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

5/13/2014 1

CODE SEPSIS (not now…maybe later)

David Shimabukuro, MDCM Associate Professor Medical Director, 13 ICU Physician Lead, UCSF DSRIP Sepsis Project

Disclosures

• I have no disclosures

Agenda

• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations

Agenda

• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations

5/13/2014 2

Epidemiology

• By the numbers…

– Greater than 750,000 adults every year – Greater then $10 billion a year in associated costs – US mortality rate between 25‐30%

Compared to other major diseases

†National Center for Health Statistics, 2001. §American

Cancer Society, 2001. *American Heart Association.

• 2000. ‡Angus DC et al. Crit Care Med. 2001 .

50 100 150 200 250 300 AIDS* Colon Breast Cancer§ CHF† Severe Sepsis‡ Cases/100,000

Incidence of Severe Sepsis

US Death rate over time

50 100 150 200 250 300 2000 2002 2004 2006 2008 2010 Heart Disease Malignant Neoplasms Cerebrovascular Disease Septicemia National Vital Statistics Reports, vol 6, no 4, May 08, 2013

Agenda

• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations

5/13/2014 3

What is Sepsis??

• A variable condition that affects each of us

differently and is initiated by an infectious insult.

• Involves the systemic activation of the

inflammatory response and an unbalancing of the coagulation cascade

Septic Shock

SEVERE SEPSIS plus hypotension (Systolic blood pressure < 90 or Mean Arterial Blood Pressure < 65) OR Lactate > 4

Severe Sepsis

SEPSIS plus evidence

• f at least one

alteration in organ perfusion

Sepsis

SIRS plus confirmed

• r suspected infection

Sepsis: ACCP/SCCM Definitions

SIRS

T > 38.3 C or < 36 C HR > 90 beats/min Tachypnea WBC > 12K or < 4K

SIRS

T > 38.3 C or < 36 C HR > 90 beats/min Tachypnea WBC > 12K or < 4K

SIRS

T > 38.3 C or < 36 C HR > 90 beats/min Tachypnea WBC > 12K or < 4K

Severe Sepsis Definition

Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637

Management of Severe Sepsis and Septic Shock

Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637

5/13/2014 4 Management of Severe Sepsis and Septic Shock

1

Management of Severe Sepsis and Septic Shock

• Blood cultures should not delay

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

5/13/2014 5 Management of Severe Sepsis and Septic Shock Management of Severe Sepsis and Septic Shock

• Normalization of lactate as a resuscitation goal

is suggested

– Use of rate of lactate clearance is mentioned, but not endorsed as a sole target

Management of Severe Sepsis and Septic Shock

• Fluid Therapy

– Crystalloids are first choice for the overwhelming majority of patients – Albumin can be used to reduce volume from crystalloids, but no difference on mortality – Hydroxyethyl starches should not be used

5/13/2014 6 Management of Severe Sepsis and Septic Shock Management of Severe Sepsis and 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 Septic Shock

• Blood Products

– 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

Management of Severe Sepsis and Septic Shock

• More recommendations…refer to original

paper

5/13/2014 7

How do we find it?? Sepsis Screening

Crit Care Med February 2013 Volume 41 Number 2 pp. 580‐637

Great….but when should we do it and how should it be done!!!!

Sepsis Screening Sepsis Screening

5/13/2014 8

Sepsis Screening

• Important to have one that works for the

hospital

• Should probably do once a shift (no clear

data)

• Screening works as a reminder for continued

vigilance

Agenda

• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations

UCSF Sepsis Work To Date

• Sepsis Work Group

– Literature review and analysis of Sepsis Resuscitation and Management Bundles – Consensus on bundle elements – Sepsis Screening Tool – APeX Sepsis Accordion – Code Sepsis

31

Severe Sepsis Resuscitation Goals*

• Lactate

– Within 6 hours from time of presentation (TOP)

• Blood Cultures

– Drawn before an antibiotic is given

• Antibiotics

– Start of administration within 1 hour of the TOP (non ED), 3 hours (ED)

• Fluid Resuscitation

– 20‐30 mL/kg or a minimum of 1000 mL of crystalloid (or albumin equivalent) administered as a bolus within 1 hour of 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
• f severe sepsis and septic shock: 2008. Crit Care Med,1, 296‐327.

5/13/2014 9

Chest 2008; 134: 172‐178

Controversies

Crit Care Med 2010 Vol 38 No 2 pp 367‐374

Controversies Controversies

5/13/2014 10

JAMA February 24, 2010 Vol 303 No 8 pp 739‐746

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 – Positive screen with organ dysfunction

Code Sepsis

Who should activate a Code Sepsis?

– RNs & MDs caring for patients

How is a Code Sepsis Activated?

– Pager Box: Code Sepsis Activation

Roles and Responsibilities

• Bedside RN

– Activates Code Sepsis & notifies Primary Team – Presents patient conditions – Assists with sepsis resuscitation

• Primary Team

– Responds to patient’s bedside – Collaborate on treatment decisions – Write orders as needed

5/13/2014 11

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

• 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

Our data Agenda

• Epidemiology
• The “Surviving Sepsis Campaign Bundles”
• The UCSF Experience
• Future considerations

Future Considerations

• State mandates
• NQF
• CMS

– TJC – Leapfrog

5/13/2014 12

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.