Sepsis

1. Sepsis • April 7, 2014 • David Griffen, MD, PhD • Southern Illinois University School of Medicine • Division of Emergency Medicine

2. “Hectic fever at its inception is difficult to recognize but easy to treat. Left untended, it becomes easy to recognize but difficult to treat.”

3. 72 Year old admitted with acute exacerbation of COPD • PMH • COPD/emphysema. • Pulmonary fibrosis. • Recurrent pneumonias • Rheumatoid arthritis on chronic steroids. • History of DVT and PE • Diabetes mellitus type 2, most likely steroid-induced. • Hypertension. • Paroxysmal atrial fibrillation. • Peripheral vascular disease.

4. Called to room for generalized body aches • Patient looks pale and uncomfortable • Temperature 38.5 Deg C • Pulse Rate 93 • Respiratory Rate 20 br/min • Systolic Blood Pressure 81 mmHg • Diastolic Blood Pressure 42 mmHg • O2 Sat Resting 88 %

5. What does this patient have?

6. What do you do next?

7. What does this patient need?

8. Topics We Will Cover • Definitions • Scope • Surviving Sepsis Campaign • Early identification and Lactate • ED treatment priorities • The controversy • PROCESS

9. Definitions

10. Definitions • Systemic inflammatory response (SIRS) • Sepsis • Severe sepsis • Sepsis induced hypotension • Septic shock

11. Systemic Inflammatory Response Syndrome = SIRS • Systemic inflammatory response syndrome is defined as the presence of 2 or more of the following: (1) temperature > 38°C (100.4°F) or < 36°C (96.8°F); (2) pulse > than 90 beats/min; (3) Respiratory rate > than 20 breaths/min (or PaCO2 < 32 torr) (4) WBC count >12,000/mm3 or < 4,000/mm3, or > 10% immature band forms.

12. Does our patient have SIRS? • Temperature 38.5 Deg C • Pulse Rate 93 • Respiratory Rate 20 br/min • Systolic Blood Pressure 81 mmHg • Diastolic Blood Pressure 42 mmHg • O2 Sat Resting 88 %

13. One Definition of Sepsis Sepsis = SIRS + Infection

14. Does our patient have Sepsis? • Temperature 38.5 Deg C • Pulse Rate 93 • Respiratory Rate 20 br/min • Systolic Blood Pressure 81 mmHg • Diastolic Blood Pressure 42 mmHg • O2 Sat Resting 88 %

15. Problem with SIRS • Not specific • Does not appear to have any real prognostic value Shapiro, N., M. D. Howell, et al. (2006). "The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection." Ann Emerg Med 48(5): 583-90, 590 e1.

16. SIRS • Silly • Inappropriate • Renaming • Syndrome

17. Why Use SIRS In Definition of Sepsis? • Relatively simple • Easy to teach • Focuses staff on sepsis • Other definitions too complex

18. And another definition of sepsis …..

20. Sepsis = SIRS + Infection • Relatively simple • Easy to teach • Focuses staff on sepsis • Other definitions too complex

21. Severe Sepsis • Severe sepsis is defined as the presence of sepsis and 1 or more organ dysfunction. Organ dysfunction can be defined as: • acute lung injury • coagulation abnormalities • thrombocytopenia • altered mental status • renal, liver, or cardiac failure • hypoperfusion with lactic acidosis. Mortality up to 30-50 %

22. Does our patient have Severe Sepsis? • Temperature 38.5 Deg C • Pulse Rate 93 • Respiratory Rate 20 br/min • Systolic Blood Pressure 81 mmHg • Diastolic Blood Pressure 42 mmHg • O2 Sat Resting 88 %

23. Sepsis-Induced Hypotension Sepsis with: • SBP < 90 mm Hg or • Mean arterial pressure < 70 mm Hg (or SBP decrease > 40 mm Hg or 2 SD below normal for age)

24. Does our patient have Sepsis-Induced Hypotension? • Temperature 38.5 Deg C • Pulse Rate 93 • Respiratory Rate 20 br/min • Systolic Blood Pressure 81 mmHg • Diastolic Blood Pressure 42 mmHg • O2 Sat Resting 88 %

25. Septic Shock • Septic shock is defined as the presence of sepsis and refractory hypotensionunresponsive to a crystalloid fluid challenge of at least 30 mL/kg) Mortality 50-60%

26. Does our patient have Septic Shock? • Temperature 38.5 Deg C • Pulse Rate 93 • Respiratory Rate 20 br/min • Systolic Blood Pressure 81 mmHg • Diastolic Blood Pressure 42 mmHg • O2 Sat Resting 88 %

27. Definitions • SIRS • Sepsis • Severe sepsis • Sepsis induced hypotension • Septic shock

28. SIRS SEPSIS SEPTIC SHOCK SEVERE SEPSIS

29. Bacteremia≠ Sepsis • Bacteremia • Presence of viable bacteria in the blood • Found only in about 50% of cases of severe sepsis and septic shock • 20% to 30% of patients with severe sepsis or septic shock will have no microbial cause identified from any source.

30. Sorting … by severity of illness (instead of site of infection or etiology)

31. SIRS SEPSIS SEPTIC SHOCK SEVERE SEPSIS

32. Sort patients…. … by severity of illness instead of site of infection or etiology The severity of illness determines the type and urgency of treatment. Site of infection and presumed etiology determines antibiotic choice.

33. Sites of Infection in Sepsis • Lung- 45% • Abdomen- 17% • Urinary tract- 10% • Undetermined- 20-30% N Engl J Med 340(3):207

34. Sites of Infection for Sepsis Patient • Lung (35%) • Abdomen (21%) • Urinary tract (13%) (However this is the most common site for patients older than 65 years old) • Skin and soft tissue (7%) • Other site (8%), • Unknown primary site (16%) Compiled from 16 studies between 1963 and 1998 that included 8,667 patients)

35. For the rest of the talk will be addressing severe sepsis and septic shock • Scope • Incidence • Mortality • Surviving Sepsis Campaign

36. Bugs • Bacteria • Gram negative (used to cause majority) • Gram positive (now in the majority) • Virus • Fungus

41. Scope • 750,000 US patients with severe sepsis • 29% overall hospital mortality rate • 210,000 deaths per year in US • Increasing by at least 1.5% a year • $16.2 to $24 billion a year • About 50% admitted through ED

44. SIRS SEPSIS SEPTIC SHOCK SEVERE SEPSIS LACTATE ≥ 4

45. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic ShockNEJM 2001 • Randomized patients (n=263) with septic shock, or severe sepsis with lactate ≥ 4, to receive standard therapy (n=133) or EGDT (n=130) • In-hospital mortality was 30.5 percent for EGDT group and 46.5 percent in the group assigned to standard therapy (p=0.009) • Absolute mortality reduction of 16 percent

46. NNT to prevent 1 event (death) = 6-8 Standard therapy 60 EGDT 50 40 Mortality (%) 30 20 10 0 In-hospital mortality (all patients) 28-day mortality 60-day mortality The Importance of Early Goal-DirectedTherapy for Sepsis Induced Hypoperfusion Adapted from Table 3, page 1374, with permission from Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-1377

47. Surviving Sepsis CampaignSponsoring Organizations • American Association of Critical-Care Nurses • American College of Chest Physicians • American College of Emergency Physicians • American Thoracic Society • Australian and New Zealand Intensive Care Society • Episepsis • European Society of Clinical Microbiology and Infectious Diseases • European Society of Intensive Care Medicine • European Respiratory Society • German Sepsis Society • Indian Society of Critical Care Medicine • International Sepsis Forum • Society of Critical Care Medicine • Surgical Infection Society

48. Bundles

49. What is a Bundle? • Specifically selected care elements from evidence based guidelines • Implemented together provide improved outcomes compared to individual elements alone