National Clinical Lead Sepsis wwwhseiesepsis Sepsis Final common pathway for death from infection National Awareness Survey 2016 25 Doctors amp 29 Nurses interviewed ID: 1037742
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1. So what about SEPSIS?Dr. Vida HamiltonNational Clinical Lead Sepsiswww.hse.ie/sepsis
2. Sepsis‘Final common pathway for death from infection’National Awareness Survey 201625% Doctors & 29% Nurses interviewed didn’t think you needed infection to develop sepsis
3. Content ValidityFace validity
4. Epidemiology201614000 cases19% Hospital mortality70-80% arise in the Community (CDC)Increasing in incidence 10 % annually pre 201667% over past 12 monthsFactors that are associated with increasing incidence & high mortality rate?
5. Epidemiology
6. Number of cases with age
7. Mortality with age
8. With co-morbidities
9. Surgical DRG
10. Seasonal variation
11. No gender difference
12. 30% Mortality
13. Risk stratification
14. 3.4% hospital cases 25% hospital deaths
15. Bed occupancy partial offset by 28.5% aLOS
16. What is sepsis?InfectionTriggering an host responseLeads to organ dysfunction & death
17. Pathophysiology
18. Sepsis 1 & 2: ‘Hyper-inflammatory to dysregulated response’Bone 1996
19. InfectionNon-specific signs & symptomsSIRSTemperatureT > 38.3 or < 36oCRigorsHR > 90 beats/minAnorexiaRR > 20 breaths/minFatigueWCC > 12 or < 4MyalgiaCRPArthralgiaProcalcitoninVomiting & diarrhoea
20. Sites of infectionRespiratory 35 - 50%Urinary tract 15 - 25%Intra-abdominal 15 - 25%Skin 11% Catheter-related, device-related, intra-articular, boney, post-procedural etc
21. Clinical signs of organ dysfunctionBrainAcute confusionAltered functional stateLungsRR > 30HypoxiaHeartHR > 130SBP < 100 or > 40mmHg drop from normal levelKidneysOligoureaCreatinine > 177SkinProlonged central capillary refillPurpuric rashLactate >2mmol/L
22. Lactate Trzeciak, S et al. Int Care Med 2007; 33(6):870-7.
23. Sepsis related organ dysfunction
24. Clinical presentationMicro-organismVirulenceInnoculation doseMulti-drug resistanceHostGenetic polymorphismsCo-morbiditiesAgeChronic health statusImmuno-modulatory medications
25. Sepsis-3‘A life-threatening organ dysfunction caused by a dysregulated host response to infection’ Advantage: ‘Now that’s sepsis!’Disadvantage:Move from ‘bedside diagnosis’ definition with SIRSLooking at higher mortality risk condition, ‘badness’, to an ‘outcome’ based definitionRisk of time delay to diagnosis
26. SOFA ≥ 2 above baselineconsequent to the infection
27. Sepsis diagnosis
28. Criteria validityHow can the patients who may benefit from early treatment be identified?
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30. Why don’t we just use qSOFA?qSOFA positive if > 1 presentRR > 22, SBP < 100, Altered mental status Prognostic indicator Not a diagnostic toolNot a ‘trigger to treat’ toolNot validated in undifferentiated patientsDeveloped in patients already on antimicrobial therapyNEWS consistently outperforms qSOFA
31. Significant Co-morbiditiesCOPDFrailty Age > 75yrsDiabetes mellitusChronic kidney disease Chronic liver diseaseCancer ImmunosuppressedHIV/AIDS infection Trauma or surgery in past 6 weeks
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33. Sepsis 6 bundle
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35. Give 3Take 31.OXYGEN: Titrate O2 to saturations of 94 -98% or 88-92% in chronic lung disease.1. CULTURES: Take blood cultures before giving antimicrobials (if no 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, FBC, U&E, LFTS, +/- Coag. 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.
36. Sepsis diagnosis
37. Context validityTranslating research into clinical practiceOrGeneralisability
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42. ReliabiltyInter-user, across place and across time
43. Audit results 2016 n= 1489With formWithout formDiagnosis made and documented87%44%Risk stratification correct74%24%1st dose antimicrobials within 1 hour74.5%46.5%Only 56% of sepsis cases were documented as sepsis in the case notes
44. 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, 2013http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201304-099OCFluid resuscitation and Mortality
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46. Timeliness
47. OperationalisationAn important feature of our pilot studiesIs the CDST useable within the clinical contextTriage screen important but a potential added burdenECG in chest painDoes it add or reduce workBenefit needs to out way any burden
48. MeasurementIf you don’t measure it you can’t change it
49. Compliance with Sepsis 6 2017Process auditNational ComplianceSepsis documented correctly60%Antibiotics within the 1st hour72%Antibiotic as per guideline64%Blood cultures before antibiotic80%Lactate taken75%Repeat lactate (when indicated)71%Fluid bolus 42%
50. OECD Health Care Quality Indicators Healthcare Quality Reporting System, Ireland, 2015Number per annumMortalityChange in Mortality 2004 - 2013AMI6,1256.4% 40%H. Stroke1,45626%I. Stroke4,48510% 13.6%Sepsis14,00019% 30% (2011)
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52. Thank youwww.hse.ie/sepsis