Surviving Sepsis

August 25, 2017

Thomas Dobbs, MD, MPHCMO SCRMC

MSDH Office of Epidemiology

• What is Sepsis?• Why do we care?• What are our objectives?• How do we get there?

• Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.

• Often leading to organ dysfunction. • Sepsis is defined as the presence

(probable or documented) of infection together with systemic manifestations of infection.

WHAT IS SEPSIS

• Clinical Definitions–SIRS based criteria–Updated SOFA score

• CMS definitions

• Two or more of:– Temperature >38°C or <36°C– Heart rate >90/min– Respiratory rate >20/min or

PaCO2 <32 mm Hg (4.3 kPa)– White blood cell count

>12 000/mm3 or <4000/mm3 or >10% immature bands

SIRS (SYSTEMIC INFLAMMATORY RESPONSE SYNDROME)

• Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.

• Organ dysfunction can be represented by an increase in the Sequential Organ Failure Assessment (SOFA) score of 2 points or more, (which is associated with an in-hospital mortality greater than 10%).

• Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.

• Term “Severe Sepsis” is redundant and unecessary

Date of download: 2/23/2016 Copyright © 2016 American Medical Association. All rights reserved.

From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

Operationalization of Clinical Criteria Identifying Patients With Sepsis and Septic ShockThe baseline Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score should be assumed to be zero unless the patient is known to have preexisting (acute or chronic) organ dysfunction before the onset of infection. qSOFA indicates quick SOFA; MAP, mean arterial pressure.

Date of download: 2/23/2016 Copyright © 2016 American Medical Association. All rights reserved.

From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

• Inpatients age 18 and over with an ICD-10-CM Principal or Other Diagnosis Code of Sepsis, Severe Sepsis, or Septic Shock.

• Included Populations: Discharges age 18 and over with an ICD-10-CM Principal or Other Diagnosis Code of Sepsis, Severe Sepsis, or Septic Shock

CMS DEFINITION

www.qualitynet.org Specification Manual

• Measure Set: Sepsis Set Measure ID #: SEP-1• Performance Measure Name: Early Management

Bundle, Severe Sepsis/Septic Shock• Description: This measure focuses on adults 18 years

and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, it assesses measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement. As reflected in the data elements and their definitions, the first three interventions should occur within 3 hours of presentation of severe sepsis, while the remaining interventions are expected to occur within 6 hours of presentation of septic shock.

• Documented or suspected infectionAND• 2 SIRS CriteriaAND• Organ dysfunction

– Respiratory failure– Hypotension– Cr > 2– Bili > 2– Platelet < 100,000– INR > 1.5 – Lactate > 2

SEVERE SEPSIS

All Within 6 hour Time

Frame

• Severe SepsisAND• Persistent hypotension 1 hour after fluid

administration

OR• Severe SepsisAND• Initial lactic acid > 4

SEPTIC SHOCK

• 72 yo female• Came to ER with fatigue, mild cough, fever• Temp 100.7• RR 22• Pulse105• Blood pressure 150/90• WBC 11,200• Is she

– SIRS – Sepsis– Severe Sepsis– Septic Shock – None of the above

MS. B

• Liver functions normal• Renal function: Bun 34 / Creatinine 1.6

• Lactic acid: normal• Platelet: 220,000• INR – not done

ADDITIONAL INFORMATION

• A leading cause of death• Annual incidence severe sepsis in US

~300 / 100,000• Translates to ~ 9,000 per year in

Mississippi (estimate of deaths ~3,000)• Compare to death from:

– Heart disease: 7,720– Cancer: 6,540– Stroke: 1,496

WHY DO WE CARE?

• Mortality rate of 10 - 50% depending on the severity

• > $20 billion annual expenditure in US (>5% of total US healthcare)

• Leading cause of mortality and critical illness worldwide

HUMAN AND ECONOMIC IMPACT OF SEPSIS

• Age– Bimodal: highest for infants and those > 50– Increases in sepsis diagnosis highest in those > 65

• Sex– Slightly higher for males

• Comorbid illnesses– DM, CHF, ESRD, liver disease, CA, immunosuppression

• Race– 2x higher risk for AA in comparison to Caucasians– May be due in part to higher rate of comorbid condtions

(ESRD, DM)• Seasonal

– Sepsis due to respiratory illness highest in the winter

RISK FACTORS FOR SEPSIS

MORTALITY RATE HIGHEST IN THE SOUTHEAST

• Staphylococcus aureus: 20.5%• Pseudomonas species:19.9%• Enterobacteriacae (mainly E.coli):16.0%• Fungi: 19%• Acinetobacter: 4%

ORGANISMS IMPLICATED IN SEVERE SEPSIS

• Staph aureus 41%• Coagulase negative staphylococcus 20%• E. coli 19%• Candida 43%• Acinetobacter spp. 40%• Streptococcus pneumoniae 13%• Pseudomonas spp. 71%

MORTALITY RISK BY ORGANISM

SEVERE SEPSIS BY ORGAN SYSTEM

JAMA.2010;303:2495–503.

• Joint collaboration of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine

• Committed to reducing mortality from severe sepsis and septic shock worldwide

• Initiated in 2002 with the Barcelona Declaration• Updated in 2012• Updated again 2016

– Recommended only using Sepsis and Septic Shock

– Sepsis = “old” severe sepsis

OBJECTIVE: IMPROVING SEPSIS OUTCOMES - SURVIVING SEPSIS CAMPAIGN

www.survivingsepsis.org

Levy MM et al. CCM 38(2):367-374, February 2010.

Change in Mortality Over Time

15,022 Patients165 Sites

GENERAL OVERVIEW OF RECOMMENDED SEPSIS RESPONSE

Early Screening for Sepsis: Vital Signs, WBC, Organ Dysfunction

Rapid Assessment:Lactic acid, blood culture

Rapid Intervention:Broad spectrum antibiotics, fluid resuscitation, pressors

Reassessment and Intervention

TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION*:

• 1. Measure lactate level • 2. Obtain blood cultures prior to administration of

antibiotics • 3. Administer broad spectrum antibiotics • 4. Administer 30ml/kg crystalloid for hypotension or lactate

≥4mmol/L

• * “Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.

SURVIVING SEPSIS CAMPAIGN

TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:

• 5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg 6.

• 6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to guidance.

• 7. Re-measure lactate if initial lactate elevated.

SURVIVING SEPSIS CAMPAIGN

Guidance for Reassessment by Hour 6• EITHER

– Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.

• OR TWO OF THE FOLLOWING: – Measure CVP – Measure ScvO2 – Bedside cardiovascular ultrasound – Dynamic assessment of fluid responsiveness with passive

leg raise or fluid challenge

SURVIVING SEPSIS CAMPAIGN

• 1. Blood Product Administration • 2. Maintain Adequate Glycemic Control • 3. Mechanical Ventilation of Sepsis-Induced

Acute Respiratory Distress Syndrome (ARDS) • 4. Sedation, Analgesia, and Neuromuscular

Blockade • 5. Deep Vein Thrombosis (DVT) and Peptic

Ulcer Disease (PUD) Prophylaxis • 6. Nutrition • 7. Setting Goals of Care

OTHER SELECTED THERAPIES RECOMMENDED BY THE 2012 SURVIVING SEPSIS CAMPAIGN:

• Surviving Sepsis Guidelines recommend al hospitals develop performance improvement program

• Collect/monitor data• Use available tools to implement evidence

based approaches• Sepsis “bundles”• EMR alerts• Multiple others…

PDSA

HOW DO WE GET THERE?

MAKE THE RIGHT PATH THE EASY PATH

• Faster response is better• ? Role of IVF volume

UNANSWERED QUESTIONS