resuscitation, then: – Add vasopressors – Measure CVP, SvO2 – Remeasure lactate Surviving Sepsis • Compliance with the Surviving Sepsis Campaign bundles is associated with improved mortality – Levy MM, et al. Crit Care Med 2015;43:3 – Levy MM et al. Intensive Care Med 2010;36:222 National Inpatient Quality Measures • Within 3 hours of identification of severe sepsis: – Initial lactate level measurement – Broad spectrum or other antibiotics administered – Blood cultures drawn prior to antibiotics • Within 6 hours: – Repeat lactate measurement if initially elevated National Inpatient Quality Measures • Within 3 hours of identification of septic shock: – Initial lactate level measurement – Broad spectrum or other antibiotics administered – Blood cultures drawn prior to antibiotics • Within 6 hours: – Repeat lactate measurement if initially elevated – Resuscitation with 30 ml/kg crystalloid fluids – Vasopressors if hypotension persists after fluid administration National Inpatient Quality Measures Reassessment to include OR • Any 2 of the following: • A focused exam including: – Central venous – Vital signs, AND – Cardiopulmonary exam, AND – Capillary refill evaluation, AND – Peripheral pulse evaluation, AND – Skin examination pressure measurement – Central venous oxygen measurement – Bedside Cardiovascular Ultrasound – Passive Leg Raise or Fluid Challenge Challenges • • • • Can Can Can Can we screen patients effectively? we measure the lactate quickly? fluids be administered rapidly? the patient be frequently re-assessed? Challenges • • • • Can Can Can Can we screen patients effectively? we measure the lactate quickly? fluids be administered rapidly? the patient be frequently re-assessed? • Who’s going to do all of this? Definitions • Sepsis – SIRS + infection • Severe sepsis – SIRS + infection + new organ dysfunction • Septic shock – Impaired perfusion despite adequate fluid resuscitation • Many patients with severe sepsis do not have SIRS • Many patients with severe sepsis do not initially have any obvious organ dysfunction • Infection + new organ dysfunction can occur in the absence of severe sepsis The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) • Definitions of sepsis, severe sepsis, and septic shock revisited • Fair sensitivity & poor specificity of SIRS • Recognition of inflammation as a normal response to infection – JAMA February 23, 2016 Volume 315, Number 8 Key Concepts • Difficult to distinguish between “normal” and “dysregulated” inflammatory response • Organ dysfunction may not be obvious • Sepsis might not be the cause of organ dysfunction Key Concepts • No “gold standard” diagnostic test for sepsis • Change in approach to screening patients for sepsis – New infectionlook for organ dysfunction – New or worsening organ dysfunctionlook for infection Proposed Definitions • Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection – Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points consequent to the infection • JAMA 2016;315(8):801-810 Proposed Definitions • Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality – Hypotension requiring vasopressor therapy to maintain mean BP 65mmHg or greater and having a serum lactate level greater than 2 mmol/L after adequate fluid resuscitation • JAMA 2016;315(8):775-787 Logistic Organ Dysfunction System LODS • • • • • • • • • • Heart rate Systolic blood pressure pO2/fiO2 Glasgow Coma Score Serum creatinine Serum urea Bilirubin White blood cell count Prothrombin time Platelets – JAMA 1996;276(10):802-810 http://statpages.info/lods.html Sequential Organ Failure Assessment SOFA Crit Care Med 1998; 26:1793-1800 qSOFA • 0-3 points • 1 point each for: – Respiratory rate ≥ 22 – Glasgow Coma Score ≤ 13 – Systolic blood pressure ≤100 • JAMA February 23, 2016 Volume 315, Number 8 qSOFA • The presence of 2 or more qSOFA points associated with a greater risk of death or prolonged intensive care unit stay • Prompt to identify infected patients outside the ICU who are likely to be septic – JAMA February 23, 2016 Volume 315, Number 8 Which are risks factors for sepsis? A. Age > 65 years B. Age < 1 year C. Immunocompromised D. Recent surgery E. Chronic disease F. Wounds G. Previous sepsis H. Invasive devices All are risk factors Keys to Surviving Sepsis • Prevention • Prevention • Prevention Prevention • Central venous catheter maintenance bundle – – – – – Hand hygiene Scrub the hub Aseptic access technique Daily review of line necessity Appropriate dressing changes https://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-22_CVC_Maintenance_Bundles.pdf Prevention • Minimize the need to access a vascular catheter – Minimize blood draws – Batch blood draws – Convert medications from parenteral to enteral as soon as practical Prevention (maybe) • • • • • • • • Antimicrobial catheter Antithrombogenic catheter Antimicrobial patch Antimicrobial dressing Sutureless securement device Disinfecting port protector Antimicrobial lock Daily chlorhexidine bath Keys to Surviving Sepsis • Early recognition – New organ dysfunction—look for infection – New infection—look for organ dysfunction – Check the lactate • Antibiotics immediately – Blood cultures prior to antibiotics • Brisk fluid resuscitation – 30 ml/kg Sample Sepsis Screening Tool Sample Sepsis Screening Tool Sepsis Screening • Look for trends – Leukocytosis & fever – Heart rate increasing – Blood sugars increasing – Platelets decreasing • Monitor for signs of new organ dysfunction – qSOFA Keys to Surviving Sepsis • It is even better to act quickly and err than to hesitate until the time of action is past – Carl von Clausewitz Keys to Surviving Sepsis • Remember—this is a time-sensitive problem, just like – MI – Stroke – Trauma Thank You!