Disclosures CODE SEPSIS I have no disclosures (not nowmaybe later) - PDF document

5/13/2014 Disclosures CODE SEPSIS • I have no disclosures (not now…maybe later) David Shimabukuro, MDCM Associate Professor Medical Director, 13 ICU Physician Lead, UCSF DSRIP Sepsis Project Agenda Agenda • Epidemiology • Epidemiology • The “Surviving Sepsis Campaign Bundles” • The “Surviving Sepsis Campaign Bundles” • The UCSF Experience • The UCSF Experience • Future considerations • Future considerations 1

5/13/2014 Epidemiology Compared to other major diseases Incidence of Severe • By the numbers… Sepsis 300 – Greater than 750,000 adults every year 250 – Greater then $10 billion a year in associated costs 200 – US mortality rate between 25 ‐ 30% 150 Cases/100,000 100 50 0 AIDS* Colon Breast CHF † Severe Cancer § Sepsis ‡ † National Center for Health Statistics, 2001. § American Cancer Society, 2001. *American Heart Association. 2000. ‡ Angus DC et al. Crit Care Med. 2001 . US Death rate over time Agenda 300 • Epidemiology 250 • The “Surviving Sepsis Campaign Bundles” 200 • The UCSF Experience Heart Disease Malignant Neoplasms 150 • Future considerations Cerebrovascular Disease 100 Septicemia 50 0 2000 2002 2004 2006 2008 2010 National Vital Statistics Reports, vol 6, no 4, May 08, 2013 2

5/13/2014 Sepsis: ACCP/SCCM Definitions What is Sepsis?? • A variable condition that affects each of us differently and is initiated by an infectious SIRS SIRS SIRS Sepsis Severe Sepsis Septic Shock insult. T > 38.3 C or < 36 C T > 38.3 C or < 36 C T > 38.3 C or < 36 C SIRS plus confirmed SEPSIS plus evidence SEVERE SEPSIS plus • Involves the systemic activation of the HR > 90 beats/min HR > 90 beats/min HR > 90 beats/min or suspected infection of at least one hypotension (Systolic Tachypnea Tachypnea Tachypnea alteration in organ blood pressure < 90 or WBC > 12K or < 4K WBC > 12K or < 4K WBC > 12K or < 4K Mean Arterial Blood inflammatory response and an unbalancing of perfusion Pressure < 65) OR Lactate > 4 the coagulation cascade Management of Severe Sepsis and Severe Sepsis Definition Septic Shock Crit Care Med February 2013 Volume 41 Number 2 pp. 580 ‐ 637 Crit Care Med February 2013 Volume 41 Number 2 pp. 580 ‐ 637 3

5/13/2014 Management of Severe Sepsis and Management of Severe Sepsis and Septic Shock Septic Shock • Blood cultures should not delay 1 administration of antibiotics. • It is not uncommon for blood cultures to be negative despite the presence of a severe infection. Crit Care Med 2006 Vol. 34, No. 6 4

5/13/2014 Management of Severe Sepsis and Septic Shock Management of Severe Sepsis and Management of Severe Sepsis and Septic Shock Septic Shock • Normalization of lactate as a resuscitation goal • Fluid Therapy is suggested – Crystalloids are first choice for the overwhelming majority of patients – Use of rate of lactate clearance is mentioned, but not endorsed as a sole target – Albumin can be used to reduce volume from crystalloids, but no difference on mortality – Hydroxyethyl starches should not be used 5

5/13/2014 Management of Severe Sepsis and Management of Severe Sepsis and Septic Shock Septic Shock • Corticosteroids – For refractory hypotension despite fluids and vasopressors/inotropes – Do not perform ACTH stimulation test • Glucose – Target level to less than 180 mg/dL Management of Severe Sepsis and Management of Severe Sepsis and Septic Shock Septic Shock • Blood Products • More recommendations…refer to original paper – HGB level 7.0 – 9.0 g/dL after hypoperfusion has resolved – FFP not to be used unless bleeding is present or for planned invasive procedure – PLT to be given prophylactically when <10K in absence of bleeding 6

5/13/2014 Sepsis Screening How do we find it?? Great….but when should we do it and how should it be done!!!! Crit Care Med February 2013 Volume 41 Number 2 pp. 580 ‐ 637 Sepsis Screening Sepsis Screening 7

5/13/2014 Sepsis Screening Agenda • Important to have one that works for the • Epidemiology hospital • The “Surviving Sepsis Campaign Bundles” • Should probably do once a shift (no clear • The UCSF Experience data) • Future considerations • Screening works as a reminder for continued vigilance UCSF Sepsis Work To Date Severe Sepsis Resuscitation Goals* • Lactate • Sepsis Work Group – Within 6 hours from time of presentation (TOP) – Literature review and analysis of Sepsis • Blood Cultures – Drawn before an antibiotic is given Resuscitation and Management Bundles • Antibiotics – Consensus on bundle elements – Start of administration within 1 hour of the TOP (non ED), 3 hours (ED) – Sepsis Screening Tool • Fluid Resuscitation – APeX Sepsis Accordion – 20 ‐ 30 mL/kg or a minimum of 1000 mL of crystalloid (or albumin equivalent) administered as a bolus within 1 hour of – Code Sepsis TOP for hypotension or lactate > 4 mmol/L • Vasopressors – Hypotension unresponsive to initial fluid bolus • CA 1115 Waiver, DSRIP Category 4, Superset of Interventions, Severe Sepsis • Dellinger et al. (2008). Surviving Sepsis Campaign: International guidelines for management 31 of severe sepsis and septic shock: 2008. Crit Care Med,1 , 296 ‐ 327. 8

5/13/2014 Controversies Chest 2008; 134: 172 ‐ 178 Controversies Controversies Crit Care Med 2010 Vol 38 No 2 pp 367 ‐ 374 9

5/13/2014 Controversies Code Sepsis What is a Code Sepsis? – A silent alert sent by pager to a designated team that includes a Pharmacist, the RRT and the ICU Fellow – Purpose is to expedite sepsis resuscitation When is a Code Sepsis Activated? – Positive screen with SIRS and lactate > 2 JAMA February 24, 2010 Vol 303 No 8 pp 739 ‐ 746 – Positive screen with organ dysfunction Code Sepsis Roles and Responsibilities Who should activate a Code Sepsis? • Bedside RN – RNs & MDs caring for patients – Activates Code Sepsis & notifies Primary Team How is a Code Sepsis Activated? – Presents patient conditions – Assists with sepsis resuscitation – Pager Box: Code Sepsis Activation • Primary Team – Responds to patient’s bedside – Collaborate on treatment decisions – Write orders as needed 10

5/13/2014 Roles and Responsibilities • RRT – Validate positive screen – Support timely blood culture collection and administration of antibiotics and fluids – Maintain time to assure resuscitation in 60 minutes Our data • Pharmacist – Facilitate verification, dispensing & delivery of antibiotics – Follow ‐ up with primary team for subsequent dosing • ICU Fellow – Assist with selection/ordering of antibiotics, fluids, vasopressors – Assist with blood culture collection as needed – Assist with determining level of care Agenda Future Considerations • Epidemiology • State mandates • The “Surviving Sepsis Campaign Bundles” • NQF • The UCSF Experience • CMS • Future considerations – TJC – Leapfrog 11

5/13/2014 Summary • A very heterogeneous disease that is difficult to diagnose in its early stages and difficult to treat in its later stages. • Routine screening can allow for earlier identification • Early intervention can attenuate its course, but the mainstay of treatment is supportive care. 12