National Clinical Lead Sepsis Bone 1996 Control inflammation - - PowerPoint PPT Presentation

Dr Vida Hamilton FCARCSI FJFICMI National Clinical Lead Sepsis

Bone 1996

Control inflammation – improve outcome Multiple studies

• Steroids
• Anti- TNF
• Anti-IL1
• Anti-IL6
• Other monoclonal antibodies

At best – no improvement Often – increased mortality

NEJM 2003

Regulated

• 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

Micro-organism

• Virulence
• Innoculation dose
• Multi-drug resistance

Host

• Genetic polymorphisms
• Co-morbidities

 Age  Chronic health status  Immuno-modulatory medications

 Hotchkiss 2013

Multi-organ dysfunction then failure

• Little necrosis
• Apoptosis of the cellular immune system
• ‘Hibernation’ theory

D4 Lymphopenia HLA – DR expression

• Eosinopenia – Eckhart 1890’s

Recrudescence of latent viruses

• CMV, HSV

New therapies

• ‘Stimulate immune system – improve outcome’
• GM-CSF

• SOFA score Rise ≥ 2 points
• Respiration

Coagulation

• Liver

Cardiovascular

• CNS

Renal

qSOFA

2/3

• RR> 22, Altered Mental status, SBP <100

1o outcome: increased specificity in predicting Mortality > 10%; ICU LOS > 3 days

Not a trigger to treat Identifies a cohort of patients with high risk of

mortality and intensive care requirement

Trigger to treat remains

• INFECTION +

 SYSTEMIC INFLAMMATION and/ or  NEW ONSET ORGAN DYSFUNCTION

Common Sepsis:

330 per 100,000 per annum

AMI:

208 per 100,000 per annum

Mortality: 20 - 55% 2013: 187 cases per 100,000

0% 5% 10% 15% 20% 25% 30% 35% 40% 0-14 Years 15-34 Years 35-44 Years 45-54 Years 55-64 Years 65-74 Years 75-84 Years 85+ Years

Mortality Rate

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0%

0-14 Years 15-34 Years 35-44 Years 45-54 Years 55-64 Years 65-74 Years 75-84 Years 85+ Years Mortality Rate

5 10 15 20 25 30 35 40 45 50 < 44 years 45 - 64 65 - 84 >= 85 Australia Ireland

 Recognised outcome measures of acute care

quality

Number per annum Mortality Change in Mortality 2004 - 2013 AMI

6125 6.4%  40%

• H. Stroke

1456 26% 

• I. Stroke

4485 10%  13.6%

Sepsis

9859 20.4%

90% of cases with poor outcome in

the Australian sepsis database, inadequate recognition was found to be the most common feature

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

Sepsis is increasing in incidence It is expensive, health and financial Patients who receive

• Oxygen
• Antimicrobials
• IV fluids

Within 1 hour in severe sepsis Compliant < 20% mortality Non-compliant > 30%

Give 3 Take 3

1.OXYGEN: Titrate O2 to saturations

• f 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 & 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
• utput

It is a continuum Infection

• Pathological invasion of a normally sterile site

Sepsis Severe sepsis Septic shock Multi-organ failure

General variables

• T
• C, HR, RR, WCC, BSL, Mental status

Inflammatory variables

• CRP, Procalcitonin

Organ dysfunction variables Tissue hypo-perfusion variables

• Lactate, CRT

Haemodynamic insufficiency variables

• Sys BP <90, MAP < 65, CO

New onset organ dysfunction Worsening organ dysfunction

• Due to infection

SIRS SOFA Treatment

• O2/ Ventilation

Cultures/source control

• IV fluids/ pressors

Tests/ investigations

• Antimicrobials Urine output/ other organs

Re-assess Repeat lactate if the 1st was abnormal (or if

patient deteriorates)

Apply vasopressors for hypotension not

responding to fluid resuscitation

• CVC
• Arterial line

Repeat lactate as clinically indicated

Trzeciak et al; Intensive Care Med (2007) 33:970–977

NEJM 2003

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

Respiratory

38%

Urinary tract

21%

Intra-abdominal

16.5%

CRBSI

2.3%

Device

1.3%

CNS

0.8%

Others

11.3%

Reduces the relative risk of death by

46.6%

1 additional life saved for every 5 care

episodes

Mortality reduced from 44% to 20%

 Daniels et al, Emergency medicine journal 2011

10 20 30 40 50 60 70 80 90 100 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Percent in Compliance

Inital Sepsis Bundle

Serum lactate within 3 Hrs Blood Culture before Antibiotics Antibiotic Compliance Fluids for hypotension or elevated lactate

Bacteria, viruses, fungi, parasites Sepsis is the common fatal pathway H1N1 – Immunocompromised host

 Elderly  Co-morbidities  Pregnant

Presented with organ failure Treatment supportive, anti-virals Vaccinate – prevention better than cure

Black death

• Famine induced immuno-compromised host
• Poverty, lack of knowledge

Spanish ‘flu

• Pathogen mutation – increased virulence
• War, mass movement, lack of knowledge

EVD

• Poverty, lack of knowledge, cultural practice

 Hand hygiene/ Sanitation / Education

High or very low temperature Fast heart rate Fast respiratory rate Little urine output Altered mental state Severe leg pain ‘I feel like I am dying’

• Survivors self reported symptoms and signs
• UK Sepsis trust

Source control

• Drainage
• Debridement

Responding

• Stabilisation

De-escalation

Decrease mortality x 20% over 5 yrs Decrease chronic sequelae More efficient use of limited

healthcare resources

Promote preventative practices

Guideline 2014 Implementation 2015 Pathways

• Paramedic
• Maternity
• Paediatrics
• Primary care
• Prison service
• Nursing homes

Awareness

• Hospital site visits
• Community awareness

Education

• Undergraduate,
• Postgraduate
• National intern training
• (Safe start programme)
• E-learning
• Smart phone app

National Sepsis Outcome Report

• Incidence
• Mortality rate
• Median LOS
• ICU admission rate

Compliance audit

• Clinical decision support tool usage
• Time to 1st dose antimicrobials

Ist update of National Guideline Quantify the burden of sequelae in

survivors of severe sepsis and septic shock

Develop and assess a rehabilitation

programme

Any questions? www.hse.ie/sepsis @vidamthamilton