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 1 o 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

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

50.0% 45.0% 40.0% 35.0% Mortality Rate 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 0-14 15-34 35-44 45-54 55-64 65-74 75-84 85+ Years Years Years Years Years Years Years Years

50 45 40 35 30 Australia 25 Ireland 20 15 10 5 0 < 44 years 45 - 64 65 - 84 >= 85

 Recognised outcome measures of acute care quality Number per Mortality Change in annum Mortality 2004 - 2013  40% 6125 6.4% AMI  1456 26% H. Stroke  13.6% 4485 10% I. Stroke 9859 20.4% Sepsis

 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 O 2 to saturations 1. CULTURES : Take blood cultures of 94 -98% or 88-92% in chronic lung before giving antimicrobials (if no disease. significant delay i.e. >45 minutes) and consider source control. 2. FLUIDS : Start IV fluid resuscitation 2. BLOODS : Check point of care if evidence of hypovolaemia. 500ml lactate & full blood count. Other tests bolus of isotonic crystalloid over 15mins and investigations as per history and & give up to 30ml/kg, reassessing for examination. signs of hypovolaemia, euvolaemia, or fluid overload. 3. ANTIMICROBIALS : Give IV 3. URINE OUTPUT : Assess urine antimicrobials according to local output antimicrobial guidelines .

 It is a continuum  Infection • Pathological invasion of a normally sterile site  Sepsis  Severe sepsis  Septic shock  Multi-organ failure

 General variables • T o 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 • O 2 / Ventilation Cultures/source control • IV fluids/ pressors Tests/ investigations • Antimicrobials Urine output/ other organs

 Re-assess  Repeat lactate if the 1 st 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

Inital Sepsis Bundle 100 90 80 Percent in Compliance 70 60 50 40 30 20 10 0 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 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 1 st 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