Sepsis ...improving reliability and outcomes

1. Sepsis...improving reliability and outcomes Dr Ron Daniels Executive Director, Global Sepsis Alliance Fellow: NHS Improvement Faculty Chair: United Kingdom Sepsis Group, Sepsis Trust & UK SSC NHS Scotland, 18th January 2012

3. Sepsis is under-appreciated. Sepsis is under-funded. We (us doctors) over-complicate sepsis care. I have less to offer septic patients once they’re in my ICU. It is inevitable that we will get our act together.

4. Sepsis is under-appreciated. Sepsis is under-funded. We (us doctors) over-complicate sepsis care. I have less to offer septic patients once they’re in my ICU. It is inevitable that we will get our act together. Only question is, how many of our patients will die first?

5. What we need to do Work out why ideal sepsis care continues to elude us Move from “recognizing”sepsis to “suspecting”it Make the case for simplifying sepsis care Establish sepsis as a medical emergency And not forgetting…

6. A U.K. Perspective

7. A U.K. Perspective North Stand

8. A U.K. Perspective Breast cancer

9. A U.K. Perspective Breast cancer Trinity Road Stand

10. A U.K. Perspective Breast cancer Bowel cancer

11. A U.K. Perspective Annual UK sepsis deaths

12. Why do we need to simplify sepsis care?

13. Revision due 2012 No Management Bundle!!

16. Standards currently achieved for ~14% of UK patients39% in my hospitalHow many in yours??? Source: UK SSC data

17. Comparison with ACS 75% in 30 mins 80%

18. Perspective

19. Early, appropriate antibiotics: the key to sepsis improvement

20. Will antibiotics prevent sepsis? Antimicrobials Infective insult CARS SIRS Organ dysfunction Time

21. Septic shock: the golden hour Organ injury Inflammatory response Toxic load Microbial load Shock threshold Acknowledgement to Anand Kumar

22. Septic shock: the golden hour Antimicrobials Shock threshold Organ injury Inflammatory response Toxic load Microbial load Acknowledgement to Anand Kumar

23. SSC- antibiotics • Begin IV antibiotics as early as possible, and always within the first hour of recognising severe sepsis (1D) and septic shock. (1B) • Broad-spectrum: one or more agents active against likely bacterial/ fungal pathogens and with good penetration into presumed source. (1B) • Reassess antimicrobial regimen daily to optimise efficacy, prevent resistance, avoid toxicity & minimise costs. (1C)

24. Cumulative Initiation of Effective Antimicrobial Therapy and Survival in Septic Shock 1.0 survival fraction cumulative antibiotic initiation 0.8 0.6 fraction of total patients 0.4 0.2 0.0 12-24 24-36 0-0.5 0.5-1 9-12 36+ 1-2 2-3 3-4 4-5 5-6 6-9 time from hypotension onset (hrs) Kumar et al. CCM. 2006:34:1589-96.

25. Running average survival in septic shock based on antibiotic delay (n=2154) For each hour’s delay in administering antibiotics in septic shock, mortality increases by 7.6% Funk and Kumar Critical Care Clinics 2011 (in press)

26. Begin IV antibiotics as early as possible, and always within the first hour of recognising severe sepsis (1D) and septic shock. (1B) Citation: Kumar A et al. Crit Care Med 2006: 34(6) Retrospective, 15 years, 14 sites n = 2,154 median 6 h, 50% administered in 6h Only 5% first 30 minutes- survival 87% 12% first hour- survival 84%

27. Early antibiotics are good...

29. Running average survival in septic shock based on antibiotic delay (n=4195) Funk and Kumar Critical Care Clinics 2011 (in press)

30. Adequacy of initial spectrum andtiming of first deliveryandachievement of MIC are collectively the key Reduce microbial and toxic load ...so hit hard and hit fast .... BUT....

31. How do we know which ‘septic’ patient is going to organ failure? We often don’t know the source, let alone the bug.... We don’t adhere to guidelines, and the guidelines aren’t much good We’re not very good with our timing So...

32. Should we have, for first dose, the ‘Sepsis Antibiotic? Pip/ taz? Meropenem? Linezolid? Forget severe sepsis??

33. How to simplify sepsis care ..community-acquired sepsis

34. Sepsis Resuscitation Bundle (To be started immediately and completed within 6 hours) Serum lactate measured Blood cultures obtained prior to antibiotic administration From the time of presentation, broad-spectrum antibiotics to be given within 1 hour Control infective source In the event of hypotension and/or lactate >4mmol/L (36mg/dl): Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent) Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/l (36 mg/dl): Achieve central venous pressure (CVP) of >8 mm Hg Achieve central venous oxygen saturation (ScvO2) >70%

35. Sepsis Resuscitation Bundle (To be started immediately and completed within 6 hours) Serum lactate measured Blood cultures obtained prior to antibiotic administration From the time of presentation, broad-spectrum antibiotics to be given within 1 hour Control infective source In the event of hypotension and/or lactate >4mmol/L (36mg/dl): Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent) Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/l (36 mg/dl): Achieve central venous pressure (CVP) of >8 mm Hg Achieve central venous oxygen saturation (ScvO2) >70% No, No, No!!

45. USA work EMS- transported sepsis patients • Sicker • Shorter time to antibiotics: 119 vs 160 mins 116 vs 152 mins • Shorter still if EMS provider SAID SEPSIS Studnek JR et al 2010 Band RA et al 2011

47. How to simplify sepsis care ..hospital-acquired sepsis (not necessarily HCAIs!!)

48. Know your reliability

49. Know your processes