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Update on Sepsis
Kristopher R. Maday, MS, PA-C, CNSCUniversity of Alabama at Birmingham
Objectives• Identify the sign and symptoms of
sepsis• Describe the common complications of
sepsis• Introduce the new Sepsis-III definition• Critically evaluate landmark Early Goal
Directed Therapy study• Appraise current literature on sepsis
management
Sepsis Statistics
Me
Mostof
you
Sepsis Incidence and Cost• 2-4% of all diagnoses– 6th most common principle reason for
hospitalization
• Single most expensive condition treated – $15.4 billion spent on sepsis in 2009• $18,500-33,900 per case
Hall MJ. NCHS Data Brief. 2011;62. Elixhauser A. HCUP Statistical Brief. 2011;112.
2000-2008 CDC Data
Hall MJ. NCHS Data Brief. 2011;62.
2000-2008 CDC Data
Hall MJ. NCHS Data Brief. 2011;62.
2000-2008 CDC Data
Hall MJ. NCHS Data Brief. 2011;62.
2000-2008 CDC Data
Hall MJ. NCHS Data Brief. 2011;62.
2000-2008 CDC DataDisposition
Sepsis All Other Diagnoses
PercentRoutine 39 79
Transfer to other short-term facility 6 3
Transfer to long-term care facility 30 10
In-hospital mortality 17 2
Other or not stated 8 6
Total 100 100
Hall MJ. NCHS Data Brief. 2011;62. Elixhauser A. HCUP Statistical Brief. 2011;112.
Surviving Sepsis Campaign • Initiated in 2002• International joint collaborative
between:– Society of Critical Care Medicine– European Society of Intensive Care
Medicine• Mission Statement– “reducing mortality from severe sepsis
and septic shock worldwide”• Developed guidelines and bundles
for sepsis managementSurviving Sepsis Campaign. Accessed February 17, 2015, from http://www.survivingsepsis.org/Pages/default.aspx.
What Exactly Is “Sepsis”?
sipsi
It starts with an infection…
Infectious Source Total (%)
Urinary Tract 34.5
Respiratory Tract 28.7
Gastrointestinal Tract 5
Soft Tissue 6.6
Other 25.2
Ani C. Critical Care Medicine. 2015;43(1):65-77
Angus DC. NEJM. 2013;369(9):840-851
…that triggers inflammation…
Systemic Inflammatory Response Syndrome
Marino PL. Infection, Inflammation, and Multiorgan Injury. In: The ICU Book. 4e. 2013.
Systemic Inflammatory Response Syndrome
Temperature> 38o C (100.4o F)
or< 36o C (96.8o F)
Heart Rate> 90 beats/minute
Respiratory Rate>20 breaths/minute
orPaCO2 < 32 mmHg
Prognosis Mortality2 Criteria 5%3 Criteria 10%4 Criteria 20%
Chen CL. Patient Safety. In: Schwartz’s Principles of Surgery. 10e. 2014.
White Blood Cell Count> 12,000
or< 4,000
or> 10% bands
Angus DC. NEJM. 2013;369(9):840-851
…that leads to hypoperfusion…
…that causes organ dysfunction
• Multiple Organ Dysfunction Syndrome– Acute reversible physiologic
derangement of at least 1 organ system
0 1 2 3 4 5 60
20
40
60
80
100
Qureshi K. BJMP. 2008;1(2):7-12
# of Organ Systems Affected
% M
orta
lity
Marshall J. Critical Care Medicine. 1995;10:1638-1652
Multiple Organ Dysfunction Syndrome
• Altered Mental Status
• Hyperglycemia
• Lactic Acidosis
• Hypoxemia
• Acute Kidney Injury
• Coagulopathy
• Paralytic Ileus
• Hyperbilirubinemia
• Elevated troponin
• Hypotension
Howell MD. Intensive Care Medicine. 2007;33:1892-1899
InfectionSystemic
Inflammatory
ResponseSyndrome
SEPSIS
Severe
Shock
The Sepsis Spectrum
Brown T. Journal of Critical Care. 2015;30:71-77
Kumar A. Critical Care Medicine. 2006;34:1589-1596
What if we miss it?
7.6% increase in mortality PER HOUROdds Ratio < 1 if antibiotics started within 1st hr
What if we miss it?
5.3% increase in mortality EVERY HOUR
Bai X. Critical Care. 2014;18:532
Sepsis-III Definition• No more “severe sepsis”• Sequential Organ Failure Assessment
Score
Singer M and Sepsis-3 Group. JAMA. 2016;315(8):801-810
Singer M and Sepsis-3 Group. JAMA. 2016;315(8):801-810
qSOFARR ≥ 22/minGCS ≤ 13SBP ≤ 100 mmHg
Sepsis Trials
Early
Goal
Directed
Therapy
Early Goal Directed Therapy• Published in 2001 by Dr. Emanuel
Rivers• Single academic tertiary hospital• EGDT vs Standard Care• Primary Outcome– In-hospital mortality
• Secondary Outcome– 28-day and 60-day mortality
Rivers E. NEJM. 2001;345(19):1368-1377
Rivers E. NEJM. 2001;345(19):1368-1377
Rivers E. NEJM. 2001;345(19):1368-1377
Results of EGDT
• Fluid difference• Transfusion difference• Vasopressor difference
Outcome EGDT Usual Care ARR 95% CI p
In-hospital Mortality 30.5% 46.5% 15.13
%3.62-
26.64% 0.015
28-day Mortality 33.3% 49.2% 15.1% 3.33-26.3% 0.017
60-day Mortality 44.3% 56.9% 14.2% 2.1-25.6% 0.029
Rivers E. NEJM. 2001;345(19):1368-1377
Levy MM. Critical Care Medicine. 2015;43(1):3-12
Ani C. Critical Care Medicine. 2015;43(1):65-77
Since 2001, Early Goal Directed Therapy
has become the …
StandardOf
Care for sepsis management
But… a lot happened in 2014/2015
The Sepsis Trilogy
TRISS Trial
SEPSISPAM Trial
ProCESS
ARISE ProMISe
Sepsis Trilogy
ProCESS Trial• 1351 patients across 31 academic US
hospitals• 2 Intervention Groups– EGDT protocol– Protocol-based standard therapy
• Control Group– Usual care
• Primary Outcome– 60-day mortality
• Results– No difference in mortality between all groups
The Process Investigators. NEJM. 2014;370:1683-1693
STRIKE ONE!!!
ARISE Trial• 1600 patients across 51 international
hospitals• Intervention Group– EGDT protocol
• Control Group– Usual resuscitation care
• Primary Outcome– 90-day mortality
• Results– No difference in mortality
The ARISE Investigators. NEJM. 2014;371:1496-1506
STRIKE TWO!!!
ProMISe Trial• 1260 patients across 56 UK hospitals• Intervention group– EGDT protocol
• Control group– Usual care
• Primary Outcome– All-cause 90-day mortality
• Results– No difference in mortality
The ProMISe Investigators. NEJM. 2015;371:1496-1506
EGDT
ISOUT
Comparison of EGDT StudiesEGDT (Rivers) ProCESS ARISE ProMISe
Location US US Australasia UKPatient # 263 1351 1600 1260
SEPSIS DEFINITIONSuspected/
Actual Infection
Yes Yes Yes Yes
≥ 2 SIRS Criteria Yes Yes Yes Yes
SBP < 90 or lactate > 4 Yes Yes Yes Yes
PROTOCOLFluid before
randomization 20-30 mL/kg ~20-30 mL/kg 1000 mL 1000 mL
Intervention EGDT 6 hours EGDT 6 hours EGDT 6 hours EGDT 6 hours
Control Usual therapy1) Protocol usual
support2) Usual therapy
Usual therapy Usual therapy
Primary Outcome
In-hospital mortality 60-day mortality 90-day
mortality 90-day mortality
PRIMARY OUTCOMEIntervention 30.5% 21% 18.6% 29.5%
Control 46.5% 1) 18.2%2) 18.9% 18.8% 29.2%
TRISS Trial• 998 patients across 32 Scandinavian ICUs• Treatment– Transfusion threshold ≤ 7mg/dL
• Control– Transfusion threshold ≤ 9mg/dL
• Primary Outcome– 90-day mortality
• Results– No difference in mortality
Holst LB. NEJM. 2014;371:1381-1391
SEPSISPAM Trial• 776 patients across 29 French hospitals• Treatment Group– Target MAP 80-85
• Control Group– Target MAP 65-70
• Primary Outcome– 28-day mortality
• Results– No difference in mortality
Asfer P. NEJM. 2014;370:1583-1593
Sepsis Management in 2016
• http://www.emdocs.net/the-dangers-of-over-resuscitation-in-sepsis/
Sepsis Management in 2016• Vigilant early identification of sepsis
• Baseline lactic acid
• Antibiotics within 1st hour of hypotension
• Identify infectious source (cultures, imaging)
Keegan J. Emerg Med Clin N Am. 2014;32:759-776 Marik P. CHEST. 2014;145(6):1407-1418
Three “T’s” of Shock Management
• 20-30 cc/kg initial crystalloid bolus• 500cc bolus thereafter
Keegan J. Emerg Med Clin N Am. 2014;32:759-776 Marik P. CHEST. 2014;145(6):1407-1418 Raghunathan K. Critical Care Medicine. 2014;42:1585-1591
The Tank
The Tubing
Norepinephrine for MAP 65-80 mmHg
Keegan J. Emerg Med Clin N Am. 2014;32:759-776 Marik P. CHEST. 2014;145(6):1407-1418 Raghunathan K. Critical Care Medicine. 2014;42:1585-1591
Dobutamine for lactate clearance or CI > 2.5 L/min/m2
Keegan J. Emerg Med Clin N Am. 2014;32:759-776 Marik P. CHEST. 2014;145(6):1407-1418 Raghunathan K. Critical Care Medicine. 2014;42:1585-1591
The Ticker
Sepsis Management in 2016
• Hydrocortisone 200mg if refractory hypotension after norepinephrine
• Transfusion only if Hgb < 7.0 mg/dL
• Transfer to ICU
Keegan J. Emerg Med Clin N Am. 2014;32:759-776 Marik P. CHEST. 2014;145(6):1407-1418 Raghunathan K. Critical Care Medicine. 2014;42:1585-1591
2015 CMS Sepsis Core Measures
Sepsis Septic Shock
Performed by hour 3
1)Initial lactate level2)Blood cultures
3) Broad spectrum antibiotics
Performed by hour 6
1) Repeat lactate if initial lactate > 2 mmol
1) Resuscitation with 30cc/kg crystalloid2) Vasopressors if hypotension is refractory to fluids
or initial lactate ≥ 4 mmol:a) Repeat volume status and tissue perfusion
assessment consisting of:a) Focused physical examb) Any 2 of the following:
i. CVPii. ScVO2iii. CV USiv. Passive leg raise or fluid challenge
So The Next Time You See This…
BP – 102/65
Temp – 102.3o
HR - 114
RR - 22
O2 – 92%
SEPT IC
end Lactic Acidarly Antibioticsressorsransfernfusionsultures
Thank You!
w w w . p a i n e p o d c a s t . c o m