SurvivingSepsis Campaing( Resultados(y(futuro( - ?· Surviving Sepsis Campaign (SSC) guidelines for…

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  • Surviving Sepsis Campaing Resultados y futuro

    Ricard Ferrer Intensive Care Department

    Mutua Terrassa University Hospital Barcelona. SPAIN

  • Phase 1 Barcelona declaration Phase 2 Evidence based guidelines

    Phase 3 Implementation and Education

  • Surviving Sepsis Campaign: Timeline

    Barcelona Declara

  • Surviving Sepsis Campaign (SSC) guidelines for management of severe

    sepsis and septic shock

    Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G,

    Zimmerman JL, Vincent JL, Levy MM Crit Care Med 2004;32:858-873

    Intensive Care Med 2004;30:536-555

  • Surviving Sepsis Campaign: International guidelines for management of severe sepsis

    and septic shock: 2008

    Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T,

    Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender

    JS, Zimmerman JL, Vincent JL.

    Crit Care Med 2008; 36:296-327

    Intensive Care Med 2008;30:536-555

  • Surviving Sepsis Campaign: Interna

  • Current Surviving Sepsis Campaign Guidelines Sponsors

    American Associa

  • Phase 1 Barcelona declaration Phase 2 Evidence based guidelines

    Phase 3 Implementation and Education

  • SSC Methodology: International Multifaceted Intervention

    National/regional/network launch meetings Identify local champions Introduce sepsis bundles Staff support for coordinating sites Regular conference calls

    Educational tools SSC manual SSC slides

    Website SSC and IHI website Sepsis list-serve

    Interactive database Automated uploading to SSC server Technical support Local audit and feedback capabilities

  • Crit Care Med 2010; 38(2):367-374

    n= 15.022

  • Crit Care Med 2010; 38(2):367-374

  • SSC: Europe vs USA

    Levy M et al. Lancet ID 2012

    Mortality Organ dysfunc

  • SSC: Europe vs USA

    Origin of infec

  • ICU bed availability is higher in the USA

  • SSC Final Report of Phase III 7.5 year analysis of 30,000 patients

    Effects: Participation Duration Dose

  • SSC Mortality: Par

  • SSC DuraHon Effect

    Levy et al; 2014 CCM/ICM

    The adjusted odds of hospital mortality is decreasing 1% per site quarter (p = 0.005)

    The longer a site participated, the greater the associated mortality reduction

  • Baseline Hospital Mortality Did Not Change over Time

    Levy et al; 2014 CCM/ICM

  • Mortality in HIGH COMPLIANCE Sites with at least 3 years of data collection

    Mortality: 45.7% to 29.5% ARR: 16.5% P < 0.001 RRR: 36%

  • Mortality: 42.9% to 26.2% ARR: 16.7% P < 0.001 RRR: 39%

    Mortality in HIGH COMPLIANCE Sites with at least 4 years of data collection

  • CCM 2014;42:1749-55

    Severe Sepsis and Septic Shock

    Empirical antibiotics after sepsis recognition

  • Predicted hospital mortality and 95% CIs for time to first antibiotic administration Results adjusted by the sepsis severity score, ICU admission source ([ED], ward, vs ICU), and geographic region (Europe, United States, and South America)

  • 26.3% 68.6% 51.8% 78.2% 84.0% 87.5% 100%

    Median time to empiric antibiotics

  • 16935

    18671

    15000

    16000

    17000

    18000

    19000

    20000

    Euro

    s

    Hospital Costs

    Preintervention Intervention

    5.445.98

    3.75 4.12

    01234567

    Years

    LYG QALY

    Preintervention Intervention

    Adjusted ICER 4,435 euros per LYG Adjusted ICUR 6,428 euros per QALY

  • Published Data from SSC: 2006-2014

    All prospective cohort studies

    40 published reports in peer-reviewed journals

    All demonstrated: Increased compliance Associated decreased

    mortality

    United States (25) Spain (1) France (1) Germany (1) Portugal (1) Netherlands (2) UK (2) China (3) Iceland (1) Korea (1) Pan-Asia (1) Latin America (1)

  • Challenges to SSC data Uncontrolled data

    Interrupted Hme series Before/aMer design

    Mortality benefit could be explained by: Secular trends in sepsis mortality Are sites shiMing less sick paHents into ICU who would have survived regardless: DiluHng mortality rate over Hme

    However, when adjusted for severity: Mortality benefit remains significant

  • Crit Care Med 2014; 42:18901898

    CONTROL INTERVENTION

  • Mortality Change in Interven

  • INTERVENTION

  • Conclusions With the adequate leadership, it is possible to do

    international multifaceted interventions. It is feasible to use data to audit and change

    clinical behavior Performance metrics can change clinical practice

    Increased compliance with performance metrics is associated with improved survival 39% RRR with high compliance

  • Conclusions: Variability Published studies demonstrate wide practice

    variation: Poor compliance with known quality indicators

    Variability based on different weighting of relevant knowledge EXPECTED

    Variability based on knowledge deficits, faulty application of knowledge or simple forgetting UNACCEPTABLE

  • Whats Next? Marked increased attention: SSC

    recommendations are being implemented Important american organizations are

    incorporating SSC metrics: National Quality Forum measure CMS: Centers for Medicare & Medicaid Services

    Governments New York System mandated reporting Catalonia: 2015 Instruction

    Many hospital networks

  • Registry: including the SSC quality indicators

    SEPTIC CODE

    Patients Flow: SEP-I centers SEP-IIa centers SEP-IIb centers

  • Whats Next?

    SSC Guidelines Sepsis Definition IMPRESS study

  • SSC Guidelines 2016

    Timeline: October 2016 Scope: Early management of severe sepsis and sepHc shock. Early is defined as within the first 24 hours.

    Target audience: Any healthcare worker in any healthcare se[ng who is caring for adult paHents with sepsis.

    Independent Pediatric Guidelines

  • SSC Guidelines 2016

    Results of studies PROCESS, ARISE are challenging current recommendaHons.

    New evidences in fluids: balanced crystalloids, albumin.

    New studies in specific subgroups like DIC or AKI.

  • Living Guideline Concept

    Living guidelines are systemaHcally developed, evidence based, and conHnually updated.

    Rigorous monitoring of published literature. Electronic format vs Paper format. EvaluaHon of the current state of the recommendaHon: no revision needed, revision possible, revision imperaHve.

  • Sepsis in Resource-Limited Nations Task Force report

    Leaders: M. Dnser/C. Farmer Global task force to explore sepsis diagnosis and management

    in resource-limited countries. This task force has developed a conceptual approach, the

    scan-teach-treat system. This approach has three steps: Scan the region of interest for key elements that influence sepsis

    detecHon, management, and outcome; Teach through public awareness and healthcare provider educaHonal

    programs on sepsis; Treat by implemenHng a sepsis first aid kit into clinical pracHce.

  • SEPSIS DEFINITION Objectives

    Improve our ability to make early bedside detecHon of the disease, and thus allow early therapeuHc intervenHon and adequate paHent allocaHon.

    IdenHfy paHents with different condiHons but with the similar pathophisiology, so same therapeuHc targets.

    Select paHents with similar severity, according to a scoring system.

    Adequate tool for selecHng paHents for clinical trials promoHng the research of new drugs or devices.

  • Consequences of 1992 definition

    Definition has help to standardize the treatment and produce guidelines.

    Quality of treatment and mortality have improve.

    However, none innovative treatments showed benefit despite lots of trials using these definitions.

    Important epidemiological differences in different areas.

  • Main limitations of SIRS criteria

    Unspecific Arbitrary cut-offs Too sensitive:

    Not useful to alert sepsis outside the ICU: almost every viral infection could be confounded with sepsis

    SIRS criteria almost universal in the ICU Not consistent in different consensus. Not always present.

  • SIRS criteria at ICU admission

    Outcome according SIRS criteria at ICU admission

    87%

  • Am J Respir Crit Care Med Vol 171. pp 461468, 2005

    DEVELOPMENT OF THE RISSC FOR PROGRESSION FROM SEPSIS TO SEVERE SEPSIS OR SEPTIC SHOCK

    BIVARIATE HR MULTIVARIATE HR

  • Crit Care Med 2005; 33:512519

    ApEn

  • Incidence of the four SIRS criteria on day 1 by variations in threshold criteria and mode of data recording: -Automatic (continuous) recordings of single occurrences -Automatic recordings of 60-min intervals above threshold -Manual (hourly) recordings of single occurrences -Manual recordings of 60-min intervals above threshold.

  • Infec

  • PIRO concept: Tool for Phenotyping sepsis

    Predisposition

    Insult (Infection)

    Response

    Organ Dysfunction

    Genetic susceptibility Coexisting health complications

    Pathogen, toxicity and sensitivity Locat